No Longer Wanting to Die
May 20, 2015 6:36 PM Subscribe
SLNYT - Suicdal treatment-resistant depression vs. DBT One man's experience with dialectical behavior therapy, or DBT.
Previously, and again.
I’d act impulsively — spending money when I couldn’t afford it, isolating myself from friends, lashing out at those people closest to me, even hurting myself physically. Afterward, I was kept low by regret. My urges to act out may have been satisfied, but now I had a set of new problems: debt, broken relationships, a hangover. Unable to forgive myself for my mistakes, the anger returned....
...Dr. Linehan found that C.B.T. didn’t always work for her suicidal patients. Some found its emphasis on changing their own thinking tantamount to the belittling notion that their pain was “all in their head.” Many of them had experienced very real trauma, and many had tried fruitlessly to change many times before.
Once a week, at $80 each, for 2.5 years.
Ten grand.
How fortunate.
posted by yesster at 6:56 PM on May 20, 2015 [2 favorites]
Ten grand.
How fortunate.
posted by yesster at 6:56 PM on May 20, 2015 [2 favorites]
I've never heard of this before but wow sites or sound like it could work for me. I know every depression is like a little dark snowflake and responds to different things - DBT sounds like something is respond to. Thank you so much for sharing it.
posted by Joey Michaels at 7:14 PM on May 20, 2015
posted by Joey Michaels at 7:14 PM on May 20, 2015
I did DBT for a few weeks as part of a partial hospital program. It was enormously helpful. I have rapid cycling Bipolar I with treatment resistant depression and I have been trying to find a DBT therapist on the outside ever since. I have found it really difficult to find a strict DBT practitioner in my area. I don't know why.
posted by Biblio at 7:20 PM on May 20, 2015
posted by Biblio at 7:20 PM on May 20, 2015
Panic, depression and stress: The case against meditation
For some, meditation has become more curse than cure. Willoughby Britton wants to know why.
posted by robbyrobs at 7:24 PM on May 20, 2015 [8 favorites]
For some, meditation has become more curse than cure. Willoughby Britton wants to know why.
posted by robbyrobs at 7:24 PM on May 20, 2015 [8 favorites]
Very very interesting.
posted by Divine_Wino at 7:37 PM on May 20, 2015
posted by Divine_Wino at 7:37 PM on May 20, 2015
My best friend is in this and it really helps her a lot. She talks a lot about the stuff she learns from it in conversation, and even though I'm not even in the program with her, the skills and vocabulary she's gotten from it can really help me when I talk to her about my problems. Part of it is that she's super empathetic and good at being validating in general, but I think DBT in particular has been pretty great. (I actually made a random DBT skill generator with her a few weeks back.)
Also I'm not sure why you're linking to meditation stuff, robbyrobs, but the mindfulness practice stuff isn't the whole of what DBT is about, and it isn't exactly meditation either.
posted by NoraReed at 8:47 PM on May 20, 2015 [4 favorites]
Also I'm not sure why you're linking to meditation stuff, robbyrobs, but the mindfulness practice stuff isn't the whole of what DBT is about, and it isn't exactly meditation either.
posted by NoraReed at 8:47 PM on May 20, 2015 [4 favorites]
Yeah it is fortunate he was able to fund the thing he found worked.
I do ACT - Acceptance and Commitment Therapy. I think it's something of a little sister to DBT. I've spend enough time in my head that challenging the negative thoughts doesn't work. Speaking them and dissecting them works right then.
Work though? That gets me through whatever biopsychological process is going haywire.
I've spent the past week and a half all over the shop - an unfortunate series of conversations with assholes who verbalise all of those negative thoughts, an unfortunate fight with a close friend who is himself in a bad space, lots of deadlines, a few situations confirming the assholes not only genuinely believe what they said but aren't going to support me at all, and then to top it off I had a spectacular flashback. Spectacular.
Previous eras this would have at least seen me with a pack of cigarettes, not eating, not working. Now though, I can accept the way this passes. I can accept the way my body reacts to the trauma and the memories and the feelings being provoked, and I can work though those things instead of believing them to be some great truth.
A conversation with the voice in my head that tells me I am a useless human being just confirms that is a thought worthy of attention, and draws me to think about ways it is true. Accepting that sometimes my brain throws this thought at me, then moving on to do something else? Lessens the impact.
Think of it as a higher version of 'don't feed the trolls'.
posted by geek anachronism at 8:51 PM on May 20, 2015 [16 favorites]
I do ACT - Acceptance and Commitment Therapy. I think it's something of a little sister to DBT. I've spend enough time in my head that challenging the negative thoughts doesn't work. Speaking them and dissecting them works right then.
Work though? That gets me through whatever biopsychological process is going haywire.
I've spent the past week and a half all over the shop - an unfortunate series of conversations with assholes who verbalise all of those negative thoughts, an unfortunate fight with a close friend who is himself in a bad space, lots of deadlines, a few situations confirming the assholes not only genuinely believe what they said but aren't going to support me at all, and then to top it off I had a spectacular flashback. Spectacular.
Previous eras this would have at least seen me with a pack of cigarettes, not eating, not working. Now though, I can accept the way this passes. I can accept the way my body reacts to the trauma and the memories and the feelings being provoked, and I can work though those things instead of believing them to be some great truth.
A conversation with the voice in my head that tells me I am a useless human being just confirms that is a thought worthy of attention, and draws me to think about ways it is true. Accepting that sometimes my brain throws this thought at me, then moving on to do something else? Lessens the impact.
Think of it as a higher version of 'don't feed the trolls'.
posted by geek anachronism at 8:51 PM on May 20, 2015 [16 favorites]
Something I find interesting is that most therapy orientations all tend to converge toward very basic principles the longer they're practiced. Recognizing that your thoughts are not reality is important. Accepting your thoughts is important. Accepting your emotions is important. Recognizing your emotions are not reality is important. Accepting your past is important. Recognizing that your past is not in control of your present is important. Staying in the present moment is important. Being kind to yourself is important. Connecting with others is important. Having boundaries is important. Being vulnerable is important.
All the various forms of therapy place different importance on those things (and I'm sure I missed some) and have different jargon about teaching their importance, which is great -- I think it's important to have variations because different clients are going to respond better to different formulations -- but all the jostling and marketing hype among the differing orientations is a bit silly, I think, because they're all working toward the same goals and, increasingly, using the same principles to get there.
posted by jaguar at 9:07 PM on May 20, 2015 [23 favorites]
All the various forms of therapy place different importance on those things (and I'm sure I missed some) and have different jargon about teaching their importance, which is great -- I think it's important to have variations because different clients are going to respond better to different formulations -- but all the jostling and marketing hype among the differing orientations is a bit silly, I think, because they're all working toward the same goals and, increasingly, using the same principles to get there.
posted by jaguar at 9:07 PM on May 20, 2015 [23 favorites]
Note to self: they're not talking about the healing blues and southern rock songs of the band Drive-By Truckers. REMEMBER.
posted by Sunburnt at 9:19 PM on May 20, 2015 [2 favorites]
posted by Sunburnt at 9:19 PM on May 20, 2015 [2 favorites]
DBT seems to be unique in taking a structured approach to identifying emotions, tolerating distress, and developing particular skills to deal with embodied feelings and behaviours in the (challenging) moment. CBT (as I've experienced it, anyway) is a little more heady, or centrist, focused on core beliefs - it can be hard to make the link between what's discussed and life as it happens. I also think the B part winds up getting dropped, in practice, a lot of the time.
I have found it really difficult to find a strict DBT practitioner in my area. I don't know why.
I think it might just be because there's been a whack of research on CBT for years now, so there are just more opportunities for people to train in it.
posted by cotton dress sock at 9:58 PM on May 20, 2015 [1 favorite]
I have found it really difficult to find a strict DBT practitioner in my area. I don't know why.
I think it might just be because there's been a whack of research on CBT for years now, so there are just more opportunities for people to train in it.
posted by cotton dress sock at 9:58 PM on May 20, 2015 [1 favorite]
All of it strikes hard, even just reading the dry Wikipedia description, but stumbling on the article was essential to me today.
It's interesting to read through the various acronyms of coping strategies and ponder how you basically are doing a twisted version of this or that thing, but in the perfectly worst drawn out self-indulgent way, or doing the complete opposite and duh of course you're making it worse dumbass, and it's like an instruction manual for how to get out of how you've totally twisted things up and piled on them for years. My last 3-5 years have had too much self-acceptance and burying depression with smugness and overconfidence without much self-improvement along the way and it's interesting and painful to go through layers of development and insight -- I just turned 35 and felt like I turned some corner at 33 that I realize is just a path to another much steeper corner and facing the reality that I was kind of right about needing to change some of the things I insisted on just accepting, and have gone through that cycle many times.
Blahhhhhhhhhh there's a long road ahead. When the author talks about his brother being taken aback by his planning, I recoiled like "duh, of course you have to process all of the pain you cause, amateur, I knew that shit decades ago." At my 35th birthday the other day I was suddenly 23 years old and out of control of sad-anger-blahness Googling whether Wal-Mart sold shotgun shells at 2AM. I ain't going anywhere but it gets scarier the older you get because you're like "ok motherfucker, if you're that underdeveloped and broken still and threatening yourself with stupid horrifying fantasies, sooner or later you probably should do it but that's CRAZY AHH GUILT GUILT GUILT GUILT DUMBASS."
posted by aydeejones at 12:28 AM on May 21, 2015 [5 favorites]
It's interesting to read through the various acronyms of coping strategies and ponder how you basically are doing a twisted version of this or that thing, but in the perfectly worst drawn out self-indulgent way, or doing the complete opposite and duh of course you're making it worse dumbass, and it's like an instruction manual for how to get out of how you've totally twisted things up and piled on them for years. My last 3-5 years have had too much self-acceptance and burying depression with smugness and overconfidence without much self-improvement along the way and it's interesting and painful to go through layers of development and insight -- I just turned 35 and felt like I turned some corner at 33 that I realize is just a path to another much steeper corner and facing the reality that I was kind of right about needing to change some of the things I insisted on just accepting, and have gone through that cycle many times.
Blahhhhhhhhhh there's a long road ahead. When the author talks about his brother being taken aback by his planning, I recoiled like "duh, of course you have to process all of the pain you cause, amateur, I knew that shit decades ago." At my 35th birthday the other day I was suddenly 23 years old and out of control of sad-anger-blahness Googling whether Wal-Mart sold shotgun shells at 2AM. I ain't going anywhere but it gets scarier the older you get because you're like "ok motherfucker, if you're that underdeveloped and broken still and threatening yourself with stupid horrifying fantasies, sooner or later you probably should do it but that's CRAZY AHH GUILT GUILT GUILT GUILT DUMBASS."
posted by aydeejones at 12:28 AM on May 21, 2015 [5 favorites]
People kill themselves more in springtime aydeejones wrote about -- maybe that's because they've got the juice, they'd been so flattened by depression through the grays of winter and now the sun is shining and they've got energy enough to pull the plug, same as when a horrifically depressed person is given an anti-depressant that gives them the clarity of thought and the energy to go on ahead and leap off the roof or whatever.
I don't think that you -- nope, me, I don't know about you -- I don't think that I can talk myself out of this thing. I don't think that I can think my way out of it. God knows I've tried. I've been suicidal off/on throughout my life, kicked off maybe early teens, maybe a bit before then. Not ever that I've wanted to die, really, just that it hurt so fkn bad to be here, to live inside of me here.
I sometimes think of that flick "Being John Malkovich" and how people could climb into him and see what his life was from inside, I feel like that's what I'm doing in my own body, I'm trapped in this crate looking out and it hurts hurts hurts in here.
Better living through chemistry, that's what I've found -- in late 2003 I *finally* found an antidepressant that worked and works for me, after finally having found a mood stabilizer that I could handle and works effectively, keeps the leaps up and down in a smaller frame, not quite so high, not quite so low, and then that anti-d really helps keep it from going too low. So there's that.
Also, human love. I owe my life to Lynn Lichtenfels, a therapist I saw when I had fistfuls of money, and then ran into when my entire world crumbled and crumpled and crashed and I was staggering about, trying to find my way -- Lynn saw me gratis, for over a year, and refused to let me try to pay her -- I couldn't have anyways -- and she refused to let me stop seeking medicinal armistice with this motherfucker. It was perhaps the largest demonstration of unconditional love I've ever seen, or heard of, damn sure the largest that I've been on the receiving end of. Lynn, she was a lover, one of the finest human beings I've ever known. Cancer took her, maybe 8 years go now; any time I think that I'm too busy or too important to help someone, I think of her measure, and while I know I'll never live up to it, it is worth striving for.
Others have loved me, too, and I love others. I can be so flattened, hurting so, so badly, but in speaking with someone else, perhaps someone who needs my help, it can lift me, if even for only that short time. Human love is incredibly powerful and no, I'm not talking here about reaching into someones drawers and fucking/sucking etc, though that's sure an awful lot of fun, but I'm talking about real human love here. People. Get on out shopping, there in The People Store, get you some good ones, some solid ones, they might not be the most sparkly looking ones IE they maybe won't look like they're from Dallas or LA but who the fuck wants them, anyways -- not I. I'll take a warm-hearted friend any day of the week, and no matter if he's missing a button off his shirt...
I still can't believe how big a slice manic depression has taken out of my life. It is awesome, in the truest sense of that word -- I'm in awe. I'm mixed states and it can come and/or go whenever the hell it wants, it gets to have a party in my life any old time it wants, I never even get asked. The most dangerous time of year for me, by far, is autumn -- that thin, fine golden light of autumn, where the air is almost a shiny golden, like that really nice holiday gift wrapping paper -- that light is a red flag for me, one I'd best heed. It's when I run the hottest, it's when mania can and does -- if it wants to -- when mania can just take over the show. And yeah, I'm successfully medicated, but mostly what that means is that instead of jumping just completely anywhere my jumping is now confined, it's cordoned, it gets to jump around still but mostly just inside these certain lines. And thank god for that -- and I do thank god for that, though I also thank the living shit out of the remarkable minds that have formulated these amazing drugs that have saved my ass. Still though, I'm still left leaping hither and yon, I'm bouncing around like a flea jumping 'round in a milk jug.
And plus lots of people think "Oh, mania, it sounds like fun, it sounds so festive and all!" but they don't get it. At all. Yeah, it's festive a lot of the time, and I'm Mr. Smile, and it's great fun to write, to paint, to fuck, to go to museums, to do all these fun things. But mania isn't always festive, consider mixed states: You've got the mood of depression (black, bleak, despairing), the thoughts of depression (I'm a big fat bag of dogshit, I suck, everything sucks, everything always will suck, etc) but you've got mania powering it, you've got this shit mood and these shit thoughts and this incredible energy to force you deeper into it, faster into it. It's like as if it's an airplane hurtling down the runway but then, instead of lifting off, it just keeps on going, smashing through the fences and shit at the end of the runway, smashing through the highways next to the airport, the engines screaming on full tilt even after the fkn thing is a burning pile of shit. It's a total pain in the ass. I fkn hate it. You would too.
Anyways, so I'm in the heat and the heart of that shit and some mope wants me to unhook it by changing my thoughts? Give. me. a. break. Best thing for me to do is to get near people who love my lame ass, and accept me, and with them laugh about the whole goddamn thing. If I'd not learned how to find understanding friends, this shit would have taken me years ago, I'd have blown my brains out, which I almost have anyways...
I go on. Sorry.
tl;dr -- Get you some real human love, some good solid people, no problem if they're missing a button on their shirt. And fight and fight and fight until you find medications to reach medicinal armistice with this jive.
posted by dancestoblue at 4:33 AM on May 21, 2015 [26 favorites]
I don't think that you -- nope, me, I don't know about you -- I don't think that I can talk myself out of this thing. I don't think that I can think my way out of it. God knows I've tried. I've been suicidal off/on throughout my life, kicked off maybe early teens, maybe a bit before then. Not ever that I've wanted to die, really, just that it hurt so fkn bad to be here, to live inside of me here.
I sometimes think of that flick "Being John Malkovich" and how people could climb into him and see what his life was from inside, I feel like that's what I'm doing in my own body, I'm trapped in this crate looking out and it hurts hurts hurts in here.
Better living through chemistry, that's what I've found -- in late 2003 I *finally* found an antidepressant that worked and works for me, after finally having found a mood stabilizer that I could handle and works effectively, keeps the leaps up and down in a smaller frame, not quite so high, not quite so low, and then that anti-d really helps keep it from going too low. So there's that.
Also, human love. I owe my life to Lynn Lichtenfels, a therapist I saw when I had fistfuls of money, and then ran into when my entire world crumbled and crumpled and crashed and I was staggering about, trying to find my way -- Lynn saw me gratis, for over a year, and refused to let me try to pay her -- I couldn't have anyways -- and she refused to let me stop seeking medicinal armistice with this motherfucker. It was perhaps the largest demonstration of unconditional love I've ever seen, or heard of, damn sure the largest that I've been on the receiving end of. Lynn, she was a lover, one of the finest human beings I've ever known. Cancer took her, maybe 8 years go now; any time I think that I'm too busy or too important to help someone, I think of her measure, and while I know I'll never live up to it, it is worth striving for.
Others have loved me, too, and I love others. I can be so flattened, hurting so, so badly, but in speaking with someone else, perhaps someone who needs my help, it can lift me, if even for only that short time. Human love is incredibly powerful and no, I'm not talking here about reaching into someones drawers and fucking/sucking etc, though that's sure an awful lot of fun, but I'm talking about real human love here. People. Get on out shopping, there in The People Store, get you some good ones, some solid ones, they might not be the most sparkly looking ones IE they maybe won't look like they're from Dallas or LA but who the fuck wants them, anyways -- not I. I'll take a warm-hearted friend any day of the week, and no matter if he's missing a button off his shirt...
I still can't believe how big a slice manic depression has taken out of my life. It is awesome, in the truest sense of that word -- I'm in awe. I'm mixed states and it can come and/or go whenever the hell it wants, it gets to have a party in my life any old time it wants, I never even get asked. The most dangerous time of year for me, by far, is autumn -- that thin, fine golden light of autumn, where the air is almost a shiny golden, like that really nice holiday gift wrapping paper -- that light is a red flag for me, one I'd best heed. It's when I run the hottest, it's when mania can and does -- if it wants to -- when mania can just take over the show. And yeah, I'm successfully medicated, but mostly what that means is that instead of jumping just completely anywhere my jumping is now confined, it's cordoned, it gets to jump around still but mostly just inside these certain lines. And thank god for that -- and I do thank god for that, though I also thank the living shit out of the remarkable minds that have formulated these amazing drugs that have saved my ass. Still though, I'm still left leaping hither and yon, I'm bouncing around like a flea jumping 'round in a milk jug.
And plus lots of people think "Oh, mania, it sounds like fun, it sounds so festive and all!" but they don't get it. At all. Yeah, it's festive a lot of the time, and I'm Mr. Smile, and it's great fun to write, to paint, to fuck, to go to museums, to do all these fun things. But mania isn't always festive, consider mixed states: You've got the mood of depression (black, bleak, despairing), the thoughts of depression (I'm a big fat bag of dogshit, I suck, everything sucks, everything always will suck, etc) but you've got mania powering it, you've got this shit mood and these shit thoughts and this incredible energy to force you deeper into it, faster into it. It's like as if it's an airplane hurtling down the runway but then, instead of lifting off, it just keeps on going, smashing through the fences and shit at the end of the runway, smashing through the highways next to the airport, the engines screaming on full tilt even after the fkn thing is a burning pile of shit. It's a total pain in the ass. I fkn hate it. You would too.
Anyways, so I'm in the heat and the heart of that shit and some mope wants me to unhook it by changing my thoughts? Give. me. a. break. Best thing for me to do is to get near people who love my lame ass, and accept me, and with them laugh about the whole goddamn thing. If I'd not learned how to find understanding friends, this shit would have taken me years ago, I'd have blown my brains out, which I almost have anyways...
I go on. Sorry.
tl;dr -- Get you some real human love, some good solid people, no problem if they're missing a button on their shirt. And fight and fight and fight until you find medications to reach medicinal armistice with this jive.
posted by dancestoblue at 4:33 AM on May 21, 2015 [26 favorites]
DBT has been extraordinarily helpful, and I would argue lifesaving, for a family member with bipolar disorder tending heavily toward depression and mixed states. He uses it in concert with other things - CBT, mindfulness, exercise, etc. etc. - but DBT in particular has given him a lot. I'm very grateful that it came into his life, and I wish it had become part of his treatment sooner.
As a strictly-unipolar depressive type myself, I've found some use in CBT and mindfulness but so far DBT hasn't spoken to me as much. But I've got a few books stacked up to read about it, and I'm sure I will find at least a few things in there that I can apply to my own mental health struggles.
(Spring, man. What the hell? Spring just flattens the family member in question. It used to flatten me but in recent years I fell in love with gardening and now spring is when I get to see all the things I planted come back to me, year after year, and watching them grow pulls me through the spring. Sometimes even through the winter - I plant new things each fall partly as a promise to myself that I'll survive to see them thrive come spring. Fucking spring.)
posted by Stacey at 7:49 AM on May 21, 2015 [4 favorites]
As a strictly-unipolar depressive type myself, I've found some use in CBT and mindfulness but so far DBT hasn't spoken to me as much. But I've got a few books stacked up to read about it, and I'm sure I will find at least a few things in there that I can apply to my own mental health struggles.
(Spring, man. What the hell? Spring just flattens the family member in question. It used to flatten me but in recent years I fell in love with gardening and now spring is when I get to see all the things I planted come back to me, year after year, and watching them grow pulls me through the spring. Sometimes even through the winter - I plant new things each fall partly as a promise to myself that I'll survive to see them thrive come spring. Fucking spring.)
posted by Stacey at 7:49 AM on May 21, 2015 [4 favorites]
DBT seems to be unique in taking a structured approach to identifying emotions, tolerating distress, and developing particular skills to deal with embodied feelings and behaviours in the (challenging) moment. CBT (as I've experienced it, anyway) is a little more heady, or centrist, focused on core beliefs - it can be hard to make the link between what's discussed and life as it happens. I also think the B part winds up getting dropped, in practice, a lot of the time.
I found it amusing, and positive, when CBT started incorporating what they call "schemas," because it seemed like practitioners were finally realizing and formalizing that people's pasts do in fact influence their present and maybe looking at that should be part of the treatment goals (after they had spent so much time denigrating Freud). DBT, to me, seems like CBT practitioners now realizing and formalizing that emotions are important, too. Which, again, is positive, and I suspect it'll trick down into CBT protocols, too.
My interested-but-unresearched guess about why DBT is not easily available yet is not only because it's new, but also because it was developed originally to treat Borderline Personality Disorder, which unfortunately still has a great deal of stigma within communities of mental health professionals, and I think it was originally developed as a group-therapy practice, which a lot of practitioners were not set up for, which means individual DBT is even newer than DBT in general, and the idea that it's not just for BPD and not just a group modality is slow to trickle down. It's also confusing, as far as I could tell Googling it this morning, whether one needs a certification to be able to claim to be a Dialectic Behavior Therapist (TM), or if it's more of an orientation, where one can incorporate techniques but not follow the protocol to the letter, as can be done with CBT.
I think there's likely also a bit of tension when incorporating emotional and mindfulness work into a very rigid cognitive therapy protocol, because therapists who thrive with rigid-guideline techniques often don't enjoy (or aren't good at) focusing on the squishier stuff, and vice versa.
posted by jaguar at 8:19 AM on May 21, 2015 [4 favorites]
I found it amusing, and positive, when CBT started incorporating what they call "schemas," because it seemed like practitioners were finally realizing and formalizing that people's pasts do in fact influence their present and maybe looking at that should be part of the treatment goals (after they had spent so much time denigrating Freud). DBT, to me, seems like CBT practitioners now realizing and formalizing that emotions are important, too. Which, again, is positive, and I suspect it'll trick down into CBT protocols, too.
My interested-but-unresearched guess about why DBT is not easily available yet is not only because it's new, but also because it was developed originally to treat Borderline Personality Disorder, which unfortunately still has a great deal of stigma within communities of mental health professionals, and I think it was originally developed as a group-therapy practice, which a lot of practitioners were not set up for, which means individual DBT is even newer than DBT in general, and the idea that it's not just for BPD and not just a group modality is slow to trickle down. It's also confusing, as far as I could tell Googling it this morning, whether one needs a certification to be able to claim to be a Dialectic Behavior Therapist (TM), or if it's more of an orientation, where one can incorporate techniques but not follow the protocol to the letter, as can be done with CBT.
I think there's likely also a bit of tension when incorporating emotional and mindfulness work into a very rigid cognitive therapy protocol, because therapists who thrive with rigid-guideline techniques often don't enjoy (or aren't good at) focusing on the squishier stuff, and vice versa.
posted by jaguar at 8:19 AM on May 21, 2015 [4 favorites]
one of the bruising ironies of therapy is that while it's much more effective if you approach it as a selective consumer, trying to find a good match, it's also far less likely that a person who really needs therapeutic intervention is going to have the capacity to do that well.
posted by lodurr at 8:36 AM on May 21, 2015 [8 favorites]
posted by lodurr at 8:36 AM on May 21, 2015 [8 favorites]
I've just recently finished ~8 months of a structured DBT program. I cannot possibly convey how much it has helped and changed large parts of my life, both internal and external.
Once a week, at $80 each, for 2.5 years.
Ten grand.
How fortunate.
Luckily, I live in a country that actually values healthcare. Paid for by my tax dollars.
The thing that strikes me about DBT is that it seems to be really possible to do on your own, for the most part. Requires some pretty severe self-honesty. Simply starting with the diary card, identifying behaviours and emotional patterns and how they interconnect can be a very, very strong tool. My individual therapist and I tracked a couple things outside of the basic scheme that's laid out, which really helped, and I know that one of the people in the group portion was tracking when they ate--found a not-particularly-surprising correlation between low mood/emotional sensitivity and regular eating patterns. Which is something they knew intuitively, and seeing it down in black and white was a lightbulb moment. That tracking allowed them to work out a more regular eating schedule, which had all sorts of knock-on effects with emotional resilience and managing distress.
(Side note: I have this vague idea for developing an app based around DBT-style tracking of behaviours and emotional states, suggesting skill usage, etc. Programmers, call me.)
For me, the most useful pieces of DBT have been a) radical acceptance, and b) right in the name. The notion that we can hold two opposite thoughts/ideas/emotional states at the same time, and they're both valid, and we can choose to sit in wise mind and thread the middle path between them has been enormously helpful. Indeed, the second piece really informed the first; I can (and have done so) radically accept that a certain person is never going to be in my life in a certain way ever again, and I can be at peace with that while still wanting--not hoping--for it to happen anyway. Or maybe a simpler way to put it: I can accept that eating a tub of chocolate ice cream isn't effective for me right now, and I can want to do it anyway, and holding those two ideas in tension is perfectly okay.
In a lot of ways, DBT is really about approaching life in a mindful fashion. And in some ways, I think everyone could benefit from DBT skills being integrated into school curricula. Ideas around managing distress, being interpersonally effective, living in wise mind--these are ideas, I think, everyone could benefit from. Partly because, I feel, if more people are working from the same playbook it's easier to communicate.
Which isn't to say that DBT doesn't have its pitfalls. It's not a perfect treatment modality by any means--jaguar can opine with far more expertise here--as no modality is perfect. It is pretty darn good though. And one of the key pieces to take away from it is that it's not an all-or-nothing approach. Not every piece works for everyone, and that's okay. The analogy my individual and I came up with was that it's like taking public transit across the city. Maybe I need to get there as fast as possible, so stick to the subway. Maybe it's a gorgeous day out so I want to feel fresh air, and so I'll take buses and streetcars. Maybe it's snowing, so I'll take the streetcar to the subway station instead of walking. Etc. Not every skill works for every person or in every situation; "the right tool for the right job" as Scotty would say. (Or "the most effective tool for the current job," as DBT would say.)
Reframing thoughts and words is also amazingly helpful. Sometimes it can seem like just a matter of semantics, and that in and of itself can be helpful: when I have to stop my thoughts (or spoken/written words) to reframe something in a given sentence, I'm pushed to think "what do I actually mean here? What is it I am trying to say to myself or to someone else? Why 'should' I do this, why am I saying 'but' here?" which reinforces the idea of approaching life mindfully.
posted by feckless fecal fear mongering at 9:54 AM on May 21, 2015 [7 favorites]
Once a week, at $80 each, for 2.5 years.
Ten grand.
How fortunate.
Luckily, I live in a country that actually values healthcare. Paid for by my tax dollars.
The thing that strikes me about DBT is that it seems to be really possible to do on your own, for the most part. Requires some pretty severe self-honesty. Simply starting with the diary card, identifying behaviours and emotional patterns and how they interconnect can be a very, very strong tool. My individual therapist and I tracked a couple things outside of the basic scheme that's laid out, which really helped, and I know that one of the people in the group portion was tracking when they ate--found a not-particularly-surprising correlation between low mood/emotional sensitivity and regular eating patterns. Which is something they knew intuitively, and seeing it down in black and white was a lightbulb moment. That tracking allowed them to work out a more regular eating schedule, which had all sorts of knock-on effects with emotional resilience and managing distress.
(Side note: I have this vague idea for developing an app based around DBT-style tracking of behaviours and emotional states, suggesting skill usage, etc. Programmers, call me.)
For me, the most useful pieces of DBT have been a) radical acceptance, and b) right in the name. The notion that we can hold two opposite thoughts/ideas/emotional states at the same time, and they're both valid, and we can choose to sit in wise mind and thread the middle path between them has been enormously helpful. Indeed, the second piece really informed the first; I can (and have done so) radically accept that a certain person is never going to be in my life in a certain way ever again, and I can be at peace with that while still wanting--not hoping--for it to happen anyway. Or maybe a simpler way to put it: I can accept that eating a tub of chocolate ice cream isn't effective for me right now, and I can want to do it anyway, and holding those two ideas in tension is perfectly okay.
In a lot of ways, DBT is really about approaching life in a mindful fashion. And in some ways, I think everyone could benefit from DBT skills being integrated into school curricula. Ideas around managing distress, being interpersonally effective, living in wise mind--these are ideas, I think, everyone could benefit from. Partly because, I feel, if more people are working from the same playbook it's easier to communicate.
Which isn't to say that DBT doesn't have its pitfalls. It's not a perfect treatment modality by any means--jaguar can opine with far more expertise here--as no modality is perfect. It is pretty darn good though. And one of the key pieces to take away from it is that it's not an all-or-nothing approach. Not every piece works for everyone, and that's okay. The analogy my individual and I came up with was that it's like taking public transit across the city. Maybe I need to get there as fast as possible, so stick to the subway. Maybe it's a gorgeous day out so I want to feel fresh air, and so I'll take buses and streetcars. Maybe it's snowing, so I'll take the streetcar to the subway station instead of walking. Etc. Not every skill works for every person or in every situation; "the right tool for the right job" as Scotty would say. (Or "the most effective tool for the current job," as DBT would say.)
Reframing thoughts and words is also amazingly helpful. Sometimes it can seem like just a matter of semantics, and that in and of itself can be helpful: when I have to stop my thoughts (or spoken/written words) to reframe something in a given sentence, I'm pushed to think "what do I actually mean here? What is it I am trying to say to myself or to someone else? Why 'should' I do this, why am I saying 'but' here?" which reinforces the idea of approaching life mindfully.
posted by feckless fecal fear mongering at 9:54 AM on May 21, 2015 [7 favorites]
How does psychodynamic therapy compare?
posted by Apocryphon at 10:03 AM on May 21, 2015
posted by Apocryphon at 10:03 AM on May 21, 2015
according to my wife (who's an LMSW), psychodynamic as a primary methodology is ineffective for most people. works really well for some -- not so well or not at all for most.
when she was in school for her MSW, CBT was dominant, DBT was increasing in mindshare, but as someone else has said, it just doesn't have as many practitioners yet. The increasing trend among therapists seems to be to take the attitude that you need to do what is going to work for the client, and it won't always be your favorite methodology.
posted by lodurr at 10:50 AM on May 21, 2015
when she was in school for her MSW, CBT was dominant, DBT was increasing in mindshare, but as someone else has said, it just doesn't have as many practitioners yet. The increasing trend among therapists seems to be to take the attitude that you need to do what is going to work for the client, and it won't always be your favorite methodology.
posted by lodurr at 10:50 AM on May 21, 2015
I'm keen to hear jaguar's professional take (not that you should feel obliged to provide it, jaguar! But I always appreciate hearing your perspective).
What I've read (as a nerd) suggests the insight-only approach of many early psychodynamic approaches hasn't always been so successful. Just understanding what happened in one's early life may not be sufficient to facilitate addressing it (although I'm sure it can, for some).
Reading about DBT, though - it seems to pick up on principles of attachment theory (which is broadly psychodynamic, in that it's understood that one's early life experiences generate models of thought and behaviour with enduring influence) and then goes a step further by tackling maladaptive, present-day, interpersonal strategies with behavioural methods, applied to an individual's particular situation/s (together with mindfulness and other techniques that support emotion regulation). I think it's really, really interesting.
(I also have to imagine that the method benefitted from the fact that its developer was herself a sufferer of bipolar.)
I'm super glad, fffm, that it's worked so well for you. (I'm sure I could profit from a number of aspects of DBT for my own issues, which are on the anxiety side of things.)
I think there's likely also a bit of tension when incorporating emotional and mindfulness work into a very rigid cognitive therapy protocol, because therapists who thrive with rigid-guideline techniques often don't enjoy (or aren't good at) focusing on the squishier stuff, and vice versa.
This seems very plausible and agrees with my experience of therapists and therapy.
posted by cotton dress sock at 11:34 AM on May 21, 2015
What I've read (as a nerd) suggests the insight-only approach of many early psychodynamic approaches hasn't always been so successful. Just understanding what happened in one's early life may not be sufficient to facilitate addressing it (although I'm sure it can, for some).
Reading about DBT, though - it seems to pick up on principles of attachment theory (which is broadly psychodynamic, in that it's understood that one's early life experiences generate models of thought and behaviour with enduring influence) and then goes a step further by tackling maladaptive, present-day, interpersonal strategies with behavioural methods, applied to an individual's particular situation/s (together with mindfulness and other techniques that support emotion regulation). I think it's really, really interesting.
(I also have to imagine that the method benefitted from the fact that its developer was herself a sufferer of bipolar.)
I'm super glad, fffm, that it's worked so well for you. (I'm sure I could profit from a number of aspects of DBT for my own issues, which are on the anxiety side of things.)
I think there's likely also a bit of tension when incorporating emotional and mindfulness work into a very rigid cognitive therapy protocol, because therapists who thrive with rigid-guideline techniques often don't enjoy (or aren't good at) focusing on the squishier stuff, and vice versa.
This seems very plausible and agrees with my experience of therapists and therapy.
posted by cotton dress sock at 11:34 AM on May 21, 2015
(I also have to imagine that the method benefitted from the fact that its developer was herself a sufferer of bipolar.)
I have no idea if Linehan has bipolar disorder. She does have borderline personality disorder, which AFAIK was her impetus to create the modality--there wasn't anything around that had any/much effectiveness in treating BPD, so she rolled her own (given her professional qualifications, it wasn't without solid theoretical underpinnings etc). Then put it through studies, etc.
posted by feckless fecal fear mongering at 11:50 AM on May 21, 2015 [2 favorites]
I have no idea if Linehan has bipolar disorder. She does have borderline personality disorder, which AFAIK was her impetus to create the modality--there wasn't anything around that had any/much effectiveness in treating BPD, so she rolled her own (given her professional qualifications, it wasn't without solid theoretical underpinnings etc). Then put it through studies, etc.
posted by feckless fecal fear mongering at 11:50 AM on May 21, 2015 [2 favorites]
Thank you for the correction! My mistake!
posted by cotton dress sock at 12:56 PM on May 21, 2015
posted by cotton dress sock at 12:56 PM on May 21, 2015
What I've read (as a nerd) suggests the insight-only approach of many early psychodynamic approaches hasn't always been so successful. Just understanding what happened in one's early life may not be sufficient to facilitate addressing it (although I'm sure it can, for some).
Reading about DBT, though - it seems to pick up on principles of attachment theory (which is broadly psychodynamic, in that it's understood that one's early life experiences generate models of thought and behaviour with enduring influence) and then goes a step further by tackling maladaptive, present-day, interpersonal strategies with behavioural methods, applied to an individual's particular situation/s (together with mindfulness and other techniques that support emotion regulation). I think it's really, really interesting.
I've not read a lot about DBT so I don't in any way want to present myself as an expert! With psychodynamic therapies, you're right in that earlier versions were more insight-oriented rather than focused on changing behavior. That's really shifted, though, enough that my textbooks from a decade or so ago specifically mentioned the shift toward applying the insights gained to facilitate behavior change, all within a psychodynamic therapy context.
I'm one of those annoying "eclectic" therapists who grabs techniques that seem to work from wherever (though I have underlying unifying theories on why I'm using them in the moment and why it's appropriate for me to grab them), so my tendency is to see similarities rather than differences between therapy orientations, and basically I just see a lot more similarities than differences among pretty much all therapy orientations. I think the similarities get swept under the rug as "common knowledge" (e.g., the idea that one's childhood experiences have a significant impact on the way one relates to others as an adult is the theory underlying psychodynamic therapies, and clients or other therapists will believe that but somehow dismiss psychodynamic therapies as irrelevant), while a lot of the differences get exaggerated as therapists try to market their own version of therapy (which is, I believe, one of the reasons CBT gets so talked up -- the Becks seem to have really good marketing instincts). And as I said above, when there are differences, over time various methods tend to borrow and adopt theories and techniques from each other in order to fill in the blind spots (e.g., psychodynamic therapies focus a bit more on behavioral change while CBT focuses a bit more on childhood experiences).
I really see a lot of what therapists do as re-parenting clients, and teaching clients how to continue re-parenting themselves. And in the same way that what works for one parent-child relationship may not work for another, I don't think there's one "right" therapeutic approach that is appropriate for every single therapist-client relationship. My approach with each individual client is a bit different, in the same way that a parent's relationship with each of their children may be a bit different. A lot of what I do is help clients find balance -- those who are drowning in their emotions may need to learn to find a bit of dry land; those who are suppressing their emotions may need to dive under and see what's there; those who are too trapped in intellectualizing may need to reconnect with their instincts; those who are too impulsive may need to connect to higher-level thinking; and some people veer among all those extremes and need to learn all of the above. And I may be using CBT techniques or emotional processing techniques or visualizations or art therapy or empowerment therapy or psychodynamic techniques or breathing exercises or who knows what, but all in all the goals I'm working toward, no matter how modern the techniques I'm using, tend to look a lot like ancient Eastern philosophies/religions. CBT's "You can't believe everything you think" idea is pretty much straight out of Buddhist thought. A lot of my own formulations for how a psychologically balanced person might be actually came from Tantric philosophy (not the sexual stuff) being taught by the yoga teacher from whom I was taking classes when I started grad school, and every bit of information I read about neuroscience and attachment and mirror neurons and brain development backs up the underlying theories of the mind we learned in yoga.
Which, for me, strengthens my belief in therapy's overall validity even while undermining the idea that the differences in the ways it's (ethically) practiced are important. Human beings have been putting work into what it means to lead authentic, fulfilling, moral lives for millennia, and have been coming up with a lot of the same answers about how to get there and what's important during that time. So I think any form of therapy that focuses on that goal, and uses techniques to get there in competent and ethical ways, is wonderful.
(And none of that negates that some people end up with bad therapists and that some people end up with good therapists who are nevertheless not a good fit for them. Therapeutic orientations and belief systems and techniques matter a lot to the success of an individual client-therapist relationship, even if I don't think they matter much to therapy as a profession.)
posted by jaguar at 1:59 PM on May 21, 2015 [4 favorites]
Reading about DBT, though - it seems to pick up on principles of attachment theory (which is broadly psychodynamic, in that it's understood that one's early life experiences generate models of thought and behaviour with enduring influence) and then goes a step further by tackling maladaptive, present-day, interpersonal strategies with behavioural methods, applied to an individual's particular situation/s (together with mindfulness and other techniques that support emotion regulation). I think it's really, really interesting.
I've not read a lot about DBT so I don't in any way want to present myself as an expert! With psychodynamic therapies, you're right in that earlier versions were more insight-oriented rather than focused on changing behavior. That's really shifted, though, enough that my textbooks from a decade or so ago specifically mentioned the shift toward applying the insights gained to facilitate behavior change, all within a psychodynamic therapy context.
I'm one of those annoying "eclectic" therapists who grabs techniques that seem to work from wherever (though I have underlying unifying theories on why I'm using them in the moment and why it's appropriate for me to grab them), so my tendency is to see similarities rather than differences between therapy orientations, and basically I just see a lot more similarities than differences among pretty much all therapy orientations. I think the similarities get swept under the rug as "common knowledge" (e.g., the idea that one's childhood experiences have a significant impact on the way one relates to others as an adult is the theory underlying psychodynamic therapies, and clients or other therapists will believe that but somehow dismiss psychodynamic therapies as irrelevant), while a lot of the differences get exaggerated as therapists try to market their own version of therapy (which is, I believe, one of the reasons CBT gets so talked up -- the Becks seem to have really good marketing instincts). And as I said above, when there are differences, over time various methods tend to borrow and adopt theories and techniques from each other in order to fill in the blind spots (e.g., psychodynamic therapies focus a bit more on behavioral change while CBT focuses a bit more on childhood experiences).
I really see a lot of what therapists do as re-parenting clients, and teaching clients how to continue re-parenting themselves. And in the same way that what works for one parent-child relationship may not work for another, I don't think there's one "right" therapeutic approach that is appropriate for every single therapist-client relationship. My approach with each individual client is a bit different, in the same way that a parent's relationship with each of their children may be a bit different. A lot of what I do is help clients find balance -- those who are drowning in their emotions may need to learn to find a bit of dry land; those who are suppressing their emotions may need to dive under and see what's there; those who are too trapped in intellectualizing may need to reconnect with their instincts; those who are too impulsive may need to connect to higher-level thinking; and some people veer among all those extremes and need to learn all of the above. And I may be using CBT techniques or emotional processing techniques or visualizations or art therapy or empowerment therapy or psychodynamic techniques or breathing exercises or who knows what, but all in all the goals I'm working toward, no matter how modern the techniques I'm using, tend to look a lot like ancient Eastern philosophies/religions. CBT's "You can't believe everything you think" idea is pretty much straight out of Buddhist thought. A lot of my own formulations for how a psychologically balanced person might be actually came from Tantric philosophy (not the sexual stuff) being taught by the yoga teacher from whom I was taking classes when I started grad school, and every bit of information I read about neuroscience and attachment and mirror neurons and brain development backs up the underlying theories of the mind we learned in yoga.
Which, for me, strengthens my belief in therapy's overall validity even while undermining the idea that the differences in the ways it's (ethically) practiced are important. Human beings have been putting work into what it means to lead authentic, fulfilling, moral lives for millennia, and have been coming up with a lot of the same answers about how to get there and what's important during that time. So I think any form of therapy that focuses on that goal, and uses techniques to get there in competent and ethical ways, is wonderful.
(And none of that negates that some people end up with bad therapists and that some people end up with good therapists who are nevertheless not a good fit for them. Therapeutic orientations and belief systems and techniques matter a lot to the success of an individual client-therapist relationship, even if I don't think they matter much to therapy as a profession.)
posted by jaguar at 1:59 PM on May 21, 2015 [4 favorites]
I really see a lot of what therapists do as re-parenting clients, and teaching clients how to continue re-parenting themselves.
That... is really profound, and making me think about my interactions with my therapist in a totally new (and positive) light. Thank you for that.
posted by feckless fecal fear mongering at 3:05 PM on May 21, 2015 [1 favorite]
That... is really profound, and making me think about my interactions with my therapist in a totally new (and positive) light. Thank you for that.
posted by feckless fecal fear mongering at 3:05 PM on May 21, 2015 [1 favorite]
I was just reading an article (pdf) on dual relationships in therapy, which isn't super relevant, but this bit of the conclusion may be:
posted by jaguar at 3:08 PM on May 21, 2015 [2 favorites]
The dumbing down of psychotherapy naturally starts in graduate schools where techniques, orientations, research methods, statistics, and risk management are the focus of learning without a balancing emphasis on anthropology, philosophy, comparative religions, critical thinking, or compassion, empathy, and intimacy. Although technical and scientific knowledge are an essential part of psychotherapy, we also know that techniques by themselves count for only a minimal variant in therapy (Lambert, 1992; Bergin & Garfield, 1994). Even though the literature has repeatedly concluded that the therapeutic relationship is the best predictor of clinical effectiveness (Frank, 1970; Norcross & Goldfried, 1992), courses that concentrate exclusively on the intimate relationships between therapist and client beyond concerns with transference and countertransference are rare.The bit on "without a balancing emphasis on anthropology, philosophy, comparative religions, critical thinking" ties in, I think, with what I've been seeing. There sometimes seems very little realization among therapists that the techniques they're developing or the theories they're espousing exist in other fields, often in much more nuanced ways.
Graduate school professors endlessly quibble about which orientation is superior rather than teach students to intervene according to the client's condition, situation, personality, and culture. As a result, instead of thoughtful, knowledgeable, and sensitive therapists who are able to think critically, form intimate connections with their clients, and effectively employ proven clinical interventions, graduate schools mostly spit out highly technical, ethically and morally insensate, frightened, and theoretically rigid therapists. In a similar manner, licensing focuses on abstract knowledge of research methodologies, techniques, and ethics and law rather than going through the much more difficult process of also evaluating therapists for the capacity for empathy, self-awareness, emotional health, and critical thinking. Given our graduate education and licensing methods, the dumbing down of our profession is virtually assured.
posted by jaguar at 3:08 PM on May 21, 2015 [2 favorites]
That... is really profound, and making me think about my interactions with my therapist in a totally new (and positive) light. Thank you for that.
Thanks! Totally not originally mine; I think one of my professors presented it as a concept, but I don't think it was original to her, either. It's a framework that helps me remember my job is to help clients move toward independence, rather than fostering any long-term dependence on me.
posted by jaguar at 3:10 PM on May 21, 2015
Thanks! Totally not originally mine; I think one of my professors presented it as a concept, but I don't think it was original to her, either. It's a framework that helps me remember my job is to help clients move toward independence, rather than fostering any long-term dependence on me.
posted by jaguar at 3:10 PM on May 21, 2015
It's a really interesting framework. I can see how it could be difficult/counterproductive to introduce the concept to a lot of clients though.
posted by feckless fecal fear mongering at 9:45 PM on May 21, 2015
posted by feckless fecal fear mongering at 9:45 PM on May 21, 2015
Oh, yeah, I never frame it that way to clients -- no, I take that back, I do often talk about how they need to learn to parent themselves, especially if they have childhood traumas that they're working on. But while I think of myself as teaching and modeling (self-)parenting skills, I don't think of myself as my clients' parent, and that would get messily projecting to explain, so I leave that part out. I do think that the "unconditional positive regard" (to steal a phrase from Carl Rogers) that therapists give to clients is a parental framework, though, so that relationship is just there, even if not acknowledged.
posted by jaguar at 9:58 PM on May 21, 2015 [1 favorite]
posted by jaguar at 9:58 PM on May 21, 2015 [1 favorite]
It has been more overwhelmingly helpful and amazing than I can ever express to learn that spring is the bad time of year for other people too. I have lived my entire adult life thinking that I was some horrible fucked up outlier. Thank you metafilter.
posted by zinful at 12:58 AM on May 22, 2015 [1 favorite]
posted by zinful at 12:58 AM on May 22, 2015 [1 favorite]
« Older English 111 / Comp Lit 115 | The Empathetic Camera Newer »
This thread has been archived and is closed to new comments
It's possible that Schizoaffective Disorder and Schizophrenia are part of that spectrum though they are classified as affective disorders that trigger psychosis and can affect mood, while bipolar is a mood disorder that can negatively affect affect and trigger psychosis as a result of mood swings, sleep deprivation, etc.
The lifelong back-in-your-mind suicidal thing and everything else in the article struck me like it was written for me to read. I was reading something else and hit one of my arrow keys and suddenly was paralyzed. And when he wonders about springtime and suicide, I can say with confidence that the answer lies in the mood lifts (and often swings or mixed states) that come with the springtime, and just as full-on-mania can give a lifelong struggling-with-depression-and-the-aftermath-of-mania person the confidence to go forward with a no-cry-for-help style suicide, so can a light touch of springtime "holy crap I love everything" hypomania accompanied by self-talk about how it'll be winter before you know it and nobody really understands you anyway.
posted by aydeejones at 6:48 PM on May 20, 2015 [13 favorites]