ABC DBT

This past winter I decided to break up with my therapist, which was a terrible idea except it wasn’t. It was terrible because breaking up with your therapist is the WORST. It’s like breaking up with a really good friend, someone you have an established relationship with, who knows all of your deepest, darkest shit, and who has invested time and brain power in helping get said shit sorted out. And then you break up. I chose to break up based on the hope that I might find a friend I liked better and who liked me and who might be able to help with the sorting more effectively.

There’s no real good way to find a therapist, at least I haven’t found one yet. My insurance company directory is entirely unhelpful because most mental health care providers don’t take insurance. The system is prohibitively complicated and costly, in terms of time and resources, for sole practitioners, and even groups of therapists, to become certified as “in network.” So there’s Google and Yelp and Psychology Today and word-of-mouth and referrals. I found my very favorite therapist in the whole wide world through her ad on Psychology Today. But eventually she broke up with me because I was too crazy. I mean, she made a very thoughtful, professional, and kind decision to recommend I seek treatment from someone with expertise in bipolar disorder and even found me someone with such expertise, but samesies.

Still, she is my very favorite and if I couldn’t have her I wanted to know who she thought I should have. She gave me two names. One had a waitlist, the other is my new best therapist friend since January.

I like my new friend for many reasons but a huge plus has been the fact that she is a DBT therapist. DBT, or Dialectical Behavior Therapy, is a modified form of your standard, white bread Cognitive Behavioral Therapy developed in the 1980s to treat people with Borderline Personality Disorder (BPD). It has since been expanded to treat all sorts of disorders, including mood disorders like bipolar. It’s also super helpful with substance abuse and suicidal ideation, so I’ve got my bases covered.

DBT involves working with both acceptance and change through the principle of dialectics. Dialectics, in really basic non-philosophical terms, means two things that appear to be opposites, or at lease contradictory, that can both be accepted as true or reconciled in some fashion. My favorite starter example from DBT is: (1) I am doing the best I can, and (2) I can do better. These are both true. For me and, I’d wager, for most of us.

DBT is chock full of these seeming conundrums that are actually simply true. Two which are particularly apropos to me are the concepts of active passivity and apparent competence. Active passivity means I work really hard to get other people to make decisions for me. Apparent competence means I am really competent at certain parts of life and, therefore, appear to be competent at most parts, when in fact I am not competent at all. Fun!

DBT has four major components or “modules,” which are core mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. You had me at distress tolerance. 

Tolerate distress? Yes, please. Sign me up for how to do that because I have a zero tolerance policy when it comes to distress, particularly distress related to my marriage or my children. Also, my job and body image. Pretty much bad tolerance all around. Lucky for me, this was one of the first modules covered in my DBT skills group. 

To start, I was a bit dismayed to learn I couldn’t just distress tolerate my way through daily life, but was supposed to use my skills only for significant emotional crises. Apparently, living at crisis-level anxiety all the time requires making significant life changes. Go figure. Still, I have a lot of significant emotional crises and the skills I’ve learned have come in quite handy. Some also make great party tricks.

For instance, there is the TIP skill (DBT loves it some acronyms). The T in TIP stands for temperature. It’s based on something called the mammalian diving reflex and is a way to calm down quickly. So, if you’re having a panic attack, or want to impress your friends, grab a big bowl, fill it with ice and water, make sure your fitness tracker is working, hold your breath, and stick your face in. Stay down for at least 30 but as close to 60 seconds as you can get. Assuming you are a mammal, your heart rate will drop immediately and your parasympathetic nervous system will be activated, further prompting a relaxation response. It works. I’ve tried it. A number of times. Obviously, its not always possible or convenient to stick your face in a big bowl of ice water but when it is, do it. 

Another, less intense but perhaps even more useful distress tolerance skill is STOP. Now, this is probably going to sound really simple but in my experience it is not simple at all. It is not easy to do it or even remember to do it when things seem to be going to hell in a hand basket. But I try. 

For example, I have a tumor in my shoulder. A very small, very benign tumor that really, really hurts a lot of the time. I have not had surgery yet because my insurance company sucks (double bird salute Empire BCBS). In the mean time, I have been prescribed Valium, both for my anxiety and for the muscle spasms associated with the tumor. I was prescribed 3 pills a day but taking that much was really messing with my depression, among other things, so I decided to cut back to two. Except holy hell it really hurts.

So, this was my crisis. Pain. Physical pain and all of the emotional and psychological pain that I like to pile on top of it. A pain hamburger, with the works, plus fries. When it hits, and all I want to do is take that third pill, I try (not always successfully, but more often than not) to STOP. I stop, freeze, just stand there in the middle of the room half way to my prescription bottle. I take a step back, mentally and sometimes physically, from where I was going and from the overall situation. I observe, what I’m feeling, thinking, doing, what’s going on in my environment and with the people around me. I also think about my options (I know, cheating with the two o’s). What might I do do instead of taking medication that could possibly help me feel better/less overwhelmed/more able to get through the rest of my day? Finally, I proceed mindfully. I take all the inputs, thoughts, feelings and I choose a path that seems right.

My favorite/least favorite distress tolerance skill is radical acceptance. Again, radical acceptance is deceptively simple. Basically, you accept life as it is. But by that I mean you really accept it, mind, body, and heart, not only as it is but also as it is not. You accept reality is not and cannot be something else. There are no shoulds with radical acceptance. There are no whys or if onlys or buts or what ifs. What has happened is not reality. What might happen is not reality. Reality is the present moment, the present minute, and it is what it is. Period.

You must accept reality because (1) you have no choice and (2) it is the only way forward. You can only effectively live your life grounded in what is real and true and present. Flailing around because what is real and true and present isn’t fair or right or something you can handle because-you-just-can’t-with-it-right-now-so-please-make-it stop won’t work. It is just flailing. Even if reality isn’t fair or right or something you can handle, it is still true. And the only hope you have of changing it is to start from that truth. Otherwise, you’re just titling at windwills.

I struggle with radical acceptance. A lot. I like to tantrum about life, the big parts and the small. For six years, I have been having a low-grade panic attack because I have failed to accept that my house cannot be as clean as it was before I had children. I am currently failing to accept that returning to my job is is negatively affecting my mental health and my relationships. Instead, I show up each day conviced that its me, not them, and if I can just be better it will work out.

Once, I spent about six weeks not fully accepting the fact that I had two newborns. I kept talking about how much easier things would be if there was only one red-faced, screaming banshee attached to my chest or failing to sleep through the night until finally my mom took me (gently) by the shoulders and whispered-screamed, “There are two. You have two babies and, unless you plan on taking one back, you will always have two. So stop. You are only making it harder.” And I was making it harder, with my constant imagined scenarios of easy outings with a single stroller, or god forbid, a baby  bjorn, instead of a truckload of gear requiring two sherpas and a donkey. So, I stopped. And, eventually, it got better. It was still really, really hard to have two newborns, but at least I wasn’t living side-by-side with the imaginary world in which I had only one. It was hard, but not harder in comparison to what wasn’t real.  

There is so much more to DBT than distress tolerance. So many modules! So many skills! I go to therapy for three hours every week: one hour individual therapy and two hours group. I have skills homework due each Monday. I complete a diary card with approximately 15 categories of how I’m feeling and what I’m thinking on a scale of 0-5 every night. I talk to or text my therapist throughout the week. I am often exhausted of my own thoughts and feelings and distress and tolerance of said distress (or not). But it’s helping. I feel better in the sense that I see more of what’s happening and I can name it and be less judgy and instead give myself some grace and a better place to settle and regroup before I try again. I get up. Then I get knocked down, or I knock myself down. I get up again. I accept that this is my life right now. I am doing the best I can and I can do better. 

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