DBT thoughts again……and self-harm thoughts

Long time readers of this blog know I have complicated feelings on DBT. These feelings have evolved continue to evolve.

Where I am at now is that I think DBT has a lot to offer but that it is not perfect. Part of me feels robbed that I was kicked out of DBT as a high schooler. I think at that time I could have benefited from the skills taught there. But since I was too anxious to complete coaching calls and didn’t want to stop self harming I wasn’t allowed access to the parts of DBT that could help me. Further complicating the matter is that the DBT I got wasn’t 100% adherent but still by calling it DBT it made me never want to try DBT again. And to be fair even in really DBT I’d have run into the same issues, though I do think a better therapist could have handled it better.

I have a big problem with the idea that non-suicidal self injury is considered a therapy interfering behavior. I feel like there are cases where it can be therapy interfering, but unilaterally across the board saying that is it always therapy interfering feels black and white in a way that in inconsistent with the philosophy of DBT. I’ve done best in treatments where clinicians pay very little attention to my non-suicidal self-injury. I guess on some level that make DBT a bad fit for me because DBT is a behavioral therapy and self-injury is a behavior.

DBT is coming up a lot for me of late. I got an email forwarded to me a couple weeks ago authored by my former DBT therapist advertising a job. It’s tough seeing him in a high level job when the way he handled things with me caused me harm.

I’m currently in a training for DBT. It’s ……. It’s ….. an experience. I can see how so many clinician’s full force jump in and drink the DBT cool-aid. There are aspects about it that are amazing and the person leading the training is a very skilled clinician. But there are places where some things get expressed and I’m like hmm I don’t feel great about that even though you presented it in a way to make it sound great. It’s not always things I can put my finger on to articulate where it feels off.

Being in this training is bringing up a lot of feelings. Honestly of stronger intensity than I would have expected. My mood on average is so much more level now a days than back when I began this blog. But sometimes I get a rush of emotions and it reminds me ‘oh yes I used to feel like this everyday.’ Some of these things it kind of amazes me how strong it can be given the amount of time passed. I still really feel anger towards that DBT therapist. I also feel angry at a system that was focused on getting me to stop self harming at the expense of the chance to learn skills that might have helped me reduce self harming as a side effect.

It’s taken years. A lot of years. But in the past several months I have gotten to a place where I am actually really looking to make changes with my self-harm. This is a desire for change that is coming from me with no one else putting pressure on me for it. I have self-harmed for more than half of my life without trying to quit. It’s strange to be in a place where I am actually trying.

It’s harder than I expected.

Let’s back track a little first though.

Why now?

I’ve felt for years that for self-harm that is in moderation and not presenting a serious danger to self that telling someone to not self-harm is driven mostly by moralistic beliefs about it being wrong to hurt yourself. Obviously I know better than to communicate this idea in my professional life. But I really do this there is at least a kernel of truth here. Especially if a patient is not wanting to stop. I think folks treating self harm could benefit a lot form borrowing harm reduction ideas from substance use disorder interventions.

So why stop now? I have lots of scars so at this point stopping isn’t going to make my legs ever look normal.

Reasons to stop self-harm:

  1. I have been telling myself for the past year that since I was probably going to get DBT training if I do DBT therapy I need to be making a real effort to stop for myself. DBT wants clinicians to be genuine and I can’t do that if in the back of my mind I’m thinking about how I am still self-harming but holding my clients to higher standards.
  2. It not unusual for me to skip a month if things are going well but I got a string of a couple months and now and maybe at 4-ish months (I didn’t track the last date I did it so not 100% sure it could be longer) so I have some momentum.
  3. I have moved somewhere warm and am wearing shorts a lot. Normally I wear long pants most days but here that’s just not realistic. I’m okay if scars are slightly visible because if seen I can say they are old. But I’m not going to feel comfortable showing fresh cuts.
  4. Joiner’s interpersonal model of suicide argues that acquired capacity is is factor that is needed to die by suicide. Non-suicidal self-injury is one way that acquired capacity increases. Basically self-harm causes you to become habituated to the idea of harming yourself putting you are greater risk over time of death by suicide. There’s a little more to the model than that but I won’t go into it here.                           I think this is important because from my perspective this is the only non-moralistic argument against NSSI that applies globally to anyone engaging in NSSI. Basically, even though it is non-suicidal it puts you are greater death by suicide when you have another time in your life where you are thinking of acting on thoughts of suicide. It’s an unintentional side effect that could increase risk of death when a suicide attempt is made.

 

So this is where I am. I’m at a place where the reasons to quit are at least a teensy bit stronger than the reasons to continue it. I’m letting myself be okay with not being perfect with it. I’m trying not to do it, but also realize that I might self-harm that that that is okay if it happens.

It’s much harder than expected. I thought it would be easier because my self-harm frequency does vary a lot. Going a month without is not unusual nor is doing it several times in one week. But right now is the longest time I’ve ever tried not to do it. In the past I’ve made myself pause it for things like women’s health visits etc.  You have to realize I’m a person who self-harmed with razor blades I snuck in when I was hospitalized and self-harmed without getting caught even on 1 to 1 observations during 3 different admissions. If I’ve wanted to do it I’ve found a way but I have also been able to not do it when needed like the above example of women’s health visits where fresh cuts would maybe been seen (though I’m good at hiding them too with the paper gown, it’s more stressful).

I’ve had evenings where I felt like I was crawling out of my skin in tension. Physical tension is the biggest cue for me to self-harm. I’ve been trying to exercise as a strategy, but ended up injuring myself from pushing too hard.

I’m handling this mostly on my own. I’m not seeing my new therapist (#30) often because of a mix of financial constraints and time constraints.

There is something amazing and specific about where I live that has brought me an immeasurable amount of joy and that is helping me cope. I wish I could share the specific thing here, but it would make my location too identifiable. But trust me if you knew the thing, it would be very clear why it is helping me. I go to this place at least once a week and it feels like a reset switch on any stress I’ve been feeling. I feel so lucky to have access to this place and frankly it is one of the best things that has ever happened to me.

But it’s tough. I’m in a new place. In a new job. And I’m working on making a big change without much support. I have tons of book knowledge about things to help me but it’s not always the easiest to apply to yourself.

I can’t help but wonder the different trajectory I’d have been on about this if DBT had been more flexible with me 13+ years ago. I’m stubborn so maybe it wouldn’t have mattered. It’s certainly not constructive going through these what-ifs but they are popping up as I go through this DBT training.

 

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