What I have learned from DBT: Suicide

What I have learned about suicide from DBT is hard for me to portray with succinct phrases.  

The first lesson was that suicide must be off the negotiating table with the client.  With suicide as a legitimate option, it is very hard to move forward into building a life worth living.  

In looking at it scientifically, there is no evidence that suicide will make life any easier.  Common beliefs are that "all of my problems would be over if I were dead" and "my pain would stop if I killed myself."  Both lack evidence to support these claims.  Perhaps you could look at the dialectic, asking what would make life harder if you tried to kill yourself. 

The second lesson was that knowing the suicide and risk assessment protocols are essential, with both classmates and clients.  Knowing how to respond to these issues can save lives.  The questions can be awkward and seem like an attack, but I imagine that the benefit of helping the suicidal person get the care she needs outweighs the risk of awkwardness.

The third lesson is that mind-reading with sick people is not effective: "You only know until you ask" and are open to their point of view.  It can be harder with individuals with borderline personality disorder because masking emotions can be a part of how they regulate their emotions.  At times, the facial expressions reflect what the borderline individual wants you to see, like putting on a smile when you feel horrible and sad on the inside.  The internal state and the external expression may not always match, so it is important to probe and explore these emotions and emotional reactions.

I will look forward to adding to this list as I continue in my DBT training.  Until then, think about the lessons you've learned from working with suicidal individuals.  Let me know what you think!

 

Recovery and Radical Acceptance- Day 11 of the Countdown to the DBT Training at Menninger Clinic

"My grace is sufficient.  My power is made perfect in your weakness."   The story of acceptance begins here.  We are fundamentally imperfect...and that's okay.  Perfection is an impossible goal, one that leads to frustration, recognition of inadequacy, and the pain that accompanies there realizations.  It is resolved in radical acceptance.  

Radical acceptance is essential.  Marsha Linehan describes radical acceptance as a continual process, one that rises with us in the morning in the choices and decisions we make.  Radical acceptance is not easy; to me, radical acceptance is the hardest skill to use in a tough, emotionally-charged situation.  People make decisions we don't like.  People treat us unfairly.  Even our decisions can backfire and block our paths toward a life worth living.  Our own actions may reflect our Rational Mind and Emotion Mind states.  Wise Mind helps us to find acceptance of self and others.

Recovery comes when application and action meet Wise Mind, radical acceptance, and chain-breaking freedom.  Acceptance is critical in recovery, whether the condition is open heart surgery or bipolar disorder.  Life can be classified as before, overwhelming struggles, moments of clarity, hope for change, and walking forward.  Like the scar, there are physical reminders of what happened.  

Acceptance fits in the process of knowing that there will be lifestyle changes and this process cannot be rushed.  You sit with acceptance.  You release the grip of what is holding you back from living a life worth living.  But life truly begins when you let go, opening your hands to receive grace and mercy.  Acceptance and owning this acceptance aren't especially different, except in degree and effect size.  

Owning acceptance is a path to freedom, moving the focus away from the pain of the past and into the uncertainty of the present and near future.


  

The Dialectic of Life, Loss, and Acceptance

I wrote this poem this morning.  Loss is a tricky concept because even when the person departs, our shared memories and truths that we know in our bones live on and walk with us.  When radical acceptance comes, the dialectic is more salient and, at times, comforting in the darkest of times. 

For some, the time before dawn is the darkest hour...logically yes, but the dawn is troubling, too, because it can be a recognition of beginning another day without them.  

The Zen response to this may be that "all is as it should be," yet that is not say that everything is perfect in the moment, "but rather to the dependent unfolding view of reality (given the pre-existing conditions, how could things be different?) and the recognition of valuation as human-generated rather than universally intrinsic (perfect for whom, based upon which criteria?)."  This concept is explored in Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition (Robins, Schmidt, & Linehan, 2004, p. 38).

 

Let's look at Marsha Linehan's point of view on acceptance.  "The experience of acceptance. . .is that of 'getting it,' opening oneself to the context, striving to wait for understanding rather than leap in precipitously, acknowledging distress as an outcome. . .rather than as a problem to be solved. . .Thus, acceptance as a state or experience may reflect the wisdom of wanting to gather rather than disperse, catching the context while enduring the moment"
(Robins, Schmidt, & Linehan, 2004, p. 38). 

The dialectic of loss is difficult for me, and I know that I'm not alone in this.  Although we may not see them, their influence lasts a lifetime.  

In us, the stories and legacy continue and cannot die.

I rose before dawn to talk to you.

It is in darkness that I see you with clarity,

And hear your voice in my head,

And feel your support in helping me move forward.

Your hands reach for mine.

My heart reaches for your sure hands

And seeks that knowing smile.

I talk to you and imagine

That you just heard my voicemail,

Just like always.

My mind can only hope for so long,

But my heart refuses to give in to the reality

That you’re not with me.

I miss you, but this is not a time for goodbyes,

Only see you soon.

And it is a time to look forward

To our next time,

And it will be so.

For a more in-depth approach to acceptance and mindfulness, check out 
Mindfulness and Acceptance: Expanding the Cognitive-Behavioral Tradition

 

"Brokenness is not the end of the story"

"Brokenness is not the end of the story.  Our pain is deep, but it is not all-encompassing; our loss is enormous, but it is not eternal; and death is our enemy but it does not have the final word."  - Ruth Padilla Eldrenkamp

For individuals with borderline personality disorder, belief in the idea that they are broken may be common...broken hearts, broken relationships, and perhaps a broken sense of self. "Getting fixed" may be a proposed treatment goal by the client, but it is a mistaken goal because healing, radically accepting yourself in the moment and recognizing the need and drive to change may be more helpful.

Defining and labeling yourself with the challenges you have experienced is counterproductive in strengthening your view of self.  Focusing on the brokenness and awfulness of illness takes the focus away from the steps of finding balance and realizations of what is going well.  

Marsha Linehan has described having BPD as lacking emotional skin.  Our emotional pain can be excruciating, with each touch as painful as a third degree burn.  Reacting to pain is understandable.  Emotional regulation and distress tolerance skills can help to ameliorate the pain and decrease suffering.  These skills can create adaptive changes that guide the process of building a "life worth living."  

"Brokenness is not the end of the story."  There is hope.  There is freedom.  There is recovery.  I have no doubt in these simple truths.

Life of Pi

So many individuals who seek treatment are looking for hope and a way out of the darkness.  I know that there is a flicker of hope remaining in even the most suicidal of people.  The flicker of hope can be a sense of longing for something to be different, for someone to leave, for something to come back, for someone to come back.  

This flicker of hope is awesome news because "therapy doesn't work on dead people" (Marsha Linehan, 2011).

I saw "Life of Pi" this afternoon.  His suffering was great and his hope was ebbing away from weeks at sea. 

Pi Patel: [Pi and Richard Parker in the boat when they're about to leave the island] No one has seen that island since, and you'd never read about those trees in any book. And yet, if I hadn't found those shores I would have died, if I hadn't discovered that tooth I would have been lost alone forever. Even when God seemed to have abandoned me, he was watching. Even when He seemed indifferent to my suffering, He was watching and when I was beyond all hope of saving... He gave me rest and gave me a sign to continue my journey... 

It is true, the darkest hour is right before the dawn.  Don't give up on your clients.  Help them find hope.  Help them find healing.