Anyone for EBT ... ?

I agreed to write this joint post with lovely Ms Melancholy, of Confessions of a Psychotherapist, after reading a post by PatientGuard: Borderline Personality Disorders Treated With Elastic Band NHS Therapy In The UK.

I am fortunate not to have Borderline Personality Disorder, but I have lost count of the number of mental health professionals who have, in their best I really do care voice, asked me whether I have ever tried pinging an elastic band against my wrist.

Or drawing on myself in red pen.

Yes, really – people who claim to have all sorts of levels of expertise in mental distress, will sincerely encourage me to try drawing on myself with a red pen instead of cutting myself.

They actually become quite irritated when I don’t put these two helpful suggestions into practice.

People cut for all sorts of reasons, none of them trivial. After decades of doing it, it’s no longer possible for me to quantify or qualify why I cut. It would be like trying to write a comprehensive list of reasons why you love your best friend.

Don’t get me wrong - cutting is not my friend. I’m not extolling its virtues, I don’t think it’s big or clever. But, for us choppers, it is reliable as a coping mechanism. And, as Ms M points out in her thoughtful post about self-harm and therapy from the therapist's perspective, most people who self-harm find that on some level it is what soothes them. Soothes them in moments of otherwise unbearable emotional discomfort. Restores them to calm and control in times of extreme turmoil. (Apparently some even get an orgasm-like kick - that’s not me).

If you present to your GP and manage to confess that you self-harm – something which takes a great deal of courage because generally the response to people who self-harm is still that we are attention seeking nuisances – you will be most likely offered a short course of CBT.

That CBT will endeavour, within six to ten weeks, to teach you to challenge negative thinking with positive thoughts, to use distraction techniques to ride out difficult emotions, and to substitute elastic band pinging for actual self-injury.

I can just about imagine the elastic band thing working for me if I was pinging it directly into my eyeball. A red pen could be useful if I snapped it in half and shoved it through my hand.

Anyway … I believe that CBT primarily provides an additional set of sticks with which a self-harmer can then beat themselves up mentally for not being able to put the ‘solutions’ into practice. We are already quite good at this; we don’t need additional training!

So, if the CBT ‘solutions’ don’t work – what does?

My own experience of working with four therapists in relation to self-harm has been that it is absolutely key that the therapist doesn’t try to offer these ‘solutions’ to substitute for self-harming. I had an initial false start with a therapist who wasn’t prepared to accept my coping mechanism, was an advocate of elastic band therapy (EBT) and wanted to enforce a contract that prevented me from cutting. I was lucky to find a creative and very open therapist who was willing to put aside her own natural discomfort and believed that cutting was too complex and too central to my identity and way of being in the world to simply cast aside.

The single most important thing she gave me was a space in which I could express my thoughts and feelings in relation to cutting and not be alone. Most self-harmers spend a huge amount of energy either hiding their behaviour or reassuring others about it. We are told, repeatedly, how distressing it is for those who care about us. We know this. I personally feel huge guilt about the concern that I cause to people who are close to me, and frustration that this doesn’t automatically prevent me from doing it. So, even in therapy, I feel a duty to protect my therapist from worrying about my physical safety – an instinct to not discuss it, in case I cause her upset.

Given that alcohol is a factor in at least 1 in 4 admissions to A&E, and that 1 in 4 adults in the UK regularly binge drink, I sometimes wonder whether there is something very artificial and socially constructed about this need I feel to protect my therapist from worrying about me. I know that many of my friends who have been in therapy would see a good session in the pub as a perfectly justifiable response to a difficult therapy session, and yet I doubt that they feel a responsibility to reassure their therapist that they are not being unsafe, or that their therapist would suggest drinking pints of Ribena, instead of beer, as an ‘alternative’.

I have had the most positive experiences in therapy in the moments when my therapist is able to be real about the dilemma they face – between on the one hand wanting me to be physically safe, and on the other hand believing that a coping mechanism does what it says on the tin. That’s ok - I want to be cared about.

If both therapist and client are able to accept that the dilemma exists equally on both sides, that there is a lot of examination that can be useful, but there will never be a ‘why’, that there is no ‘solution’ – simply a (very) slow growth in tolerance of emotional discomfort, until the need to use cutting to soothe and reintegrate is diminished – then you’ve got a hope of doing the work that will eventually make cutting less influential.

There are things your therapist says to you that stay with you forever, perhaps initially stinging and burning before later returning as a calm clear voice that points the way in times of confusion. I did not know at the time which of my therapist’s words would be so important to me. I am almost certain that my therapist couldn’t predict which of her sentences I would carry with me, and which would be left in the room. Most of those that echo were said in moments of intense honesty – in which one or both of us was frustrated, or teasing, or a mix of the two.

I don’t believe CBT allows much space for the relationship - for frustrations or for teasing. But apparently that’s ok, because they’ve got red pens and elastic bands.