Sunday, May 20, 2007

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.

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23 Comments:

Anonymous Anonymous said...

I know I have said adding a bit of colour to the weave would make the clan tarten look so much more shishy but red pen instead! God have these therapists got no style - Ms M excepted of course:0) I really have not much more to say than I said in the email before comments appeared to be enabled - computer expert? ha-ha, god gives me hope.
Have decided to 'out' myself by cutting and pasting, if that's not ok do delete this drivel eh.

" Beautiful courageous self loving post just like the person who wrote it. Being neither a therapist nor a cutter there is only one thing I feel qualified to do, be, say.....hello I'm your friend and I love you, all of you including the tartan designs across your body but know that as your friend I need to say like Ms M, I want you to be safe because I care about you but will continue walking with you holding cotton wool, antiseptic and butterfly stitches and smiling because I see the epitome of courage walking when I watch you continue to discover the beautiful courageous self loving person you are and how best that is expressed for you."
From your mad, often a little bad, nodding at sad Welsh fan club member:0)

20 May, 2007 12:53  
Blogger Ms Melancholy said...

Lovely Stray, thank you for your willingness to out yourself on this very sensitive topic. I have huge admiration for you. Your words will comfort many, and I hope that some practitioners will read and reflect on their own practice in working with those who self-harm. I am very proud to call you my friend x

20 May, 2007 14:09  
Blogger JJ said...

Stray, I've just left a message on Ms M's blog. This is something we need to talk about: it's so hidden away my people's ignorance, terror and distress. My son told me he saw someone at school recently who had cut themselves and it so upset him. Thankfully, he came home and told me, and we were able to talk. It's incredibly brave of you to talk about it, and so important for people to have some understanding.

20 May, 2007 14:46  
Anonymous Anonymous said...

Well done, Stray, that was utterly outstanding. I've never resorted to this myself, but the compulsion to do so used to be overwhelmingly strong.

Oddly enough, I was snapped out of these darker contemplations by a confrontation with a knife-wielding intruder. I remain a bit too freaked by sharp objects to seriously consider harming myself with anything remotely kitcheny. So I'm still looking for for an effective and un-yucky way to cash in my chips.

I'm not suggesting that this is the preferred way to overcome these feelings - and intruders are notoriously unreliable as therapists - but it certainly strikes me as more effective than pinging myself on the wrist with a freaking elastic band. Now I have to look elsewhwere to get my fix of self-harming. It's so unfair.

You should take hope from this, clearly - although I do still recommend checking your windows before bed. Make sure they're unlocked.

This was one of the very best things I have ever read in space, Stray, and I'm sorry for travelling anonymously. If she's not too drunk, I have a feeling Ms Melancholy will be able to tell you my bloggy identity - and I'm perfectly happy for her to do so, of course, not that it should matter.

I like the way you sometimes use a dark humour, incidentally. It often feels essential to do so.

Gobsmacked admiration for a most stunning work and wishing you nothing but inner calm....

Kind regards etc,

Anonymous in space.

20 May, 2007 14:55  
Blogger Stray said...

Lovely anonymouse - hell, I like that typo - many many thanks for your words here and by email and in person over the last year or so.

You have taught me to expect more of others. To challenge people to accept and understand.

Loving you always! xxx

Oh Ms M - I don't feel brave at all. It seems much braver to me to be a therapist and ask people to come to you in their personal agony and work through it with you. Trust you. You must have to trust yourself a great deal! And the process of course ...

Very proud to call you my friend as well :) x

JJ - yes, it must be very difficult for your son - I know that if even adults with supposedly giant brains can't 'get it' then how do children begin? I know it confused the hell out of me as a child, and I was the one doing it. I'm so glad you were able to talk with him about it - so glad. I guess my only advice would be that maybe that's also a conversation he could have with the person he saw hurting themselves?

Anonymous in space - I shall think of you as a masked but non-knife-weilding intruder. I shall rely on Ms M to reveal your secret identity (how exciting) - it's barely gone lunchtime so I think she's still sober ;) I actually think I have a hunch that I recognise the cadence.

I'm happy-sad that you understand the feeling, and glad you haven't resorted to the action - if rather alarmed by the reason you're so resolutely blade-phobic. I'm afraid that unfortunately I live in a house which is completely invisible to the outside world, and has never been the scene of even a minor break in. We sleep with doors and windows open ... and the shack I live in is buried in an overgrown woods, and is evocative of misery or the shining, but to this day nothing more dangerous than our exotic spider collection has threatened me in the night. (We do get some bloody big badgers).

Thanks so much for your kind words - I really didn't know how this would be received. I'm glad you can hear what I wanted to say :)

Sx

20 May, 2007 15:07  
Blogger Ms Melancholy said...

Hey anonymous, I'm sure I would take exception to your comments, except the red wine I have just consumed with my Sunday lunch has put me in an extraordinarily good mood.

You say some very wise things. The dark humour is Stray's particular talent. Through that, we listen to her and truly understand her words. We seem to have a tendency in our culture to rely on either sentimentalism or desperate public tragedy in order to express our emotion. I shall stop there. You know what I mean.

Anonymous, I have no idea who you are, but I like you almost as much as a blogging friend I used to know.

Much love xxx

20 May, 2007 16:56  
Blogger Caroline said...

You never cease to amaze me with your honesty and courage. You address issues and give words to subjects that require a strong voice. Self harmers come in many different forms as does the method of harming and perhaps if people talk about it as honestly and openly as you, well then perhaps others will begin to ask the right questions.

I am proud to know you Stray.

xxx

xx

20 May, 2007 18:42  
Blogger trousers said...

I'll use the same word I used for Ms M's post on this subject - excellent.

Its amazing how the irony is completely lost on people about how self-harm is attention seeking behaviour (supposedly) but, as you state, it takes courage to tell a health professional - or anyone else for that matter.

I seem to remember that changes were being proposed in how statutory services were to approach self-harm. Sorry to be vague about it, but I recall that the changes were positive and progressive and gave scope for much more tolerance and understanding.

I don't know whether these proposals are still yet to come into force, or whether they have been sidelined. I may be wrong, but I think its wise to suspect the latter.

20 May, 2007 19:16  
Blogger PatientGuard said...

Well said Stray .... Plenty of experience there . I've done a piece on UserWatch to cheek the "NHS whirled" again and support a good opening up of this subject with you and Ms Melancholy ...

Good for you Stray.. You have accepted more of you over some trials and time ..

Hugs for you a-plenty...

And a cake for Ms Melancholy ..

I'll have to go an hug someone or the cat now ......!

This has been human-band-therapy

HBT !

Yeeeee Hahhhhhhh !


.

20 May, 2007 20:59  
Blogger Stray said...

Ms M - thank you for saying nice things :)

Cas - honey. Your faith in me and willingness to see me as I am is wonderful. Thank you.

trousers - yes, the attention-seeking label is wrong in so many ways. People frequently miss the fact that there are situations in which attention seeking is a useful, necessary activity - calling for help when you've broken your leg is essentially just attention-seeking - so it seems to me that there is some implicit judgement about whether attention is deserved or not - and as cutting is frequently about managing things which aren't yet able to be spoke about, it seems arrogant that people think they can make that assessment with no information!

I have to say, in places the treatment is really much much better. My own CMHT was terrible to start with, but have come on in leaps and bounds recently. It often still comes down to individuals though - single doctors and nurses and their own personal compassion and understanding, or lack of.

Patientguard - many thanks for the support! HBT is definitely the way forward :)

Sx

20 May, 2007 22:46  
Blogger That's so pants said...

Dearest Stray

I'm in awe of your strength and courage in telling us your story with such honesty and finesse.

xxx

Pants

20 May, 2007 23:06  
Blogger Stray said...

Bless you Ms Pants - interestingly I feel like I've avoided telling much of my story at all! But - yes, I suppose the fact that it seems like such a revelation simply to give the barest outline is a big statement about just how taboo these things still are.

It was a little scary 'coming out' here - though I have touched on self-harm in a previous post about the mental health bill.

I'm relieved people are so receptive. As Caroline said - self-harm has many forms - probably as many different forms as there are people who find themselves doing it, but I still believe that any voicing of experience is a step forwards.

Sx

20 May, 2007 23:41  
Blogger Dale said...

Dear Stray, a lovely piece of writing, and an important one.

It's funny, I was about to start off "though I'm not a cutter myself" -- and I looked down at my forearms, a knife-scar on one and a cigarette burn on the other, both deliberately done by myself in my teens -- and I realized that a more accurate thing to say is "though I don't identify as a cutter myself..."

Back then, in the 70's, I had never heard of cutting or cutters, which was probably a blessing; I didn't encounter anyone else's characterization of it, so I was faced only with the thing itself, rather than with a whole identity to either take on or duck. Which is always wearisome and usually irrelevant.

Now I have of course completely forgotten what the main clause of the sentence was going to be, after that :-) Anyway -- hugs --

21 May, 2007 08:28  
Blogger Stray said...

Thanks Dale - yes, in the 80s (when I was a kid) there was little widespread experience of the phenomenon - no stereotypes or cliches beyond "hysterical woman / teenager" to work with.

I would say that it's really only in the last 10 years that self-harm has entered mainstream consciousness in the UK, appearing in TV shows and being associated with high profile people.

On the one hand I think it's a good thing that it's at least being acknowledged, but on the other I've been very disappointed by the shallow exploration it has received. Typically TV characters begin, are discovered, get help and are 'cured' all in the space of a few episodes ;)

Sx

21 May, 2007 09:13  
Blogger PurpleSparkleBright said...

What an excellent post, Stray. I have to admit it does worry me when you cut but because I do it myself I cant really make judgement other than the fact that I'm really worried is not becasue of the behaviour itself, but that you are in enough distress to do that. No one wants to be in that much distress. No one at all. This post, also, reads like a summary and a goodbye to your most open therapist. A bit like the one where you wrote about having got over your ex. onwards and upwards! If you could only see for just one second how strong and beautiful and together and articulate and unselfish you are, you would amaze yourself. X

21 May, 2007 13:03  
Blogger PurpleSparkleBright said...

PS. Red pen would just encourage me to go the whole way..... then I would end up with home-tattoos in wonky stripes!! Why do these people never think of that eh?

21 May, 2007 13:10  
Blogger Drak said...

I have to echo PSB here - its not the act, but the knowledge that a friend/human being is in such an intolerable position that cutting (or harming/binge-drinking/control-eating/whatever coping method of coping they have come up with) is the only viable option. It is that awful realisation that while one can help, it is impossible to 'make it all better'.

I wish there was some way for those of us living with depression/extreme anxiety etc. to be able to turn round to the rest of the world and say "Yes. Thank you for your concern. I know this isn't the best way to deal with the problem, but it is the best way available right now. When I come to a point where I can use a better way I will"

Once again I fear that the 'works for a few' model is being applied to the many in mental health. Flicking an elastic band has none of the 'release/crossing boundary between self and outside world' connotations that I know are vital to some cutters. Holding an ice cube until it hurts can be an alternative if all you need is to 'feel something'. Drawing on youself in red pen? I suppose if you were a very visual-oriented person it might help. Also works for the 'needing to show, but cannot explain' crew I guess.. Again - all these things will help someone, just as lobotomy helped a few, and ECT helps a few. I suppose we should be glad that its not drilling holes in our heads to let out the demons, or being hung or burnt to death or imprisoned for being too different.

I had to stop using a red biro at work cos one of my habits is doodling, and I'd started doing join-the-dots on my arm, when I suddenly realised that it looked like I'd been in a fight with one of those cats so many self-harmers seem to have - you know the sort - cats with one or two claws, that never quite swipe you the same way twice, and always seem to go for one body part at a time. Silly cats.

22 May, 2007 23:38  
Blogger Stray said...

hey PSB - thanks for caring :) Yes, I know it's not easy to watch others in distress ... but as has been said here, many people have coping mechanisms of all kinds ... sometimes it's just harder to recognise how destructive they are.

Wonky tattoos = very bad! Don't want to ruin your lovely geometrical ones :)

Cheers Drak - yes, those cats can be ever so naughty!

I think you're right, it's the "worked for a few" model of therapy. Ug. Whatever you do, don't be an individual!

Sx

23 May, 2007 20:48  
Blogger Vanessa said...

I too have struggled with self-injury for many years and have reached a point in my treatment where I am no longer ashamed to talk about it. Having felt alone my whole life, I was convinced that no one could ever relate to the level of emotional (and subsequent physical) pain I was feeling. How misguided I was! There are literally millions of people in the world who self-injure, yet few will talk about it. I am working to change that. I encourage you to visit my blog about self-injury and eating disorders and leave comments.
http://comes-the-light.livejournal.com

24 May, 2007 22:43  
Blogger Prada Pixie said...

Stray, as a therapist who thinks CBT is shite and who feels that the only way to help people is be with them on their journey your words touched me deeply. The people who have stayed with me over the years in my head are the ones who I have connected with as a human beings, not because of my theraputic understanding, OK that helps, cause it gives me a framework. But ultimately what helps both my clients and me is acceptance of both of us. I am responsible for myself as is anyone else and if I can help someone understand that, and that they have choices within their own framework then I'll have done my job. It is not for me to impose my 'cure' on another human being.It is for me with my skills help them find a way that works for them, and if that ultimately is less harmful then great, if not that they learn to accept themselves and not judge themselves in a detremental way. Life is too short to hate ourselves.

28 May, 2007 19:01  
Blogger Stray said...

thanks Vanessa - you are doing some good work in terms of opening things up it seems over on your blog :)

Prada Pixie - that's a lovely description of therapy. Learning what choices we have ...

Thanks for dropping by :) I checked out your brand spanking new blog and it looks great. I hope you stay well :)

Sx

28 May, 2007 19:31  
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