DBT and dissociation

I came across a blog post alleging that many survivors of childhood sexual abuse have been further traumatized by therapists applying DBT to them.

Basically, they are told to stuff their feelings related to the abuse, because it’s in the past. No connection allowed to that past self and his or her experiences, even though those experiences are hanging in limbo and can never be metabolized without revisiting them. It’s yet another authoritative voice saying “Shhh! Don’t tell, or you’ll get in trouble.”

Part of the trouble seems to be in the wrong application of the various skills, as if any of them were always universally applicable.

The skill of distraction is overapplied, as if it’s appropriate for all situations, and as if dissociation were not a danger. The skill of temporarily storing overwhelming emotions is likewise misapplied, as if the therapist were conveniently forgetting the “temporarily” part and the need to revisit those feelings at a more safe time and place. The skill of not catastrophising is applied as if there’s no such thing as a catastrophe, instead of only when the distress is NOT a catastrophe. The skill of acting opposite to feelings is misapplied, as if the idea is to hide one’s yucky self or deny one’s yucky feelings, instead of mere impulse control: being able to have one’s feelings, own them, but act according to wisdom instead of impulse. In fact, I remember DBT focusing on emotions being value-less — that even the so-called “negative” emotions are important and have something to say to us. They shouldn’t be pushed aside any more than they should be deliberately sought after.

Some of these skills seem to me clearly intended for distresses that are mild to moderate, not severe. They’re for distresses that recur after you’ve already dealt with the root issue — distresses that you KNOW are based on lies.

Take the half-smile, for example. Of course it’s ridiculous to think that simply smiling will solve all of your sadnesses. But I don’t think that’s the point of the skill. It’s just one small tool. For occasional no-good-reason blues, it’s a great physiological feedback tool. For deep sadnesses, it can be a very small comfort, again purely physiologically, not as if you’re pretending not to be sad. There’s no “should” or “must” about it, and it’s not about denial or stuffing.

Then there’s apparently an idea that using the skills is a matter of instant perfection, and not practice. The blogger writes about people being chewed out for mentioning their distress in group. Yikes! How can you learn distress tolerance if you can’t even mention distress? And again, distress tolerance isn’t the same thing as distress denial or not being bothered by distress at all. It’s about letting each distress be its own true self, neither making it more of a catastrophe than it is, nor minimizing it less than it is. It’s about trusting that the true self can survive, can get through, will not be destroyed by the distress.

It sounds to me like part of the issue is a matter of language and connotations. When a therapist says something like “acknowledge without attaching,” it might mean something very different to their client. Maybe the therapist means “Stay in the present, but allow yourself to feel the feelings that are coming.” Maybe the client hears “The person that experienced those feelings is not, and never was, you.”

Suppose you’re the client and you’re experiencing distress because of something from your past. I think there are at least three possible approaches.

1) You might get sucked into the past moment as if you’re time traveling, reliving it exactly as you did in the past. In this case, there’s no sense of the present moment at all. There’s not enough separation from the past moment to observe it, listen to it, evaluate it, and respond to it. There is only reliving and reacting. I don’t think this approach can solve anything, and it seems clear that it could cause problems in the present.

2) You might push away, deny, or ignore the past moment as if nothing from the past matters anymore. This approach is even less helpful, even though it might preserve a semblance of functioning in the present. The present self grew out of the past self, and so the past DOES matter. Past experiences — especially those that haven’t been fully metabolized — will continue to exert pressure on the present self, causing all sorts of present problems.

3) What seems to me the best approach, in line with how I understand DBT and what I learned in other therapy as well, is to be present while the past moment is speaking. Don’t time travel, and don’t shut your ears. Feel the feelings, experience the experience, mindfully, neither pushing away nor clinging. Listen with compassion. Listen with your present self’s wisdom. See what the past self is saying, what the past self needs from the present self. The only way to metabolize that past moment’s feelings is to feel them — in the present.

You can’t change what happened in the past, but that doesn’t mean it’s safe to ignore the past. Ignoring the past and time-traveling into it are both ways of fighting against reality. Mindfulness is NOT saying reality is wonderful and peachy-keen, but it is accepting that reality is what it is — including the realities that this is the present, and that the past really happened and really matters.


10 thoughts on “DBT and dissociation

  1. i very much agree with what you say. a bane on therapists who force their patients to bury their past! one small point on “time travel.” sometimes, it’s all we can do. sometimes, we are so damaged and dissociated that time travel is what our psyche inevitable does. with a good therapist who can, and will, eventually, take us back, i think that’s okay too. very good post. thank you.

  2. I really understand what you’re saying. I really do. But some things NEED to be ‘clinged to’ for a time. Especially if they are brought by a dissociated self-state. They have to be processed on a deep emotional level for the person to get any real peace from the event(s) and finally be truly freed up a little to do something more than spend their time and energy ‘practicing mindfulness’. The bottom line here for trauma is that if you ‘listen with your present self’s wisdom’, then you are not really feeling the feelings, they are simply being intellectualized. The intellectualized feelings have to AND WILL show up somewhere else. They will become part of the person’s ACTUAL present moment in any number of messed up ways, and the connection to where they truly belong is lost because the person was not able to lay it to rest with a deep emotional working through. Never send an intellect to do a gut’s job. It never ends well. You know what though? I completely understand those who need this to be the way because it is extremely upsetting to deal in raw emotional honesty and it is very difficult to find support for. Dissociation, in all its forms, is much easier in the short run. That’s why it’s such a popular human pastime (pardon the pun:-). It’s because nobody really wants to see the ugly. And they CERTAINLY don’t want to feel it or witness someone else feeling it. Even when that is the path to some real resolution. It’s sad, really.

  3. We might be differing on our definitions of “cling to.” It sounds a bit like “not clinging” is tantamount to “pushing away” in your experience. To me, “clinging” would be trying to make a feeling last longer, or feel more intense, than it really is — if it truly is a long feeling and an intense one, than mindfulness would let it be long and intense as it needs to be.

    But overall? I’m thinking that the timing of DBT might be what really makes the difference.

    I had three years of heavy deep therapy before I ever heard of DBT. The DBT came in several years later when I was deep in PPD — who knows to what extent hormones and sleep loss were responsible for my PPD, but my existing baggage surely played a role. Any major event can bring that stuff out again in a new way. I was able to talk with my therapist during those months, to revisit the old material with the new experience, and the DBT was an extra thing. As I’ve said before, I didn’t find it at all pushing dissociation in any form, and for me it meshed well with what I’d learned in my other therapy. Perhaps the key is that I’d already done so much of the deep work, and so DBT gave me practical skills for the functional stuff. Perhaps if I’d started with DBT I would have felt that my true self and past experience were being kept out of reach, out of bounds.

    And I do have a tendency to intellectualize.

  4. Gio, true. Perhaps I am being unfair to time travel. I think the problem would be if you can’t get back again. However long it takes, the goal would be to work through the past in such a way that one could live in the present.

  5. I think you are right on target with the general principles of mindfulness when you say that ‘clinging’ is defined as trying to make a feeling last longer or feel more intense than it really is. And therein lies the problem. I’ve never known any trauma survivor who was trying to do such a thing. They basically want out of the torment and just want to feel better. Enter mindfulness, which implies that the intrusive aspects of the trauma response and the corresponding high levels of distress are likely to be due to the survivor possibly ‘clinging to the trauma’ by making too much of things – that it is possible to make too big a deal out of a toddler being repeatedly raped and sodomized by her father for instance, and that if the distress is great enough in the present, then the person is attaching too much importance to this event and the havoc it elicits. The same problems arise for those who are in a ruminative phase.

    This is extremely invalidating for any therapy to even imply because there are certain things that are so awful, it would be pretty hard to ‘make too much’ of them. This is a double-bind because mindfulness says to accept your feelings because it is understood that really being able to do so is the key to relief and yet it implies that doing so might be making too much of things. And the worse your trauma was, the more intense or long-reaching the emotional devastation, the more likely that you are ‘making too much of things’. If such a message came from a family, a therapist would call it crazy-making. But it’s okay if it comes from a therapy. This distinction is also crazy-making. Dare to call the therapist out on it when you finally figure out why you are losing your mind under the manipulative influence of such a therapy and no matter how many contradictory quotes, how much independent study and how many notes you have made, they will look right at it and deny the reality and common sense of what they are looking at. This is called gas lighting. It is dishonesty, denial and minimization masquerading as enlightenment and anyone who recognizes the truth about this is said to be incorrect and suffering ‘distortions in perception’.

    This is all very crazy and toxic, but that is how mindfulness works. It effectively silences the client and blunts and shames their naturally strong emotional expressions (which are treated as ‘behaviors’) and it accomplishes all of this with a double-bind. This is emotional and psychological abuse and it is re-traumatizing. And for the dissociative client, it causes even more insidious damage and they often end up having to heal the damage caused by the abuse perpetrated against them from the invalidating and crazy-making therapy before they can have productive access to the material that originally drove them to seek help in the first place. This can add years to the healing process and I wouldn’t be surprised if it makes integration impossible for some. This is a perfect example of the toxic and damaging effects of spiritual dogma.

  6. Any therapist who applies that double-bind should be removed from practice. Yikes.

    I don’t think mindfulness itself is the problem — it’s this awful mis-application of it that you’re describing, that’s the problem.

    I continue to be appalled that this is happening, and Lord, please stop it.

  7. Marcy, I find it interesting that you say you went to DBT classes AFTER you worked through 3 years of “deep therapy” (Which, I’m not exactly sure of what deep therapy means as it relates to what you went through). My experience has been that DBT is intended to teach mindfullness, distress tolerance, emotiona regulation, and interpersonal effectiveness. Skills that I’ve been told are required PRIOR to workin through any “deep” therapy.
    I am interested about how and why DBT was suggested to you and why you chose to participate…if you wouldn’t mind sharing.
    ~ Grace

  8. Grace,

    My first therapist, Joe, was largely psycho-analytic in orientation. He also did some stuff with object relations, a little with systems — whatever theoretical framework seemed helpful for the situation. He had a deep respect for the past and the subconscious, without neglecting the needs of the present and the conscious.

    Those first three years started because I’d long been often depressed and / or anxious, and was becoming increasingly angry. There was nothing spectacularly evil in my past, but there were evidently things that were tripping me up in the present — not so much in my daily functioning, but bothering me in the heart and mind. I wonder if having DBT along with this therapy would have been helpful; perhaps, perhaps not.

    Several years later I had a baby and got post-partum depression and especially anxiety. I was expecting the depression and the sleep loss, but not the anxiety, and I wasn’t prepared for managing anything but the depression, and that only if it stayed moderate. I hospitalized myself a week after we brought her home, and only got to stay two days. I tried a few local therapists and ended up back with my first therapist by phone (we were now living in another state). In the hospital they started me on Zoloft, and afterwards the psych nurse practitioner I saw added Risperdal and just about threatened to report me if I wouldn’t go to a DBT group. (She didn’t think phone sessions with Joe were adequate help; wanted me with someone local.) So I went, and found it much better than expected.

    From my conversation / reading with Ethereal Highway, I am coming to understand that for serious trauma survivors, DBT might be far too light and present-focused as a starting place for therapy. DBT does seem mostly about present functioning, which is fine unless it becomes a hindrance to working with past material. I haven’t yet heard from / read anyone who’s discussed how doing DBT first helped him/her delve into the deep stuff later.

  9. I was talking about this stuff on a facebook page about DBT, and here is what two other participants had to say:

    Seth says: DBT teaches NEVER to stuff or fight your feelings. It is all about observing them and naming and describing them. And be curious to find out where they came from and talk about it for validation. DBT is more about stopping suffering and misery not ignoring pain. And I know from personal experience I have stayed stuck from rumination a long damn time in the past.

    Sue says: Marcy, I have chronic PTSD from childhood sexual abuse. I’ve been using DBT for over 8 years now. It has both empowered me and saved me from so much suffering. Learning that I have the right to have my emotions ( and what the purpose is in having emotions!). It was extremely validating to learn that I had my feelings for very good reasons! Marsha tells us to have our emotion like “riding a horse skillfully.” And as for pushing away the past…my favorite analogy that Marsha gives is “the purple room.” If you had a purple room but hated the color purple yet ignored/pushed away/denied the existence of the color of the room, you would never be able to do anything about it It would be like ignoring the eight hundred pound gorilla in the room. I felt that CBT was mainly to help me to be ale to change/modify my thoughts since my thoughts were causing my emotions/actions/reactions. There was much more acceptance in what Marsha says…that most people feel bad for good reasons! Sorry for the long response but I was just getting started 😉

  10. More from Sue Soper — basically, that the peeling an orange thing (or other techniques / skills) doesn’t have to feel like abandonment, dismissal, inattention, etc to the inner parts who are distressed:

    Yes, I have permission to cut my hours down at work and take a walk, take a break or even go home if I need…so far these last few months. They do not want me to quit.A Dr.,therapist, teacher, etc. can make suggestions on how to use any skill. It will be up to US to decide which ones help us and use them accordingly. The motive is always to help oneself; It’s not helping me to invalidate my previous suffering when it gets triggered. We are trying to” reparent” ourselves! I’ll give you an example. At work, I was dealing with a client who had a similar personality to my worst family perpetrator and I felt like I was being( perceived) victimized. I was able to observe the panic, step back (which was like I picked my inner child up to hold her) and excused myself politely from the room. In my line of work, this is acceptable/usual behavior. I have been reactive at work many times and taken care of myself for about 2 years and no one knew that I was ill in any way;I have been sooth myself quickly.But back to my example. Since I removed myself from this perceived threat, I have a notebook in my pocket in which to dialog with the part of me that is highly distressed. This is very validating to my small damaged parts. I observed the feelings, acknowledged them but started to shake and sweat so I went to our kitchen all the while comforting that panicked part of me that we were going to get an orange to peal/eat it. It was as though my inner child was safe and sound until danger (perceived) came and I scooped her up to help her!. I have done much work and healing in earning “inner trust” so I can risk working again. I used to feel so unsafe even in therapy, now I’m back to work after 8 years…does the example help? It’s hard to break down what happened without writing a novel 🙂

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