Monday, October 12, 2009

Psychologists love alphabet soup, right? Well, I have an entrée that I predict will one day be added to the diagnostic manual. It won’t be in our lifetime, though. It will take hundreds of years and perhaps a loud and bloody revolution for people to wise up to that extent. It’s this -- CBT/DBT PTSD. Yes, it means PTSD symptoms caused in part by CBT and/ or DBT. And I would be willing to bet that the vast majority of sufferers will be trauma survivors like me. They will be people who were powerless against adults as little children. They will be people who were repeatedly beaten, ridiculed, tormented, threatened, molested, sodomized and otherwise raped when they were children, were never allowed to tell the truth and whose pain was marginalized or ignored. They will be people who were hated, punished, rejected and abandoned for telling the truth in childhood and then also in adulthood. Some of these CBT/DBT PTSD sufferers will be highly dissociative. Because that’s what happens to brutalized children who have no safe place to go for comfort and then grow up to be marginalized and psychologically and emotionally assaulted as a punishment whenever they cry out in pain and confusion.



Case Study:

Ursula Underpants was a 40 year-old woman who became very angry and began to withdraw from her therapy. She began verbally abusing the therapist, shouting, cursing and sending hateful and insulting emails whenever he said words and phrases like wise mind, use your wisdom, present moment, mindfulness and discipline. She also displayed these behaviors after she cried excessively or had panic attacks in therapy and was met with suggestions to use drugs, store her emotions and memories away in containers or rely too heavily on distraction. Upon further investigation, it was found that Ms. Underpants had already used these methods for many, many years. She experienced problems with them, including alcoholism, drug abuse and suicidality, because the amount of energy needed to maintain the dissociation from her memories and feelings was very exhaustive and she would often collapse. She was always given drugs to treat these collapses. They had many serious and negative effects on her health, physically and mentally. Whenever she could no longer use drugs with any measurable success and also remain reasonably healthy, she sought therapy and was again instructed to distract, store and otherwise dissociate her thoughts and emotions and the cycle repeated many times until Ms. Underpants gave up her work and her social life in an effort to stay alive. She didn’t feel she could be depended upon to commit to anything outside of her home because she was too busy maintaining her dissociation to be reliable and she had no energy for anything else. It was all she could do to keep up with the needs of her family and distract herself by renovating her home. After she isolated herself, she did the renovation alone and on her own schedule so her sleeping disorder and frequent breakdowns would not disrupt her nonexistent friends or job and thus require treatment that she had unconsciously recognized was unhealthy and not working.

When she contacted her current therapist, she presented with anxiety and difficulty adjusting to a change in life circumstances. Three months later she experienced a full-blown flashback in which she uncovered the memory of a rape that had occurred a decade earlier and had previously been available only in memory fragments and sensory associations which produced distress ranging from hypochondria to anxiety and depression, severe panic attacks and dissociative episodes. With the support and care of her therapist, she was able to integrate this experience in a six month time frame and no longer experienced intrusions related to the rape. She still suffered from some anxiety, but felt much better and was attempting to regain some of the activities she had abandoned before she discovered and worked through the memory and emotions of the rape.

Shortly thereafter, Ms. Underpants experienced another full-blown flashback from an earlier sexual assault which her therapist handled differently. He broke the warm connection that she had with him and behaved coldly and clinically, suggesting that she either use drugs or focus on the present moment. She confronted him with her true feelings about this and he quickly apologized. Ms. Underpants lost contact with this event and dissociated the pain and the feelings of betrayal that were part of that experience. This began a decline for Ms. Underpants during which she began displaying hostility toward the therapist. The feelings of hostility further undermined her self-esteem because she did not know why they occurred and she loved and respected the therapist and was not in the habit of being hostile toward people about whom she felt warmly. Her decline was greatly exacerbated by the shock and fear she experienced when she began to understand the implications of having more than one ‘forgotten’ rape while recognizing the existence of other anxiety producing memory fragments and sensory associations that she knew did not belong with anything she had already remembered. It took her much longer to process the second memory than it did to process the first.

A few months after the second assault memory had been integrated, Ms. Underpants had a dissociative episode outdoors in the cold after suffering for weeks with increased anxiety in response to the weather. She sent her therapist an email in which she confessed that she thought drizzle was really snowflakes hitting her face and that she had been overcome with the fear that she would begin to run down the street and 'lose track of herself’. She was very suddenly 'cured’ of her waking anxieties (via dissociation) after making this disclosure and only the sleep disorder remained. Weeks later, and a full year and a half after the upsetting event in the relationship with the therapist, Ms. Underpants was again faced with the full recollection and feelings of a stored trauma. This time, it was the negative event with the therapist. She told him and he was understanding and willing to work through it with her. It was difficult for her to do this and it had to be done in small bits and pieces over a large amount of time. It is still being processed to some degree. In the meantime Ms. Underpants suffers because frightening sensory associations often dominate her time and dissociated memory fragments rise to the surface of her consciousness even though they cannot be placed in time and context. She has a lot of difficulty accepting these things without being able to fully feel the care and support of her therapist. When she uses her old skills and ‘stores’ them, her sleep disorder becomes even worse and she also experiences severe somatic symptoms which trigger hypochondria which triggers more dissociation. She is often reluctant to mention certain problems to her therapist because she fears he might say things to further perpetuate the old cycle of distraction, denial, minimization and invalidation as he has on a few occasions, with each one further eroding her trust, hope and self-esteem. Ms. Underpants feels she has spent her life being further damaged by very popular philosophies and therapies which mimic the dissociation that first saved her life and then destroyed it. She feels stalked by these philosophies and sees no escape and no sufficient refuge. She is afraid to trust anyone and currently has a drinking problem that began recently after thirteen years of sobriety. Ms. Underpants has CBT/DBT PTSD.



edited to add: 4-22-2010

If you think you might have CBT/ DBT PTSD, click here. You are welcome to leave your story in the comments. Both Grace and I will be happy to read it. Believe me - WE UNDERSTAND YOUR PAIN. We wish we didn't because of how much it hurts us to know these things so personally, but we do understand and you are not alone.

22 comments:

  1. I think I have this...In fact, I'm SURE!

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  2. I seriously think you should consider emailing this to Marsha Marsha Marsha @ brtc@u.washington.edu
    Subject line: To Marsha Linehan

    I am not joking.

    AND I'm thinking of starting a seperate blog to talk about the negative side effects that DBT/CBT causes survivors. I'll be in touch when it's created - and you can co-own with me, if you're interested.
    RIDICULOUS!
    Love this case study though!

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  3. this case study ought to be required reading for all therapists professing to utilize CBT/DBT. I've never understood advising someone who has issues with dissociation/repressed memories, to stuff memories down or take them in small doses or distance yourself from them. As if that is possible?

    I could rant and rave myself but I'd hate to hijack your post with my own comments/rants.

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  4. So what does Ursula Underpants do next?

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  5. Oh and I have long accepted that I am thick sometimes. So I wont feel even denser by asking what you mean by alphabet soup?

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  6. Yep. I swore off therapy for YEARS after my dose of CBT/DBT.
    And even though my current therapist has never, ever suggested such a thing I think I am less trusting in her than I would be without my prior therapy experiences.
    One of the things that I think is really good about my current therapist is that she primarily works with traumatized children. I don't think any therapist worth their weight would ask a little kid to use those kinds of techniques.
    My therapist is a full-on christian... and she borders on whacky sometimes... and she's a TERRIBLE dresser.... but she has NEVER asked me to put anything aside.
    I also want to know what happened to Ursula Underpants. How does this story work itself out?

    Kahless - "alphabet soup" just refers to the mass of letters in the acronym "cbt/dbt/ptsd". Just a bunch of random letters thrown together really...
    -else

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  7. Oh. And Lynn, could you tell "saving grace" that I love her blog but since I F'ed up my laptop I can't comment... Blackberry won't let me...
    -e

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  8. Were you aware that Ursula Underpants has an identical twin?
    Her name is Petunia Pink Panties.
    She was also told to shut up and behave. The sadess part is that by being told to shut up and behave and shut up and drug up - the MHPs have served to "validate" retraumatized her leaving her feeling hopelss much of the time, and have only reinfoced her old thoughts of "no one can be trusted", "I will be punished if I tell", "no one will help me anyway", "I am bad"...Sadly it seems as though there is no where to go for help...as the "Invasion of the Validating/Caring Therapists" seems to be running rampant throughout the MHP world. One week, you think you really can trust your T and you feel cared for and heard - the next? She is replaced by a STEPFORD MARSHA FOLLOWER. It's frightening really. Maybe someday we can find the PODS of the caring Ts that were left behind...

    My word verification is "exopse" so close to EXPOSE (the "real" truth about DBT!)

    And Quacks Like a Duck - Thank you!

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  9. I think I'm lucky - my therapist won't lead me down the path to CBT/DBTPTSD. I hope not anyway. I HATE HATE HATE it when CBT therapists say things like, "Anxiety disorders are very easily treated." Ha! How can anyone lump all anxiety related disorders into one category - those easily treated? Grrr.....

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  10. Hi, Grace. I think a lot of people have CBT/ DBTPTSD. I bet the lady who put her feet up and drank a beer while her feelings rolled off the conveyor belt and onto the floor doesn't have it. :-) I wish we could take that woman out for a drink. We'd have a blast. We might get kicked out of the joint for getting loud, but we'd have a blast until then. (At this point I could only do guest posts on your very genius idea or it would be too triggering.)

    Hi, Enola. There are probably quite a few things that ought to be required of therapists that are not. And FYI - You can rant and rave in my comments ANYTIME YOU WANT. I could rant about the repression therapy thing for hours, too. That stuff really hurt me. Right this minute I'm angry, but under that, deep down on the inside in a place I can't touch, I am face down on the floor sobbing. That's probably why I am so tired that I can barely move.

    Hi, K. You are not dense and I love you just the way you are. What does Ursula Underpants do next? Well, after the narrator wrote this blog post, our dear Ursula emailed her therapist and sent him a link. Right now she's guzzling beer. I have no idea what she might do tomorrow, but I sure hope it involves real work of some kind. Things are getting a little behind in her affairs. You know, because of all the energy it takes to store things.

    Else, it does not surprise me at all to hear you say that you would be more trusting of your present therapist if not for the CBT/ DBT debacle. I am SOOOOO not shocked. It's fucking sad, isn't it? To need freedom so goddamn bad only to be told to stow it. (And I've been wondering about that dream you had - maybe your therapist represented some past therapist or some collective feeling about therapy that is influenced by past therapy experiences? I can't know, but you can. Sometimes I don't figure out my own dreams until weeks, or even months later. That could happen for you sometime, too, so it's really good that you wrote it down.) And I'm so glad Grace got your message. Makes me smile (and not one of Marsha's fake half-smile pieces of crap, either).

    Yes, Grace, I am aware of Ursula's twin, and I fucking rejoice over her like you wouldn't believe (or maybe you would). I feel bad for Ursula and Petunia, but I am also proud of them. There are some people who take that kind of shit off people and say nothing about it, and then there are those like Ursula and Petunia who know that it is usually best to tell the truth as soon as it is safe to do so. And they also know (R & PAG) that if all else fails they can kick up a really mean fuss in the interest of justice. And I don't blame them one little bit.

    Harriet, you are very lucky to have J. Very lucky. And I think you are doing one hell of a good job, my friend. You really are.
    {{{{{{{{Harriet}}}}}}}}

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  11. I had no idea.

    I had minimal interaction with two therapists who were CBT-ish, and it seemed all surface and no depth, no acknowledgement of the subconscious. Yuck for that.

    But I looooooooved my DBT group. Unlike CBT, to me it seemed much more willing to acknowledge the depth of things and the importance of feeling feelings.

    Maybe much is in the way it is applied. Maybe much is in what the therapee is presenting with. (I'm not a survivor of childhood abuse, for example.)

    At the time I started DBT, I'd already had three years of semi-psycho-analytic depth work, and had been pretty stable up until I got postpartum depression and anxiety quite bad. So the practical aspect was -- and felt -- appropriate for me at the time. I also went back to my analyst at the same time.

    I didn't ever have any impression that DBT could or would suggest more drugs or stuffing feelings. The people in my group needed encouragement to use the drugs they had when they needed them, but I never had a sense that drugs were being pushed.

    And never anything about stuffing feelings. We spent a lot of time talking about feelings, helping one another interpret, working on the Prompting Event worksheets.

    All that to say -- my experience was quite different, and I am dismayed to hear that others have had such negative experiences with DBT. (And I'm surprised to see it lumped with CBT, which to me felt so very different.)

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  12. CBT and DBT seem to have something fundamental in common just under the surface. As you say, CBT does not want to acknowledge the unconscious. Though DBT ‘claims’ to acknowledge it, it does it in a way that, in my way of thinking, can be more damaging for some than if it were never acknowledged at all.

    As you say, so much depends on what the person’s problem is. For many who endured early childhood abuse, the damage is such that the unacknowledged unconscious material is actually parts of the true self of the person who were left behind in order to survive.

    Now imagine, if that were your situation, and then you were told to ‘acknowledge without attaching’. Still not being allowed to attach to your own self. After surviving and struggling and searching for help and possibly feeling like you are hanging on by a thread by the time you think you have found it.

    For me, the unconscious was… ME. Me searching to reunite with me. The distress of my broken self looking for real attachment with my present self, the one that separated from the previous selves and their reality in order to keep some version of me functioning in the world while I was still living in the trauma.

    Enter the DBT stuff. WOW! I was finally allowed to ‘acknowledge’ my broken self, see it, admit its existence. And then?… I was told that feelings (broken self) are not facts, that I was not to attach to them, I was to contain them (again!), but under no circumstances should I take my broken self seriously enough to ‘attach’ to it. This was cruel, devastating and very damaging. Can you say cold double-bind mind fuck? It was a re-traumatization.

    If DBT helps someone to stay alive, then I’m glad. But it will never integrate trauma. For me, integrating a trauma is the only thing that has ever stopped its material from continuing to intrude. Everything else was a temporary band-aid that required constant and exhaustive work to maintain because it was all simply more dissociation.

    Sometimes I think much of the so-called treatment is more damaging than the child abuse. I am one of the lucky ones, though. I had the brains to see it and the balls to get angry and stand up and tell the unpopular truth even though it pissed off those who ’help’ me. Too freakin’ bad. They can all bite me. I won’t let them steal my backbone or keep me broken. I won’t give them that authority. I alone have claimed authority over how I regard my true self and that can’t be taught in any class. It can’t be learned in ANY venue that discourages attaching to the broken self.

    ...............
    end of DBT rant
    ...............

    Thank you for commenting, Prochaskas, and I'm glad you found something that provided some relief from your own situation.

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  13. I think the most important thing Prochaskas said is that she is NOT a CSA survivor. THIS is KEY...and I've always said: if DBT works for you, then FAB! BUT! If you are are CSA survivor, who uses "maladaptive" coping skills and you're told to shut up and behave, then DBT IS in fact, retraumatizing - and I am LIVING proof! DBT made me suicidal and self-destructive. It was HELL!

    Fot the record, DBT skills is a form of CBT that focuses on mindfulness and spiritual bullshit.

    CBT is GREEN TEA! DBT is GREEN TEA with a twist of lemon.

    I hate green tea

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  14. "Enter the DBT stuff. WOW! I was finally allowed to ‘acknowledge’ my broken self, see it, admit its existence. And then?… I was told that feelings (broken self) are not facts, that I was not to attach to them, I was to contain them (again!), but under no circumstances should I take my broken self seriously enough to ‘attach’ to it. This was cruel, devastating and very damaging. Can you say cold double-bind mind fuck? It was a re-traumatization."

    Again, this language of not attaching doesn't ring a bell with me. Maybe my group was unusually good...

    It makes me sad and a little afraid, because I can now add DBT to my list of things I'm afraid to recommend to any friends, because I certainly don't want to recommend anything that could hurt them.

    I'm really terribly sorry that anyone would ever tell someone that their broken self -- the feelings and experiences of their past -- are not to be attached to.

    How blessed I am that my first real therapy experience was with someone as good as it was -- (the psycho-analyst guy, not the DBT group) -- which has allowed me to see mediocre and bad therapy for what it is when I've been looking for new therapists. Either that or I've idolized him to the point that I can't see the good in any other therapist.

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  15. I just had a thought to add -- and again, this is just my own experience -- my DBT group felt like a place where people could finally learn to notice and identify feelings, and from there to explore what the feelings have to say to us, and from there to be compassionate toward ourselves, have a more full and authentic experience of reality with less avoidance...

    Wish it could be that for everyone!

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  16. You know what it almost sounds like to me, Prochaskas? It sounds like some pretty decent therapists in your area got together to form a group and just slapped the name DBT on it to get clients because DBT is the 'in' thing to do! Which, in this particular case, is not a bad thing. If you can refer select friends to this specific group that you went to, then maybe it would help them. I would still worry about CSA survivors though, because I don't know everything about that group and you would be surprised how many of us there are out here and we just don't tell anyone what happened to us. Since people, even CSA survivors, are all different individuals with their own experiences, I'm sure there are some survivors out there who feel differently about DBT, but most folks I've stumbled upon have stories like this one:
    http://kate1975.wordpress.com/2009/05/23/a-reiki-story/

    In any case, Prochaskas, if you took good things away from there that help you, then that is a very good thing. Though I still wonder about the appropriateness of labeling the class you attended as a true DBT program. It sounds like they simply used the basic concept of acceptance and left out the poisons. :-) Is it still DBT if no one tries to convince you that the appropriate thing to do when you are sad is to smile and that you are supposed to behave in the manner that is opposite to how you feel if the feeling is a 'negative' one? Is it still DBT if the therapists don't use manipulative methods of shaming clients when they are at their most distressed and if they are not instructed to quickly label their feelings and then stuff them away in containers? Your class doesn't even sound emotionally abusive! The folks who run it should watch out. If Marsha (program creator) finds out, she might strip them of the right to call it DBT. :-)

    I wish I had all the links right now, but I have heard stories of survivors being yelled at and berated for their distress in DBT, being kicked out of the class for mentioning their abuse or for getting triggered by the invalidation and then having an emotional meltdown that they just couldn't 'store' or pretend away, and the list goes on. What really gets me is knowing that so many therapists who send trauma sufferers to DBT know exactly what they are doing to them when they do it. I hope Grace won't mind, but consider this story: When she complained to her therapist about how bad DBT was making her feel, this was the response she got in her email: “Of course you are going to feel irritable after DBT class as this class runs counter to what your emotional mind wants which is to be heard, understood and comforted, vs being told to modulate, distract, “pretend” to feel good.”

    We were abused, scared and distraught. We asked for help and our helpers abused us some more. It's enough to make a person afraid to tell anything ever again. Which is exactly the point. They don't care if we are suffering just so long as we can hide it from them and stop whining so they don't have to deal with it and then they can just go on pretending the world is not so bad. DBT does not exist to help us, it exists to help them.

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  17. I think there are as many people out there who have not business doing therapy as there are people who have no business having children! Thanks you for sharing with us so deeply and for letting us use this important post for The Blog Carnival Against Child Abuse. As survivors, we really have to be careful what kind of "therapy" we get into. So much of it is totally re-traumatizing!

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  18. Yikes, yikes, yikes.

    All that stuff is there in the manual, and yet, how obvious it is, or should be, that THAT is NOT the way to apply it!

    The half-smile? I use that -- but not when I'm deep in the pit. I use it with moderate distress. It's just one little tidbit with a mild effect, like a nice cup of tea or a cuddle with the cat.

    The labeling feelings? Yes. But not stuffing them, immediately or otherwise -- no -- exploring them, observing, noticing, staying in them, neither pushing them away nor trying to make more of them than they are. The labeling isn't supposed to be about dismissal, but about identification, articulation, connection.

    Behaving in an opposite manner? This is another technique that I can use in moderate distress, but not deep in the pit. And it was quite clear that it's not denying or pushing away the feeling -- it's just not acting on the feeling either. It was a light bulb for me, actually -- it was a freedom. I COULD feel my feelings completely and fully, AND not have to be ruled by them in my behavior!

    Distress tolerance isn't supposed to be about denying the extent of distress -- it's supposed to be about being able to face the distress squarely, fully itself.

    None of the techniques were presented to us as always appropriate for every situation. They were tools -- to learn how and when to use, and when to reach for a different one.

    As for what emotional mind wants, well, the whole deal with that was to listen to emotional mind! Listen carefully and compassionately to it. AND listen carefully to rational mind. And THEN choose.

    When I go back now and re-read my manual, I don't feel like my group was twisting or adding to or subtracting from the text -- to me it seems like the text fits this group's practice.

    And I continue to be so very dismayed by what you're telling me.

    I don't at all mean that I'm trying to deny your experience or these others -- what I mean is that I feel really sad (and furious!) that my experience is not the more common one.

    Ugh.

    Ugh.

    Thank you for engaging with me on this stuff; and blessings to you in your continuing healing and recovery.

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  19. DBT is like Communism, Prochaskas. It sounds good on paper, but it doesn't practice well. Human nature prohibits it. You got lucky, honey. Take it and run with it.

    I'm wondering if how any DBT group functions might have to do with how much trauma exists for those attending and how much of it is dissociated. Most therapists don't have the balls to be with someone when they explore and stay with BLIND TERROR that comes from dissociated trauma. They can't stay with the feelings that come up from that even though it's not their trauma. But they think *I'm* the weenie? Hee hee. I find that funny. Personally, I think the average therapist is a big puss who wants to *fix* others to make up for not being able to fix their self. And that's where it all breaks down.

    It about trauma and dissociation, Prochaskas. Trauma is a different animal (yet more common than most want to admit). It is with trauma that the therapists twist the concepts because THEY can't stay with what's going on EVEN THOUGH IT'S NOT THEIRS. It's pathetic, really.

    I choose not to employ Marsha's fake half smile when I am dealing with abuse memories. I rarely ever use anything fake and prefer authenticity. The mere suggestion offends me and launches me off on a verbal attack of any therapist ignorant (or dissociated) enough to approach me with such a concept because it is NOT the same as a cuddle with a cat or a cup of tea. And unless I'm feeling homicidal or feel like screaming in the middle of the bank or the grocery store, I have ZERO interest in acting opposite to my real feelings. When people get too good at things like that, they lose their ability to relate honestly with their real self and with others (especially their children). Such dishonest practices can even make someone the target of criminals because they cannot respond from their gut anymore. This is especially dangerous in the case of dissociative survivors because such techniques are not really different from dissociation. They are the same. It's about pretending and separating the self from the truest inner experience and most survivors have spent a lifetime doing that and it eventually kills us if we can't find our way out.



    continued in next comment...

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  20. {{{{Grace}}}} and I (since we share the same sense of humor) have decided that there should be oranges in every rape kit. Maybe you can guess why? Yes! Because the rape victim should mindfully peel an orange and 'emotionally regulate' in the emergency room instead of crying and bothering others with their hysterics!! The nerve of those whining rape victims actually wanting comfort and compassion from somewhere outside of themselves! Bunch of cry babies. They really need to suck it up, you know? And did I mention that it makes me especially sick when trauma survivors have the true integration of their trauma prevented by being shipped off to DBT Land just because their therapist is a pussy? Well... it does.

    If I did not have any onboard skills of my own, I wouldn't have made it to age 43 without being arrested or locked in the psyche ward. It hurt me and completely OFFENDED me to be treated like a first grader having a tantrum when a major dissociative wall collapsed and I was horrified and crying because I had been raped and I will NEVER AGAIN forget how it made me feel to be treated that way. I CHOOSE not to for my own protection. I made that very clear to the new therapist when he asked me to make a list of the things I need from a therapist. The allowance of complete honesty was on that list with the following caution: "Any therapist who hands me a bucket or any other container in which to store my feelings will end up wearing said container on his/ her head right after I pee in it." And yes, I wanted him to read the list right in front of me while I watched because I have an EXCELLENT pussy detector. Because of my refusal to pretend.

    If you want to read more about dissociation and the rampantly popular twisting of the concept of mindfulness, I wrote something here:
    http://etherealhighway.blogspot.com/2009/11/on-time-and-great-dissociators.html

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  21. Did I tell you my doctor has referred me for cbt?
    I don't want to go, but I do want the anti depressants.

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  22. It is a bit surreal reading this. I'm having a really hard time with PTSD from my severe childhood trauma and everyone that I sought help from pushed me to try DBT. I did and it did not help me at all. It didn't comfort me. I can't stuff things in buckets for later. That's how I survived my childhood. I stuffed everything away...and now it's later and I can't fit anything else in the bucket.

    DBT did not help me at all. It only made me lose hope of ever getting any better.

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