DBT – Chronically Living

How Do I Become a Castle with My Boundary Setting?

A lot of people struggle with boundary setting in their relationships. I often see people complain that their family members don’t treat them well, that their spouses don’t, and it seems all the worse for people with chronic illnesses. And actually, that is part of what Gabor Mate says in When the Body Says No. Boundary issues are common within families, and perhaps are part of the “social” part of the biopsychosocial aspect of disease.

Image from: https://positivepsychology.com/great-self-care-setting-healthy-boundaries/

And look, I’ve been there. Though I have good boundaries with my family members, it’s often because I set them. For example, I tend to not talk politics with some of my family because our differences in views were causing me stress (and stress is bad for chronic illness!). I do sometimes still struggle in romantic relationships and friendships. Setting a boundary means being assertive, and sometimes that pisses other people off, especially if they’ve gotten a way with violating that boundary for a long time. As chronic illness warriors we need to get good at setting boundaries as part of our self-care. Here is one way of thinking of boundary setting.

De-stressing does not just mean bubble baths…

Imagine that you are a castle, and the boundary is the personal space that you are placing between yourself and other people. The walls of the castle show that personal space. The moat lets other people know how close they can get to you, and in this case it can change size depending on the person and/or situation. The draw bridge itself is what allows people to get in, and keeps people out. This draw bridge helps us to feel secure. The castle guards are the actual skills we have to protect our boundaries. They can also help us when someone crosses our boundaries. And it’s important to remember that boundaries can be verbal, physical, emotional or spiritual.

This is the image my practicum site gave clients when we gave psychoeducation on boundary setting.

So how do we exactly do this? Well, short answer is to say no, resolve conflicts, follow our values, be assertive, and express our needs. But that is easier said than done. Saying no and being assertive both require practice, and if we’re nice (which most of us with chronic illness apparently are), it’s super difficult to do these two things. If you have a therapist, then that might be where you practice these skills. Otherwise, it’s easiest to start with boundaries that aren’t going to upset the other party as much. The other pieces of this: resolving conflicts, following our values and expressing our needs can be handled with some self-exploration, by answering the following questions for ourselves:

Who are the most important people in my life?
Who is there for me when I’m struggling?
What are these above relationships like for me?
What are the positive things I get from this other person?
What are the negative things this other person says or does? And how does that affect me?
What do I want to get? And what am I willing to give?
What have I tried already in regards to boundary setting and how has this worked for me?

Once we’ve done this, we have three options:

Leave or end the relationship.
Stay and live by our values: change what we can (remembering that we can’t change other people’s behaviour) and make some room for things that we may not like (that aren’t in dire need to change)
Stay and give up acting effectively – which is all to common an occurrence

The more you practice setting boundaries, the easier it will be. It will also start to reduce your stress, which means you may start to see an improvement in your symptoms (be it physical or mental health), and are more likely to improve your well-being. Let’s keep making the most of it everyone!

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How Can I Become More Resilient?

This isn’t the first time I’ve posted about resiliency on this blog. The truth is, it’s a topic that comes up often. I see it on online support groups, on Instagram, and hear it in conversation with people. I also read it on other blogs, and many healthcare organizations post about it on their sites. Here’s the thing, if you have a chronic illness and you’re not feeling resilient, just know that you are not alone. A lot of people feel that way. Are people born resilient or do we develop resilience? I think it’s an interesting question and possibly a bit of both. Children tend to be more resilient than adults, suggesting we can lose some resilience as we age. In one of my courses for my graduate degree we had to more-or-less do a family tree. Except this family tree was supposed to trace something like a mental health or substance use issue. I chose to trace resilience, and found that going back just to my grandparents generation (that was the requirements for the project) there was a strong theme of resilience (my maternal grandmother/baba faced abuse, neglect, lost 2 children, and she and my mother were trapped in Siberia for a week during the Cold War – I know it sounds too crazy to be true). Yet she not only survived but was a loving parent to her other children and an amazing grandparent. Had my mom not shared my baba’s history I would not have know. She was that resilient.

Three generations of resilience in my family.

The good thing is, that even people with chronic illness can develop resilience. Warning: it does require work on your part. Luckily, some of the work may not feel like work at all… it just requires consistent commitment to it. I want to add, that many of these suggestions overlap with what the National MS Society suggests, in case you don’t want to just take my word for it.

finding meaning and committing to that action: what is the reason you get out of bed in the morning? If you don’t have a reason it will be difficult to do so. Is it your family? Or work? I know a lot of people with chronic illness go on disability, but work provides meaning and purpose for people. If you are on disability what is your purpose going to be instead?
improvisation/adaptability/problem solving: I think these all kind of overlap and go together. We often have to improvise in order to do things we enjoy. Maybe we can’t go on the 5k walk with our friends, but we could meet them for coffee afterwards. How flexible and adaptable are you to changing plans? Or asking others to? What’s an alternative way you can participate or do the things you like to do? I would go as far to make a list of ideas (remember when brainstorming there is no such thing as a dumb idea) and try out some to see if they work.
Self-care: we all know I love self-care, and this includes the basics (getting out of bed, making breakfast, taking a shower) and then doing activities like relaxation techniques, yoga, meditation, or prayer. What hobbies do you enjoy that you can participate in? Pick one a day. Reading is an example of something that is low energy and can be fulfiling.
Being able to tolerate “negative” emotions: I personally don’t categorize emotions as negative or positive. All emotions are important because they tell us very important things. If you’re not used to be able to just sit with emotions, try out this mindfulness practice that aims at helping people do just that.
Self-efficacy: I did a post on this recently, and you can read it here. Do you believe you can cope with your illness? Part of this is being a realistic optimist, being hopeful.
Using skills such as curiosity and humour: When is the last time you laughed? Are you able to have fun and joke around (and not in a self-deprecating way)? Do you get curious about your situation or feelings or sensations or emotions? What are you noticing about them right now as you read this? The noticing self is a helpful skill to develop. We touch on it in this podcast episode (about half way through).
Radical acceptance: This is a skill from Dialectical Behaviour Therapy (DBT) and essentially the same used in Acceptance and Commitment Therapy (ACT). It is about fully accepting your situation/thoughts/feelings/sensations/etc. Fully. Accepting. It doesn’t mean you have to like it. It’s hard to do a lot of the above without this kind of acceptance.

My curious, nonjudgmental, accepting, “what am I noticing” face.

I hope this helps give you some ideas for building resilience some more. Well-being and a good quality of life do require us to be resilient, and trust me, it is possible even with chronic illness. Here’s the link to the MS Society page on resilience. Take care, and keep making the most of it!

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Treating Depression

Depression is one of the most common mental health problems (right up there with anxiety). It also commonly co-occurs with chronic illnesses. If you’re feeling depressed, or have been diagnosed with Major Depressive Disorder, it’s really important you are treating it in some form. As a therapist-in-training, I see many clients with depression – some with both depression and anxiety, some with perinatal depression, some with depression and chronic illness – and there are a lot of evidence-based treatments out there. It’s really important to know that you don’t have to suffer alone. So I thought this week, we’d talk about some common treatments, and some up-and-coming ones for depression. I also have an entire podcast episode dedicated to depression and chronic illness this week, which you can access here.

For chronic illness, depression most frequently occurs in people with Alzheimer’s, autoimmune diseases of all sorts, cancer, coronary heart disease, diabetes, epilepsy, HIV/AIDS, hypothyroidism, and Parkinson’s. I got into the criteria for major depressive disorder in the podcast episode, so definitely check that out for more information. When it comes to treating depression, the two most common routes are anti-depressant medications and psychotherapy. Anti-depressants most commonly come in the form of SSRIs (selective serotonin reuptake inhibitors) that alter our brain chemistry because it is implicated in depression (our brains are not the only thing that is implicated though). There is a lot of research that supports anti-depressants in treating depression, though research also shows that it works as well as a placebo. In other words, if you believe it will help it will. Now don’t get me wrong, I fully support someone taking medication (unless you’re pregnant or breast-feeding and can’t – thus why I see many perinatal moms in my practice), however what a lot of people find is that just taking medication isn’t enough to see significant improvements in their symptoms, and many people don’t want to rely on medication forever.

Depression affects about 20% of the population in their lifetime.

That’s where option 2 comes in: psychotherapy. As a student, I see about 10 clients a week plus I co-facilitate a group for 2 hours a week. There is a lot of research that supports the use of psychotherapy. My podcast episode on anxiety, which you can access here, breaks down how much your therapist and you each contribute to your outcomes in therapy, which is important to know. As for what type of therapy, there are many to choose from and they all have good outcomes. CBT (cognitive-behavioural therapy) and it’s third-wave counterparts (DBT, ACT, SFT, etc) are the most common. Typically this involves a combination of talk therapy, where you tell your therapist about your thoughts and feelings, and then the therapist giving you some things to try out in session that you can also practice between sessions (some people call it “homework” but I don’t like that term). Another option for therapy is psychodynamic, which involves talk therapy plus the therapist often makes interpretations. And then there are the therapies that rely mostly on talk, utilizing the therapeutic relationship, such as person-centred, existential, etc. All of these can help and are something I highly recommend. There is also evidence that different lengths of therapy are beneficial as well, from one session of drop-in counselling to short-term (10-20 sessions) of CBT or long-term (more than 20 sessions) of person-centred therapy.

Our thoughts and feelings can be like quicksand. Our natural tendency is to struggle, but that only makes us sink deeper in. The actual way to get out of real quick sand: be a still and flat as possible and let yourself float to the surface.

If you are in immediate crisis because of self-harm, abuse, trauma, and suicidal thoughts/plans, then please contact your local help line. I’ve put some numbers in the show notes for my podcast on depression. A quick Google search can help you find them in your country. If you don’t like talking on the phone, there are some organization that offer texting services. I volunteered for Kids Help Phone in Canada which had switched to primarily a texting hotline since many young people prefer to text. You are strong for reaching out because it is not easy to.

In terms of other treatments, a few are available for treatment-resistant and severe depression. Electroconvulsive therapy (ECT), which used to be called “shock therapy” can be helpful for people with severe depression, though there are some potential harmful side effects, and psychiatrists don’t commonly use this unless necessary. Transcranial Magnetic Stimulation (TMS) is another option for treatment-resistant depression where magnetic pulses stimulate the nerves in your brain. Newly approved in Canada (and how I got the idea for this post) is the use of Ketamine for treatment-resistant depression. Ketamine is a dissociative drug that has a lot of research supporting its use for depression. It activates your glutamate, dopamine and serotonin receptors in your brain. It takes effect much quicker than anti-depressants and has shown to decrease suicidal ideation. So far research shows no long-term side-effects, though because it is a psychedelic drug, there is the chance of substance dependency.

Great video for anxiety and depression.

Whether or not you have chronic illness, if you have depression there is hope for recovery, and lots of options available. Talk to your GP, your psychiatrist, a psychotherapist or whomever else is or could be part of your mental health care team. That way, you can keep making the most of it.

Daily Mindfulness: Mindful Stretching

This mindful stretching exercise is from Marsha Linehan’s Dialectical Behaviour Therapy Skills Training Manual. The point is to focus on your breath and movement while doing a stretch that allows you to “reach for the stars.” Mindfulness can be done in many ways, and stretching (and yoga) is one of them! If you’re having trouble with mindfulness meditation, I suggest starting with these types of practices first. There are two versions in the video, one standing and the other sitting so this is accessible to everyone!

For more on the benefits of stretching, check out my podcast episode with Danielle Potvin here. And for more on the benefits of mindfulness for health, check out that episode here. Until next week, keep making the most of it!

Setting Boundaries

Boundaries are super important for all of us. With work, relationships, even ourselves. While boundaries are important for everyone’s mental health, I think that for Chronic Illness Warriors, the key is to be able to set boundaries that still allow you to ask for help when needed. I would say that I am pretty good at setting boundaries, but that was definitely a skill that I developed over time. I was reminded of boundary setting as I was preparing for group counselling that I’m co-facilitating as part of my practicum. So I’ll admit I’m borrowing some of this information from Marsha Linehan’s Dialectical Behaviour Therapy (DBT). The group has a few pscychoeducation components as well as counselling, including mindfulness (you know that’s my favourite), emotional regulation, distress tolerance, and interpersonal relationships. Though I’m not a “DBT-er” (I’m clearly happy to be co-facilitating the group though and learning all of this) I think that many bits of information from DBT and this course have great applications for many of us! (For those of you wondering I am drawn to existential therapy as well as Acceptance and Commitment Therapy).

Okay, so why should we set boundaries? Boundaries allow us and others to know what we are okay with and what we are not. For example, some people are huggers while others don’t like to touch (granted Covid, so many of us are in the non-hugging category right now). The person who doesn’t like to be touch needs to tell the other person (politely, if possible) that they are not okay with that. The tough part with boundaries is that if they are crossed, it can be awkward or feel rude to point that out. However, your mental health is important and if you’re really not okay with something it’s good to be vocal about it. Another example is a work one. Is it okay for your work to contact you when you’re not there? I was in a position about 6 years ago where I told my work it was totally okay for them to contact me when I wasn’t there. About two years ago (same company, different store) I told them I wasn’t okay with it. I set the boundaries and stuck with them based on the level of stress I was able to handle at the time.

When it comes to chronic illness, setting boundaries can revolve around many different areas, but I’ve found two are the most important: others, and ourselves. With others, you can decide how much or how little information those in your lives get about your illness/health, mental health, etc. I totally believe in sharing but everyone has different comfort levels with sharing, and I totally respect that, as I expect others to respect mine. Boundaries can also include what other people get to help you with. I loosened my boundaries after my hip surgery because I acknowledged I needed more help. Now granted I found myself feeling more grumpy at the time, but it wasn’t because I changed my boundaries, it was because I couldn’t as much myself! And that ties into our boundaries with ourselves. What are we okay doing? Saying? When we push our boundaries are we doing it to help ourselves or because we “think we should”? Sometimes it’s okay to push personal boundaries. With phobias for example, it’s possible to get over them by stepping out of your comfort zone and confronting the feared animal/situation/whatever it is (best to do it with a professional but I’ve known people to do this on their own). Getting over a phobia can be helpful for overall mental health. Saying yes to a night out with friends when you’re not feeling up to it is an instance of crossing your personal boundaries when it is not okay.

I’ve been sharing example from a “personal bill of rights” (Linehan, 2015) throughout and if you’re struggling with boundaries, I would say create your own (or use which ones of these resonate with you). Even stick it somewhere that you’ll see it often. Remember, that boundaries while important should be flexible because they lead to healthier relationships (including the one with yourself). I would love to see what you come up with so feel free to share on Instagram and tag me (@janeversuspain)!

Have a great week and keep making the most of it!