“Tell me what happened. What led you to start cutting?” I would ask.
“Uhm… I’m not really sure!” Frith (not her real name. All pseudonyms will be marked with an *) would say. “I just felt very sad and started to cut! I just wanted to get rid of the pain!”
Or, as Peter (*) had said:
“I felt so numb, it hurt so much that I just went numb. And to feel something I started cutting!”
Or, as Sipho (*) said – he does it before bedtime as it helps him to sleep otherwise his mind cannot shut down and keeps sleep far, far away.
That is often the case that clients are sometimes uncertain why they cut. Sometimes it is due to immense and overwhelming feelings of sadness, sometimes it is a feeling of being numb and wanting to feel something.
Although the examples mentioned above focussed on cutting, other types of self-harming and/ or impulsive behaviour are analyzed, such as suicide, binge eating, burning, scratching, alcohol abuse, substance abuse, impulsive sex, gambling, and more.
In this blog I will be discussing the analysis of behaviour as it is done in DBT.
In DBT we refer to the process of the analysis of behaviour as Chain Analysis of Problem behaviour or just Chain Analysis.
As DBT facilitators we teach the analysis of behaviour to our clients for the following reason: analysing behaviour allows us to determine the causes of the problem behaviour and what maintains it. Once we know this we are able to change our behaviour should we want to.
Furthermore the Chain Analysis is a series of questions which helps the client to figure out what factors lead to the problem behaviour and which factors make it difficult to change those behaviour.
More eloquently, it is looking at the chain of events leading up to certain behaviours including emotions, thoughts, events, consequences, etc. that lead to the impulsive/ self-harming behaviour.
Ok! Great! But how is this done?
There are a couple of steps that will be outlined below as well as a vignette.
Carly (*) felt suicidal. She had been at her boyfriend’s apartment when she had the suicidal thoughts. What follows is a chain of events that lead up to Carly wanting to commit suicide.
Target behaviour: to reduce suicidal behaviour.
It was 2:00 am Saturday morning. I went up to the roof of a 10 storey building. I sat on the edge of the roof contemplating whether I should jump. At the same time I was thinking that my boyfriend and everybody would probably be better off when I die. I sat there for about 45 minutes.
Prompting event: events that usually lead to impulsive behaviour.
I was at my boyfriend’s apartment. He had some friends over and they were watching a soccer match between Liverpool and Manchester United. There were some beers around and I too had had a couple of beers. Somewhere midway through the match, about 10-ish, I remembered that my sister had an engagement party on Sunday. I asked him if we were still on for Sunday. He ignored me.
Vulnerability factors: these are usually factors happening before the event that leads one to be more vulnerable.
I have been struggling with insomnia the last few days.
My appetite has shot through the roof and we have not been on a date for a while.
I have been feeling depressed for some time now. I got to my boyfriend’s place at 5pm. His friends came over at 7pm and they were quite rowdy, high-fiving each other and I felt left. Things got worse as they got louder and rowdier. I felt even more left out. And the last straw was when I asked him about Sunday’s engagement party and he ignored me.
Drinking beers during the evening.
Links: the links are things that link the prompting event and target behaviour together. These would be actions and behaviors (B), emotions/ feelings (E) and thoughts (T).
In Carly (*) case there had been a time span of approximately 4 hours from the time that her boyfriend ignored her (10pm) till she sat on the roof (2am).
Silence from boyfriend. He ignores me, doesn’t answer me and keeps talking to his friends.
Thought: This is so humiliating
Emotion: Shame, humiliation, anger
Thought: he is such a jerk! How could he treat me like this.
Emotion: Anger!
Thought: if i disappear, he won’t even notice. I am so useless.
Behaviour: Went to the room, lay on the bed watching TV for a couple hours.
Emotion: stewing and boiling with rage at the way he treated me.
Thought: he shouldn’t be treating me like this. He hasn’t even noticed that I have gone. He is such a jerk!
Behaviour: I got up and went down stairs (12:30-ish). His friends were still there. They all seemed to be in a happy mood. He did not even look up at me. I asked “What’s happening?”, they answered “Nothing much!”
Emotion: Pissed off, Angry and sad.
Thought: Do I mean nothing to him?
Behaviour: Sat in the kitchen and had two beers.
Thought: Started having suicidal thoughts. Started ruminating. It hasn’t been the first time that he has ignored me when his friends were around.
Emotion: Really felt hurt and fed up with him.
Thought: I’ll show him!! He probably wouldn’t even care if I kill myself.
Behaviour: I started crying…
Thought: maybe i should call my therapist, or even a Sarah (*), but it is late and they are probably fast asleep.
Behaviour: Drank two more beers (1:30-ish).
Thought: Well, stuff all of them I am going to do it.
Behaviour: Get up from the kitchen stool, head to the staircase and go to the top.
Emotion: Still angry, my boyfriend didn’t even see me leave.
Tought: I’ll show him, I’ll do it. He’ll be sorry he ignored me.
Behaviour: Sat down on the edge of the roof, with my feet dangling over.
Consequences: These are usually the consequences of self-harming behaviour.
Immediate: felt a bit of a “rush” and “excitement”, but once I sat down I felt anxious and panicky. I thought “I don’t have the guts to do this…”
I Whatsapped my boyfriend and told him where I was. He said he is coming up to the roof immediately.
He was visibly upset and scolded me for wanting to do that. We spoke for a while and I could tell him that I felt ignored and left out. He apologised and said that we need to get me down from here, and that we could speak about it after we had slept and were refreshed.
Above is a typical example of what the Chain Analysis looks like. The aim is to identify areas where Carly could have tried different methods to deal with being ignored and the pain that she felt. Instead of acting impulsively she could approach the situation differently.
Missing Links
In order to intervene, or for Carly to have approached the situation differently or if it happens in future again, we apply what is called Missing Links. These are a series of questions that assists a person to figure out what got in the way of applying effective behaviour, or where did things go wrong in the “chain” which interfered with effective behaviour. In other words – how could Carly be more skillful or do things differently in order to be more effective.
Let us look at Carly’s chain of events.
The first area would be the prompting event. Carly could communicate to her boyfriend that when he does have the boys over, she could perhaps go to one of her friends, or have some of her friends over. This would help her not to feel left out or ignored. Communication though is key. Make a note to address the issue of the sister’s engagement party the following day.
If she chooses to stay she could reason with herself that her boyfriends are guys and are going to be doing guy-things.
The next step would be to reduce vulnerabilities. Carly could go to her GP for medication to enable her to sleep better, as well as address the Depression. She could also look into a healthy eating plan. Reducing alcohol on the night of the prompting event would further be recommended.
DBT has a variety of skills that will be addressed in future blogs that one can implement at any of the links that lead to effective behaviour. A skill that could be applied when she was ignored by her boyfriend was to deal with her emotions and feelings at the time. She could also realise that the situation is not ideal to ask her boyfriend and that she should not expect any kind of sensible response. Reducing the intake of alcohol would also be hugely beneficial. She could watch movies or series instead of just TV in general.
One of the great benefits of the Chain Analysis is that it brings one to an awareness of ones own behaviour and how one reacts to certain situations. If Carly would see a therapist, the therapist would be able guide Carly in finding healthier and more effective ways dealing with her discomfort in situations like these.
In DBT we believe that one cannot get rid of discomfort and painful emotions – and one shouldn’t – but rather learn to tolerate the discomfort. With this in mind I end with Marsha Linehan’s (Founder of DBT) slogan:
Build a life worth living!