Behavioral Therapy (bt)

Behavioral therapy has evolved over the years. Today, it generally involves increasing contact with feared situations to increase your tolerance for discomfort. So, for example, a friend who was afraid of spiders avoided them to decrease his discomfort. It worked in the short term, but only encouraged him to avoid spiders and situations related to them in the long term. If there was a spider in his way and he ran from it, his anxiety decreased. However, he realized pretty soon that avoiding spiders limited his activities; he couldn’t get near a campsite, go on a picnic, or take a hike in the woods, for example. In fact, during the summer, he was almost unable to go outside at all. You can see how short-term relief of anxiety can result in impairment in life; the long-term consequence of avoidance is isolation and stagnancy. If this person exposes himself to spiders and doesn’t run away, he’ll initially experience extreme discomfort, disgust, and anxiety. However, continued exposure to spiders will eventually evoke a lowered emotional response. The long-term benefit will be the ability to do things in spite of anxiety and other sources of psychological discomfort surrounding spiders, allowing him to go camping, hike, or spend prolonged periods outdoors.

Changes in your anxiety response occur on a neurological level. Basically, your brain sends out distress signals when it perceives something that could potentially be dangerous. Responding to the distress signal by fleeing from whatever makes you uncomfortable will bring much relief, thereby increasing the likelihood that you’ll respond this way in the future (for example, if you see a spider and run from it, you’ll be relieved and will be more likely to employ this strategy in the future). Neurologically, the response to run away is strengthened. However, if you stay in the situation that makes you uncomfortable and no disastrous consequence occurs, you’ll strengthen the response of not running away. Once exposed to something that provokes anxiety, your brain will continue to put out the distress signal for some time. But a neurological state of arousal is not one that can be maintained indefinitely. Eventually, your brain will get tired and relax; you’ll have no choice but to relax because this process is your brain’s natural reaction. Likewise, exposing yourself to your depersonalization experience will eventually cause your brain to adjust, and theoretically, you’ll acclimate to the discomfort. Behavior therapy strives to put you into contact with all of the things depersonalization causes you to feel uncomfortable about. Other behavioral techniques put you into contact with things about life that are important to you and reinforcing for you. We’ll discuss these strategies next.

Exposure and Response Prevention (ERP)

Exposure refers to coming into contact with things you fear; response prevention means preventing avoidance responses that would be dysfunctional for you.

Depersonalization frequently causes people to avoid situations that provoke the depersonalization experience. This may include social situations, professional settings, or mentally taxing activities. If you have depersonalization and you start to feel very alienated during a dinner party, noticing how little you are connecting to the situation and others around you will likely worsen your depersonalization experience. When your feelings about being depersonalized worsen, the pain you feel may intensify to the point of inducing panic. At this point, the avoidance or escape response would be to excuse yourself from the party, thereby relieving the discomfort of alienation. In this example, ERP involves remaining at the dinner party and really allowing yourself to feel the panic that may arise. This sounds simple enough, but ERP can be a bit more complicated than it first appears. The following sections will introduce various ERP exercises.

EXERCISE: Exposure to Traumatic Experiences That Preceded DPD

As mentioned earlier in the book, depersonalization is often preceded by some kind of traumatic incident, such as sexual abuse or a physical trauma, or by use of psychoactive drugs. Referring back to the personal scenarios presented throughout the previous chapters, Emily initially experienced depersonalization after an episode of marijuana use; John acknowledged an early experience with depersonalization following a sports-related injury, though it didn’t cause any significant physical trauma; and Danny acknowledged an early history of verbal and occasional physical abuse from his mother. Many people with depersonalization relate having experienced emotional neglect or abandonment by their parents and other caregivers.

Thoughts about traumas and prolonged abuse may bring about feelings of anxiety, disgust, and depersonalization. Behavioral principles tell us that rather than avoid something that makes you uncomfortable, the best thing to do for your well-being is to go into the discomfort, really explore it, flesh it out, create elaborate mental imagery about it, and sit with those feelings until they run their course. The best system for doing this is to carefully recount the events leading up to depersonalization, writing them out in a specific and detailed narrative. Once you have written your narrative, pull it out whenever the feelings come over you, reread it, and try to reexperience the feelings. The sample narrative we provide next is what Emily wrote about an incident of marijuana use, after which her awareness of her experiences seemed permanently altered.

Against my better judgment, I said yes when the joint was passed around. My history with pot should have dissuaded me, but I figured it would be okay. I distinctly remember the feeling that came with the inhalation: it cut into my lungs aggressively and had sort of an overwhelming, spicy, tingly, itchy feeling that abruptly hit me. Suddenly my bodily sensations were hijacked. It felt like every molecule in my body was standing on end and rotating quickly. I felt like my body was about to act independently, without my instruction. I was afraid I was going to fall on the floor; I was afraid I was going to be pulled into space; I was afraid gravity would reverse; I was afraid my limbs would abandon my body. It was terrifying. Every time I moved my head or tried to reorient my awareness, I was overwhelmed by the feeling that I’d lost control. So I closed my eyes, curled up on the couch, and tried to block out awareness and ride it out. When I woke up the next day, the feelings of dissociation weren’t nearly as bad, but things weren’t right. My environment felt unfamiliar, alien. I had trouble taking in a scene; if I was looking at a kitchen, I knew intellectually that that was what I was looking at, but somehow individual parts of the scene didn’t fit into a complete whole. This was also how I felt about my body: when I walked, I knew my arms and legs were moving, but it didn’t feel as though they were working as part of an integrated whole. I kept waiting for these feelings to dissipate. I felt like there were cotton balls in my brain; the fuzziness felt like TV static humming constantly in the background.

Notice how Emily’s narrative describes the experience in a visceral way. This technique is useful because this type of language allows Emily to experience her memories similarly to how she originally experienced them. Writing this type of description will allow you to reexpose yourself to the original discomfort, thereby helping you acclimate to it.

When you write your narrative, be as specific as possible, paying particular attention to your internal experiences (for example, your sensations, feelings, and thoughts). Then when reviewing the narrative, read each sentence and really try to put yourself back into the scene; try to imagine exactly how it felt. This type of narrative works very well for exposing yourself to feelings associated with rape or witnessing a violent act; obviously you can’t (nor would you want to) reexperience the original trauma, but imaginal techniques allow you to experience some of the feelings associated with the original event. This allows you to become desensitized to the feelings and move beyond the trauma.

EXERCISE: Exposure to the Disastrous Consequences of Depersonalization

Most people with depersonalization can imagine a disastrous scenario in which depersonalization completely takes over and ravages everything that was previously enjoyable about life. These scenarios can haunt you. Also, in and of itself, depersonalization can become a source of anxiety. But willingness to have feelings of depersonalization and to face the fears surrounding it will allow you to overcome it. In other words, if you are willing to face the potential devastation depersonalization might cause, you’ll be less likely to succumb to it. Disastrous consequences are therefore a target for exposure. Similar to the previous exercise, the best way to expose yourself to the disastrous consequences of depersonalization is to write a narrative, or what’s sometimes referred to as a flooding statement. Basically, the goal is to flesh out the specific fears, making them awful and taking them to an absurd level. Usually these flooding statements end in death, isolation, or physical and emotional agony. Again, the purpose is to face the ultimate worst-case scenario so that your fears about depersonalization no longer control you. Flooding statements are usually phrased in the past tense, to make it sound as though your future self is telling the story retrospectively. Keep in mind that the goal here is not to describe what does happen to people with depersonalization but, rather, to blow up your worst fears about what could happen. The following flooding statement is from Susan, the person with DPD who was introduced in chapter 2. Again, her flooding statement doesn’t represent a realistic course for depersonalization, but rather, it inflates her fears about loss of autonomy, her doubt of her control over her actions, and her loss of affection for her loved ones.

Depersonalization just kept getting worse. At first it felt like I was becoming more and more alienated from my husband and children. I reached a point where I felt nothing more for any member of my family than a stranger on the street.

It was around this time that I started to feel like everything I did came from some source outside of me; I started to completely lose my autonomy. Slowly I began to realize that my body was, in fact, moving without my consent. It began slowly, with just the lift of an arm here, a tap of the foot there. But eventually I was having whole conversations that I wasn’t in charge of; I was driving to places I had no intention of going to. At first the things I did were more or less what I would do, but as my loss of autonomy got worse, I found that I was doing more and more stuff that disturbed me. I would say nasty things to my loved ones and put myself and others in harm’s way by driving in a risky manner.

Depersonalization just kept getting worse, and eventually I felt like I was merely an observer in a tower, looking down on what my body was doing and cringing at the choices “I” was making. I became violent in several situations, when normally I would be able to keep my cool. One time, I was in the parking lot, and a woman bumped into my car with a shopping cart. I flew off the handle, screamed at her, and started hitting her car with a baseball bat in retaliation. All the while, I couldn’t stop myself; I could only look on, horrified at my actions.

Several other incidents ensued, and all the while, my grasp on my experiences was collapsing. I found it difficult to integrate information, or even understand where I was or what was happening around me. I thought this must be what Alzheimer’s feels like. I couldn’t form new memories or remember what my body had been doing earlier in the day. I began to hear about things I had done that I had no memory of, horrible things. Apparently I had attacked my husband, scratching and slapping him. He was going to leave me, declaring that he couldn’t take this anymore, that he’d had enough. Furthermore, he was taking the kids. I was going to be completely alone.

It was around this time that my body stopped moving much at all. I found that I no longer had any control over my body and that whatever had been controlling my actions had now ceased. I was beginning to succumb to a sort of numb paralysis. My awareness of sensations was distorted and disintegrated. I can now sort of notice being in a room. Intellectually, I know it’s a room, but I can’t take in the whole scene at one time. My awareness is foggy and my attention is nonexistent. My family has completely abandoned me due to the tumultuousness of my situation. I believe that I’m in a hospital of some sort, and my arms are restrained. I receive no visitors except people in white coats. I have virtually no experiences I can retain. My awareness of my body and every one of my experiences come in glimpses but are merely fragmented snippets of my former awareness. Feelings of social alienation have given way to complete and utter isolation, leaving me more or less trapped inside my mind, observing my experiences in a disjointed fashion and having no life to speak of that exists outside the bed restraints. And what’s worse is that the doctors believe I can live a long life this way. This is all I have to look forward to forever.

Many people with depersonalization fear completely losing control. Susan’s flooding statement exposes this fear, providing a description of the absolutely worst imaginable inflation of this fear.

Compose your own flooding statement. If your greatest fear about depersonalization is loss of control, try to determine what really frightens you about that prospect. Is it doing harm? Is it being at the mercy of forces outside your control? Is it abandonment? If your fear is loss of social connection, what really upsets you about being unable to connect to people? Is it feeling as though you are missing out on one of life’s greatest joys? Is it losing someone who’s important to you? Is it having no one in your life and becoming a complete recluse? Really get creative with these stories. This is your opportunity to go into your worst fears to expose them for their absurdity.

EXERCISE: Interoceptive Cue Exposure

If you had a broken leg, you would feel the pain of it more if you tried running than if you were lying down. In other words, when we are engaged with sensations, those sensations will be more prominent to us. People with depersonalization often try to limit their internal sensations to avoid awareness of their numb feelings. But again, while that may provide relief in the short term, it naturally restricts what you allow yourself to do and consequently limits the richness of your life. That’s why interoceptive cue exposure (ICE) can be helpful. ICE involves awareness and exacerbation of internal discomforts in order to help restore your awareness. This exposure to the physiological components of arousal (such as increased heart rate and blood pressure, and shortness of breath) can also be helpful because it will shift attention from the anxiety and other psychological discomfort that depersonalization has you all wrapped up in.

Following is a list of interoceptive cue exposures you can practice to increase your flexibility so that you experience a variety of unpleasant or alienating physical sensations. As you read over the list, keep in mind that your safety is the most important priority. Don’t participate in an activity that you believe you may not be able to do safely (such as extreme exercise if you have a heart condition). Be sure not to do anything in the interest of exposure to extreme sensations if it will cause you physical harm, because self-induced physical harm will not only be physically unsafe but also counterproductive to your psychological health.

Stand outside in the cold or heat for an extended period.

Induce panic symptoms by:

holding your breath as long as you can; sprinting around the block to get your heart rate up, increase your blood pressure, and induce shortness of breath; straining your muscles to increase blood pressure; hyperventilating.

Take a shower that’s a bit too cold or too hot.

Fill a sock with screws and nails, tie it closed, and rest it on your hand, noticing any sensations that occur to you and how the sensations change over time.

Hold an ice cube for as long as you can.

Kneel on a broomstick.

See how long you can tolerate listening to really loud music.

Throw a pot on the floor to hear the loud noise it produces.

Slam doors—again, to hear the loud noise.

Eat something you don’t like.

Suck on a lemon.

Deliberately smell something you find unpleasant.

See if you can think of any extreme sensations you would typically resist, and give them a try, too. Notice that exposure activities are all aimed toward increasing your flexibility and tolerance so you can experience a range of sensations, including unpleasant ones.

EXERCISE: Exposure to Extreme Emotions

Depersonalization can sometimes arise in response to extreme emotional experiences, as discussed throughout this book. Therefore, exposure to extreme emotions may allow you to become desensitized to them, thereby increasing their tolerability. Next are some suggested activities, but don’t limit yourself to this list. You know better than anyone what types of things arouse intense emotions in you, so give it some thought and come up with some additional activities on your own.

Watch emotionally evocative movies—tearjerkers, violent imagery such as rape and murder scenes, or scary movies—and notice what emotions are inspired.

Have a loved one practice saying critical or upsetting things to you. This is not an opportunity for your loved one to take out frustrations or air grievances. Rather, you’ll choose exactly what your loved one will say, in an effort to inspire extreme emotions; then your loved one will recite the phrases verbatim.

Listen to angry or sad music for an extended period.

Look at photo albums.

Watch home videos of you and your loved ones. This type of activity tends to inspire bittersweet feelings, which is a good thing; don’t try to distance yourself from the discomfort that arises as a natural consequence of caring about things.

If you are an animal person, go to a pet store and give some love to a furry creature. The whole point is to feel something you can experience intensely.

Exposure to Feared Situations

Other important avenues for exposure are concrete things, or people in your life who tend to inspire feelings of depersonalization and consequently have been neglected or abandoned. Suppose chronic DPD led you to drop out of school, and now imagining being in an academic situation inspires incredible fear. This is the ideal exposure challenge. You can regard all anxiety- and depersonalization-inducing things as therapeutic exercises; imagine that your exposure exercises are merely practice.

If you really think about it, certain situations are more associated with depersonalization than others. Make a list of activities, places, scenarios, people, or settings that tend to inspire depersonalization, and then rank them from 1 (no depersonalization, no need to avoid) to 10 (very extreme depersonalization, always avoid), according to how strong your urge to avoid them is:

This table represents your hierarchy of feared activities. Start with the easy ones and start making contact. Get yourself into the situations, and will yourself to experience the emotional consequence no matter what it is. Don’t judge whatever reaction you have during this exercise; just be willing to experience it. At some point during one of these exposure exercises, you may have an urge to flee, to get out of the situation and neutralize your discomfort. Notice how you can have that urge but not act on it. Notice how your will and the corresponding action of your muscles have ultimate authority about what you’ll allow yourself to experience. Using the mindfulness and willingness strategies explored in chapters 6 and 7, notice how your mind chatters at you when you’re doing something unpleasant. It may say things like, “Wow, this is uncomfortable. I just want to leave,” “I can’t stand this anymore,” and “This exercise is stupid.” Notice how your mind responds to everything and that you aren’t necessarily required to act on your mind’s “two cents’ worth” about the situation. Getting back into contact with things that make you uncomfortable, whether it be social activities, mentally taxing exercises, or contact with certain people, will allow you to start getting back into life. A rich life is full of things that are pleasant and unpleasant. Having depersonalization, you’ve been dealt a particularly rough hand, but this doesn’t mean you won’t be able to live a rich existence.

Behavioral Activation

Behavioral activation is reengaging in things in life that are enjoyable or otherwise reinforcing for you. As is often the case when depersonalization interrupts your life, you have probably found that things hold less joy for you than they used to. Now’s the time to get back into those things, even if your heart’s not in it. The whole theory behind behavioral activation is that, often, people who are experiencing any sort of psychological problem become completely overwhelmed by psychological dysfunction. Some people who are depressed spend all day in bed, which reinforces their depression; people who really care about social acceptance to the point where they become very anxious in social situations don’t wind up having any social experiences; people with depersonalization want to feel something so badly that they lose contact with all the things that used to make them feel. Though an ironic tendency, it’s a very real obstacle to recovering from any psychological disorder. Fortunately, this tendency provides you with an important leverage point for treatment: even if you don’t feel like doing something you used to enjoy, do it anyway, and, hopefully, eventually you’ll find it rewarding in some way.

Make a list of hobbies, activities, day trips, and other things you found enjoyable at one time in your life. Then plan to do them. Schedule times for these activities and write them on your calendar. Don’t let yourself off the hook when the time comes; hold yourself accountable, and consider this a necessary step in your recovery process. Again, even if you don’t feel like it, do it. If you really make time and do these things, your life will become richer as a consequence. Your life will come to stand for more than just depersonalization.

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