Re-Traumatization in Mental Health Care (Part 2): Improvements

In my previous post we spoke about re-traumatization, what it is, and how it can happen within the mental health system. Now it’s well and good for me to sit here and say what is wrong with the system, but can it be fixed? The short answer is yes. Most systems are capable of reform if the work is put in. Mental health care has changed drastically in the last 50-60 years. Gone are the days when you could be put in an asylum just for having a child out of wedlock or even being unhappy with your housewife lifestyle. Although flawed we have a mental health act and a human rights act. Treatment is not yet where we want it to be, but we’ve stopped drilling into people’s heads for the most part.

I’ve recently been through some peer support worker training and training on working with personality disorder. This has been so valuable to me, both professionally and personally. It’s helped me come up with some ideas around how we can work on this issue. 

5 Steps to Trauma Informed Care  

1. Train staff on trauma and how it works - There is no point in setting up your service to be trauma informed if you don’t bother to train staff. It sounds silly, but I’ve seen it happen. New policies are put in place, but no one even knows they exist. For a topic as serious and complex as trauma, I would suggest a whole day of training; this should include someone with lived experience co-delivering it. 

2. Get to know the person you are working with - work with the whole person and not the diagnosis. No two people handle trauma the same way. 

3. Ask the person if they would like to make advanced decisions - What does this person want to happen in the event of an acute episode where staff may need to intervene? They may ask not to be restrained in a certain way as it reminds them of their trauma. Maybe there is something else that helps them when they are in distress that staff don’t know of. 

4. Consider gender, sexual orientation and race - many people have experienced trauma because of their protected characteristics. It’s been shown that race plays a huge part in the choice to restrain and detain people. Consider if someone with sexual trauma may not want the opposite gender involved in their personal care. 

5. Involve peer support workers (PSWs) - many people under mental health services find it easier to talk to them, because they have less power over them than a nurse. A PSW isn’t going to get you sectioned if you say the wrong thing. PSWs often have their own experience of trauma and so are able to empathise more easily. 

As someone who has used services for over 10 years and worked in mental health for almost as long, trauma informed care is essential to recovery. This advice is based on evidence and if it changes the way just one mental health worker thinks, then I'll be happy.

For those of you who are under mental health services, I would suggest trying to find a Service User Network in your area, by asking your nurse or therapist. These are usually run by those with lived experience and allow service users to have a voice in decisions being made by the NHS. It’s a really effective way to bring about change within the service. The old saying is true ‘there is safety in numbers’, but there is also power. 

Re-Traumatization in Mental Health Care (Part One)

When talking about mental health care it’s essential to talk about trauma; even more so when we’re looking through the lens of complex needs. Not addressing the needs of traumatised individuals leads to care that simply doesn’t work and in the worst scenario causes serious harm. I have experienced this personally and seen this happen as a healthcare worker. Today we’ll be diving into re-traumatisation and how the healthcare system in the UK can cause it. 

So, what is trauma? 

The dictionary definition of it is “Emotional shock following a stressful event or physical injury, which may lead to long term emotional problems”. In this post trauma will refer to any life event that has caused significant ongoing stress, emotional or visual flashbacks, nightmares or even just an awful feeling that washes over you. Feel free to define your trauma in a way that makes sense for you. 

What causes trauma? 

• Sexual, physical, financial or emotional abuse - this includes witnessing abuse

• War, natural disasters, terrorism, religious abuse, racial abuse

• Bullying, parental divorce, emotional neglect, death of a close relative

• Having a parent in prison or a parent with a severe mental health condition

All of these and many more can lead to someone becoming traumatised. It’s also worth mentioning that sometimes it’s not the ‘big’ life events that can traumatise an individual, but ongoing smaller events that slowly grind someone down. We know from the Adverse Childhood Experiences (ACEs) Study that those who experience a certain amount of trauma actually have a lower life expectancy than others, if untreated. Trauma is serious business and the NHS is beginning to acknowledge the dangers, not to mention the suffering that it causes.  

What is Retraumatization?

Reliving your previous traumas when faced with a similar event.

When I was around 10 my parents had a fairly messy divorce. My dad wouldn’t show up for visits and disappear for months on end with no explanation. This went on for many years and because of my age and previous attachment to him it caused me to become traumatised. I would become emotionally overwhelmed and clingy when situations triggered me. In my mid-teens I was able to push the memories down, but I never truly dealt with them. However, things got better and I got on with my life. Now here’s the thing with unresolved trauma, it has a way of rearing its ugly head. In my second year of university my parents decided to make an attempt at getting back together. It made me deeply uncomfortable, but I was happy for them. For a while it worked, but unfortunately I found out that my dad had started cheating on my mum again. I didn’t necessarily think they would stay together, but a fear started to arise in me that he would be gone from my life all over again. Dealing with these constant triggers from their relationship were what retraumatised me and pushed me over the edge. It was the biggest cause of me falling into my first proper breakdown of my adult life and when they eventually did split up, what caused me to drop out of uni. The emotions around being abandoned by a parent all came back to me and in my panic I ended up putting myself in A&E. This is the reality of the damage retraumatization can cause.

What happens in mental healthcare that retrumatizes? 

So this is what we’re really here to talk about today. You might be wondering how a service that is set up to help people could ever exacerbate the symptoms they are seeking to treat? Or, like me and many others I know, you might have first hand experience of this happening. In my eyes there are two main things that healthcare professionals and the current Mental Health Act do that causes retraumatization.

Coercion 

This is a tactic that I have experienced both in hospital and community settings. Coercion is a bit like emotional blackmail. It’s used to get people to do things that they don’t want to by threatening to give a punishment or take away a privilege. I remember once I questioned some of the long term medications I was prescribed, explaining that I didn’t think they were helping and that since the side effects were so bad I wanted to stop taking them. I was informed by the community nurse that if I didn’t take them that they would remove me from the therapy waiting list as I ‘clearly didn’t want to get better’. I immediately knew what she was doing was wrong, but she used her authority and power to take away my choice to make decisions about my own body. It wasn’t protective, it was to make her life easier. Even if the healthcare professional thinks the coercion is for the benefit of the patient, it’s almost always for their own. What she should’ve done was open up a conversation with me and schedule me in for a medication review. But that was going to take her more time than threatening me.

Control 

This is an aspect of mental health care that you almost certainly have heard of. It conjures visions of old asylums and straightjackets. Whilst we have largely moved on from these methods, some still remain. These range from medical and physical restraint to being secluded for emotional outbursts. Now those of you that work in health care might be insisting that restraint is essential to keep others safe in certain situations, and I actually agree with you. However, I’ve seen it happen to a person for simply raising their voice and becoming emotional. Restraint should not be happening until there is no other option to prevent harm. 

Coercion and control are used to force people into complying with mental health workers and services as a whole. It even goes higher than this. The current mental health act can leave those with mental health conditions with even less rights than prisoners. 

So why do these actions re-traumatize people? 

• Physical restraint can look a lot like what survivors of sexual violence may have gone through. Being physically forced and held down can bring back horrific past memories. 

• The previous point is also relevant to the violence that BAME people may have experienced at the hands of the police force. 

• Those that experienced emotional abuse during childhood or domestic violence, will likely be triggered by coercive behaviour. Leaving them fearful and unable to trust their health care worker. 

• Those who have been abandoned in the past (like myself) might find the way that services suddenly discharge people to be very triggering. They then get labelled as clingy or problematic when they have a trauma response. 

This is by no means an exhaustive list. There are many flaws in the system that are causing more hurt than healing. The way in which mental health services deal with trauma responses perpetuate further trauma. Thus creating a vicious circle of emotional and physical damage. Do I think the system can change? Yes, very much so. By educating organisations and staff we can minimise the damage caused. In my next post I will be talking about the steps that need to be taken in order to achieve this.

BPD & Daily Life: Work

Work has a pivotal part to play in the day to day lives of many, if not most people. For some, work is what keeps them occupied and thriving. For others, it’s simply a means of survival. But how is work affected when you have a severe and enduring mental health condition like Borderline Personality Disorder? 

Before I dive into the ins and outs, I think it’s really important to note that not all jobs are going to give the same experience. People with BPD can work all sorts of jobs; full time, part time, 9-5s, shift work, self-employment, small businesses and large corporations. Then of course there are creative roles that you can get paid for via donations. These and many more types of work are valid and mustn't be discredited. For the most part I have only had roles where I’ve been employed by an organisation or company, so my personal experiences will come from that environment. 

Living with BPD for all of my adult life has meant that I’ve formed a rather complicated relationship with work. Up until the last couple years I associated work too closely with the meaning of my existence. My unstable sense of self has often meant that when I get a new job that becomes my new identity.

Perfectionism & Burnout 

I throw myself into the role fully. Often over exerting myself and taking on a workload that would be way too much for most people. If you have BPD work can be extra tiring, as we attempt to mask our symptoms for fear it will cause our colleagues and bosses to dislike us. So what does work see at first? An eager employee with a glowing record who is generally well liked by their colleagues. At home? An exhausted mess of a human who will engage in maladaptive coping mechanisms. I can usually keep this up for a few months before the burn out starts to show. I wake up to my alarm, wishing I didn’t exist, before forcing myself to go in. At my previous job I had to take numerous breaks hiding in the toilet or the store cupboard just to let my facade drop for 5 minutes and allow myself to cry. Eventually the stress of it all stops me from coming into work altogether.  

Paranoia & Boredom

At the point of early burnout my perception of the job easily flips, and I begin to demonise the place and everyone in it. Managers I once saw as friendly and fair, become villains that are out to make me miserable at any cost. I worry that my coworkers hate me and just want me gone. My perfectionism slips and I try to avoid doing tasks for fear that people will judge. I make myself look busy even though all I’m doing is panicking. If it was a job that I previously enjoyed, I lose all interest, grow restless and bored. Honestly, when it gets to this point there is no going back for me. It won’t be long until I have to quit and find a new job. 

Dissociation & Distraction

Another aspect of BPD that can make work difficult is dissociation. This is a common symptom and for me the most disruptive. It causes me to disconnect from the present moment, to become lost in thoughts, or unable to understand that the world is real. Because of this I might miss out on important details, causing me to make mistakes. Whether or not I get in trouble for them, I will usually tear myself up about it and put myself down. The critical internal voice tells me I am stupid and worthless. Even though I know it’s because of my mental health issues I still won’t cut myself any slack. 

Medication

It’s worth writing a very short note about mental health medications. They often have very complicated and unpleasant side effects such as: drowsiness, stomach/bowel issues, shakes and nausea. Dealing with these at home is bad enough, but dealing with these at work can be a nightmare. 

So, I’ve talked about the struggles with BPD in the workplace, but I wanted to add a more positive note. People with BPD are often creative and passionate, and can thrive in the right workplace. 

Here’s 5 ways of working that might create a better environment for people with BPD: 

1. Part time work - If this is an option for you financially.

2. Self Employment - I know several women with BPD who run dog walking or small crafts businesses. 

3. Working for a disability confident employer - Some organisations have extra support and offer mental health days.

4. Flexible working schemes - Check out if your employer offers this and what would best for you.

5. Working from home - This is becoming ever popular after the pandemic, so many office based jobs offer this.

Whatever you choose to do, remember that work is not your entire life. Whilst essential, it’s important to practice self-care and if you really need that sick day then take it.

Your health is more important than any job. A lesson I’ve had to learn the hard way.

Why is Serenity Integrated Mentoring (SIM) destroying the outcomes of vulnerable people?

Content warning: A triggering discussion with mentions of abuse, self-harm, suicide, systemic abuse. 

I'm taking a break from my usual topics today to bring your attention to a harmful programme being used by 23 out of 52 NHS trusts in the UK. Please stick with me until the end and I will try to explain why you should sign a petition and write to your local MP.

Serenity Integrated Mentoring (SIM) is a scheme developed by Sgt Paul Jennings (ex police in Hampshire constabulary). It is worth mentioning that Jennings' limited company (HIN) is in the private sector. SIM allows emergency services/crisis services to turn so called 'frequent flyers' away; even if these people are actively harming and suicidal. Let's run through a scenario of how someone could be flagged, put on the SIM list, and what this would mean for them: 

For the last few years I haven't been coping well with life. I was abused throughout my childhood and grew up living in fear. When I finally found a way to leave my abusive home, it was through moving in with a partner. Here I experienced sexual abuse and domestic violence. I began self-harming. Healthy coping mechanisms were never modeled to me in childhood, so I become extremely overwhelmed by even small stressors. The self-harm was a way of coping. On my dark days I feel empty, I feel hopeless, and I think that everyone I love will leave me. But, I don't want to hurt people by taking my own life, so I go to get help from mental health professionals. They tell me that I should just stop self-harming, that I should use better coping techniques, but waiting lists for the treatment that will teach me those skills are years long. I am sent home with a harsh word and no support. Over the next few years I frequently turn up to A&E begging for someone to help me. Each time they tell me to stop what I'm doing and offer a limited service (usually involving 1 or 2 home visits before immediate discharge). They grow increasingly sick of me as they are not trained to help me. One day they tell me that due to my frequent contact they will no longer be allowing me to come to A&E or use crisis services. They have given up on me, just like everyone else in my life has. Despite my increasingly self damaging self-harm and suicide attempts, I am told that I am an 'attention seeker' that I am 'wasting public funds' - finally they have confirmed what I have always known - nobody cares if I live or die. 

These are common life experiences (and emotions) of people with complex needs and personality disorders. This leads onto the topic of who is being affected by these barbaric practices: 

• Heavily traumatised women with complex PTSD

• Survivors of repeated rape, incest and other abuses

• Those diagnosed with a personality disorder are more likely to be listed

• Those who grew up in poverty

• Those who are homeless and/or involved in sex work

• BAME and/or LGBTQ+ people

The only 'support' (as HIN describes it) that those on the SIM list are offered, is to be assigned a police officer who discusses management of their 'behaviour'. Police officers are there to enforce the law and shouldn't be used to coerce people into not seeking psychological support. In many cases the trauma that people have experienced has involved the criminal justice system, especially in the case of BAME and LGBTQ+ people. 

Personality disorders are described as severe and enduring mental health conditions. In fact Emotionally Unstable Personality/Borderline Personality Disorder has the highest mortality rate of any mental health condition (excluding eating disorders for physical health reasons). 10% of people living with BPD will complete suicide, compared to 0.0112% within the general population. By rolling out SIM the NHS is choosing to minimise these statistics and create their own reality, in which they ignore the suffering and potential risks of those with complex needs. It is widely known that personality disorders don't simply clear up on their own. It takes years of intense therapies such as DBT. Without these interventions outcomes are deeply concerning. These people are consistently presenting to crisis services, because society and the system has failed them. We also know that severe mental health conditions, if not treated, will worsen and increase the likelihood of poverty and homlessness, vulnerability to further abuse, and substance misuse.

For anyone who understands mental health, it is clear to see that SIM is an unethical scheme not fit for purpose and is actively causing lethal harm. There have also been no trials made public that support its use in improving outcomes for any patient groups. It also comes with an extremely dangerous idea bubbling just under the surface. 'People presenting in this manner are not mentally ill and do not need treatment. This is the way forward for treating people with complex trauma.'  Having worked in the mental system for many years and having been a service user myself for even longer, I know that ideas like this spread like wildfire. Part of my current role involves looking at the treatment people with complex needs experience. Our service user led team has been fighting the stigma and trying to improve attitudes among healthcare professionals. The NHS trust that commissioned us, actively using SIM, is massively undermining all the work that we are doing. It is moving away from a people first model and onto a business first model. Read: Saving money over lives - siphoning money out of the NHS and into the wealthy pockets of private business owners.

There is currently no independent enquiry or investigation taking place. Some trusts have promised an internal investigation, but 'marking your own' work is not sufficient when we are talking about the lives of severely traumatised individuals. As of last week HIN appears to have removed their website for unknown reasons.

Please sign the petition for a halt to SIM and an independent enquiry to be launched. I've included a link to more information and on this page you click to sign the petition. https://stopsim.co.uk/

Let's end the systematic neglect and abuse of those living with complex mental health needs. 

BPD & Daily Life: Physical Health

Can Borderline Personality Disorder have an effect on your physical health? Short answer: yes! In fact if you have BPD you almost certainly realised this long ago. Poorly managed mental health is often detrimental to our bodies. Depressive or low moods may lead to us not being able to eat balanced meals, do exercise and take care of our personal hygiene. 

I remember one very hot summer I hid under my duvet, with no water, no showers, and a box or two of pizza for the most part of a week. I think in the end my housemate intervened by bringing bottles of water to me. All I could think of at the time was how I couldn’t face another 20 years of existence. Looking back on it I was emotionally exhausted from learning to ‘mask’ my symptoms, trying desperately to keep up with uni work, and learning to live away from home. I had a lot on my plate and it simply caused me to freeze up. 

These days I have learned to manage my burnout in a healthier way, despite it still hitting me hard at times. I am much more in control of my symptoms, but my physical health has suffered over the years. Let’s talk about a few of the problems people living with BPD encounter: 

• Weight - In my experience this one is very common. This could be either being overweight or underweight. There are lots of contributing factors here: medications that cause increased appetite (or the opposite), lack of motivation to exercise, emotional overeating and even not having the mental stability to cook a healthy meal. It is also vital to mention that those with BPD often have a comorbid eating disorder that can go hand in hand with poor self-esteem and feeling out of control.

• Underlying health conditions - Because people with BPD face a lot of stigma from healthcare professionals and therefore are more reluctant to seek help, things can get missed. Repeated invalidation from services is enough to re-traumatise us and make us avoid getting help from our GPs. Alternatively the BPD diagnosis becomes a distraction and often symptoms of other illnesses are contributed to mental health. I recall one story of a girl with BPD who was going to her GP for months, presenting with chest pains and feeling clammy. The GP put it down to anxiety and did no further investigation. It was only after she had a heart attack in her early twenties, that they realised she had a heart condition. This isn’t an isolated event, I’ve heard many stories like this from friends and other BPD content creators.

• Liver/kidney damage - This is something I’ve heard less about, but if you take a couple of things into consideration it makes sense. Firstly liver damage can be caused by excessive alcohol use. We know that many people with BPD also struggle with substance misuse and impulse control problems. Secondly, we know that overdoses of certain medications can also damage the liver. So we can safely assume that acting on our impulsive urges can cause us some pretty serious physical problems. With regard to kidney damage, I used to work with a woman who developed this through refusing to drink much water due to her low mood. 

• Digestion issues - this one is quite personal to me, but if you’ve read the ACEs study (seriously go research this, it’ll blow your mind) you can see how this could happen. I’ve had on and off stomach problems for most of my adult life, and I’ve suffered a lot of pain in my abdomen. I kept going to the hospital in agony; a roaring burning pain in my stomach that would have me on the floor screaming. No one could ever work out what the problem was - mainly due to the very long waiting times at my A&E. The pain would subside and I would be sent home. Eventually the doctors decided to do some investigating and it turned out that I had developed a stomach ulcer. There are many reasons why someone can get a stomach ulcer, but mine was put down to constant stress. Not really a situation I can fix when I live in a perpetual state of anxiety. I take medication for it and it is better managed now, but I have to be careful of what I eat and drink and take my meds wherever I go. 

• Dental problems - I wasn’t planning to write about this, but as I was thinking I realised how much of an issue this one is. I have been lucky. Countless nights of passing out without brushing my teeth and days where I simply couldn’t get the energy together, haven’t really caused me problems. I’m 29 without a single filling and have never had major work done in my adult life, despite not going to the dentist for a decade at one point. Others aren’t so lucky. It is a known fact that some antipsychotic medications can cause dental problems and weaken teeth. I know a few people who have rotted their teeth beyond repair thanks to not cleaning them, smoking cigarettes and avoiding the dentist. There have even been studies correlating poor dental hygiene with heart disease. 

As you can see, living with BPD and other mental health conditions can take a huge toll on your physical wellbeing. Remember when you are in treatment to talk about your physical health concerns and needs. You’re going to need help with it and you deserve to be looked after holistically.

BPD & Daily Life: Masking

 

Those of us living with Borderline Personality Disorder will be aware of the common experiences we share, but often we talk about our symptoms at crisis point. So what about every day? What’s it like to live with this persistent and pervasive disorder every moment of our lives? 

I’m approaching this as someone who was diagnosed over 8 years ago. I’ve had time to get to know myself and develop some coping mechanisms. I’ve been through several types of therapy and I appear “functional” most of the time. I’m going to address different aspects of my life and how they are affected by BPD over the next few posts.  

I wanted to talk about why many people that know me personally don’t know about my diagnosis and often act shocked when they find out. It’s called “Masking”. If you’re familiar with the autistic community or other forms of neurodivergence you may have heard of masking before. Within the context of personality disorder, masking is hiding your symptoms in an attempt to “act normal” and avoid being detected. For me this involves using bathroom breaks to hide anxiety attacks, dissociating rather than letting people see my emotional reactions, mirroring the likes and dislikes of others so they don’t find out I have no stable sense of self, and simply not talking about any of the struggles I go through. Whilst masking has come in handy for things like holding down a job and fitting in temporarily, there is a price to pay. All that effort put into controlling what others see, leaves me burned out and exhausted. I’ve jeopardized a few jobs and even friendships this way, when I disappear/isolate for a few months to recover. 

So what sort of things do I have to mask about my day to day experience? 

• My intense emotional reactions - these can be triggered by the smallest things, such as someone looking at me the wrong way, me misinterpreting a comment or even feeling as if I’m doing “too well”

• The constant judgemental commentary of myself and others that leads to intense social anxiety

• Trauma flashbacks that can be triggered by smells, sensations or sounds (yes, there are periods where this might happen every day)

• The panic of someone asking me about my likes and dislikes - these days I have a stronger sense of my preferences, but it still causes me to have an internal meltdown

• Intrusive thoughts - these can be around self-harm, paranoias or delusions

More recently I am finding more ways to cope with my symptoms that don’t involve the tiring process of masking. I’m starting conversations with my friends about the “real” me, and looking for ways of working that allow me to be myself. Let’s not pretend that recovery from BPD is easy, but it certainly is possible with the right help and support.

Hey guys, I'm back

And it's great to be back... 

As I mentioned in February, I had a lot on my calendar in the name of career development and self improvement. It's been great for me, but I'm really pleased about finally having some time to sit down and write. 

Recently I've been writing a lot about DBT skills, but I would love to go back to what the core of this blog is about. I'll be writing some short pieces about how Borderline Personality Disorder affects my day to day life. It was originally going to be one post, but it turns out there are so many aspects, I needed to break it up. So look forward to this new content over the coming months. 

Out of Darkness Xx

Brief break in posting

 Hi all,

By now you may have noticed a slowing down in my posts. I just wanted to explain the exciting things going on for me. 

I have worked part time for a couple of years now, which suits my health. This year on top of this job, I started DBT (after many years of waiting) and a level 2 qualification in counselling. I've also been spending a lot of time doing paperwork, because we're also about to become homeowners.

I've been given a fantastic opportunity to work closely with the NHS Personality Disorder team in my area. I will be working to help improve services and deliver awareness training to staff.

Because of all these (positive) things going on at once, my blog might not get content as quickly as usual. I appreciate everyone who enjoys my content. This is not the end of the journey, far from it and I hope in a few months I will have some of my time back.

See you all soon, 

Out of darkness Xx

DBT Skill: How you can create your own emergency self-care kit

Part of the Distress Tolerance module of DBT, creating a Soothe/Distract Kit can really help you out in a pinch. It helps you to put the distress tolerance skills in a more physical place that doesn't require much thought. If you're feeling overwhelmed, but still have the ability to open up your toolkit, then this is the time to prevent your emotions from taking control. Alternatively, you've just used your STOP and TIPP skills, and now you need to bring down your emotional arousal. 

Each person's toolkit will look different and is extremely personal to the owner. It needs to reflect what helps to take you away from the situation and what helps to calm you. Today I wanted to walk you through what's in my Soothe/Distract Toolkit. 

So I think the best way to start is to find a nice box or gift bag. My toolkit resides in a shoebox, but mainly because I love The Nightmare Before Christmas. If you have a more plain box then you can decorate it with patterns or themes you like. 

Under the lid I've put ways to soothe my senses that you can't box up. Such as suggestions to listen to soothing music or using my weighted blanket. There are a list of extra distractions as well. Finally I've put some self-affirming coping statements to help me feel more confident. 

Inside you'll want to include items that either distract you from the way you are feeling, or that help to soothe your body and mind. In DBT we talk about soothing the 5 senses, which are: Vision, Hearing, Smell, Taste and Touch. Try to include as many of these as you can to give you more options. 

Taste is probably my 'go to' way of soothing myself in a crisis. As someone who has always struggled with binge eating the key to balance is to use these food items for mindfulness. I put down everything I am doing to purely focus on the food. The way it looks, the texture, the aftertaste. Sugar free lollipops are especially good for this as you have to eat them slowly. Another tip is to find foods that take you back to a pleasant, safe memory.

The sense of hearing is slightly harder to embody physically in your box. I only have one item which was a gift from my godmother for my 18th birthday. It's a metal heart filled with small pins, which create a pleasant, mysterious sounding jingle. It's actually a larger version of a baby rattle that made the same sound she'd gifted me at my christening. I find the noise it makes really soothing. Another way you can incorporate your sense of hearing is to make yourself some playlists of both soothing and distracting (upbeat) music. You can make a note instructing you to use these and put it in your toolkit. 

Sense of smell can be incredibly powerful. It can bring us back to certain places and times with just one sniff. I've often experienced perfumes or aftershaves bringing on panic attacks if they remind me of people/situations I don't want to remember. However, you can use this to your advantage! Look for smells that take you back to good times or just those you enjoy. Scented candles or incense are brilliant for this. I really like the smell of dragon balm so always keep a pot of that around. The perfume is good, because I can still smell it on me when I'm away from my toolkit. 

I have quite a few items for touch. I have some more physical distractions here. The green thing is called a tangle. It's bits of plastic that you can rotate and make different shapes with. I find it to be good for channeling anxious energy or grounding yourself. You can get them online, but I got mine for free during one of my mental health admissions. You can see some bath items here such as salts and a bath bomb. If you can manage to run a bath whilst you're feeling overwhelmed then they are good for focussing your senses. Again the dragon balm and a lip balm can be used for the sense of touch. Smooth stones or other textured things can also be good. 

Here are some visual items. Anything you enjoy looking at. I have a stone I found on a beach walk with my partner some years ago (it also holds a happy memory). Some people use pictures of loved ones or maybe stickers you can put over the inside of your toolkit if it's a box. 

Not everyone will want to do this and it's not necessarily covered in DBT, but for years I have kept letters to myself. Usually they talk about better times and self-encouragement. I've found them helpful when I'm in a crisis and don't feel like I know who I am. Letters from loved ones can also be helpful, but I'd be wary about using ones from partners incase of a breakdown in the relationship or the crisis being triggered by something related to them . 

Items for soothing can be easily kept in your toolkit, but distractions need a bit more creativity. I bought a really small flip book and wrote a distraction activity on each page. That way I can flip through and see what I land on. If I don't feel like doing that one I can move to the next. It doesn't take long to do and you can always add to it. 

So there you have it. My emergency self-care kit based off of what I've learned in DBT. You don't have to be involved in DBT or even have BPD to use one of these. Personally I think we should all be taught skills like this as children. Learning how to distract and soothe myself rather than relying on others has been a godsend. It has also made it easier on my partner, because there is a physical aid he can give me to help me cope better. I'd highly recommend creating one of these toolkits, as I get so much use out of mine.