DBT Haiku

Tags

acceptance, DBT, mindfulness, practice, therapy, willingness

learning to accept

resistance slowly fading

I practice willingness

Hope and Stuff

Tags

anxiety, birth control, DBT, depression, Emoquette, estrogen, group, hope, meds, Pristiq, side effects, transitions

Monday started out full of anxiety and worry, plus three appointments: the PNP (psychiatric nurse practitioner), Hippie Dude (therapist), and the DBT group. Between that and the requisite pharmacy stop, there was time for only one work task all day.

It began with the PNP – let’s call her Nurse Nycta, since her awesome blonde-with-black-and-purple hair reminds me of night-herons. I went in armed with my entire binder of medical info (nowhere as impressive as Ruby’s) and was ready to wrap things up as best we could. Like a space cadet, or someone who’s been out of her head with depression and side effects for much too long, I assumed my appointment was the usual 9:20, and showed up at 9. It was at 10:20. Fortunately, I had a book.

Anyway, after just a week, we felt 99.44% certain that a therapeutic dose of Pristiq would cause panic attacks and side effects that demand immediate discontinuation. It’s become a clear case of hypersensitivity and genetic contraindication – for literally every antidepressant except one (Wellbutrin). I handed back the second sample pack and that was that.

Here we go again…

There’s no question that real issue to clear up first is this pesky estrogen thing. Estrogen basically messes with everything in your head. And then some. Nurse Nycta prescribed a birth control pill, even though it’s not her usual purvey. Making me wait for a gynecologist’s blessing would be downright cruel, and I just can’t afford to keep losing so much time. We’ll follow up in two weeks, but I’ve decided to follow her when she changes employers. It’s a huge relief.

After acquiring a copy of all my labs to date (knowledge is power, yo) I was off to the pharmacy with a renewed sense of hope and a touch of optimism, both of which have been sorely missing of late. The new pills (a generic for Desogen) have quite possibly the worst drug name yet: Emoquette. I mean, seriously, who names this stuff? Yeah, I’m an emo coquette. Right.

Next stop was Hippie Dude for the therapy appointment I made during last week’s total freakout. It was a good discussion; we talked about the meltdown, all the medical care changes, the Intrusive Thoughts, and the notion of getting off psych meds. We’ll see where that goes, but don’t worry, I won’t do anything rash or stupid.

Finally, DBT group topped off the long day. It was actually a really good session, aside from Peppy Mommy being all “me me me”. Since I blogged the entire sequence of DBT from the first round and I’m tired of writing about it, I’ll just be making updates here and there going forward.

I’m grateful to be in a much better place than last week. A little hope goes a very long way.

Back to DBT

Tags

anger, BPD, DBT, distress tolerance, emotion regulation, group therapy, invalidation, judgment, mindfulness

I had a nice break from DBT over the holidays – 3 whole weeks off. We started back up again with Core Mindfulness. I’m finally getting it, instead of just being annoyed by it; of course, we also had 3 new people. One seemed like a nice kid, another a rather sullen woman with really bad hair, and the third a peppy perfect mommy sort. As usual, it reset the comfort level in the room, but that’s to be expected.

Then came an unwelcome opportunity to practice distress tolerance and emotion regulation in the moment. I shared about coming out with my diagnoses to my supervisors, and a few others made mention of having to tell people in authority positions as well. It’s hard to do, all around.

Peppy Mommy spoke up about how she’d figured out a perfect way to easily describe BPD to others. Let me quote – because I actually wrote this down verbatim, I was so furious:

Borderline Personality Disorder is like bipolar on crack. People with bipolar, they have their ups and they have their downs, but I’m like up-down-up-down-up-down.

My reaction was immediate: face burning, heart racing, jaw clenched, hands in fists. I pushed my chair back even further from the table so I couldn’t see Peppy Mommy, clearly sitting outside the circle. I quickly started deep breathing to keep myself from verbally attacking her. I dry-swallowed an Ativan, thought about just leaving the room (more than once, with consideration of door-slamming as well), decided I could do better, and tried to just breathe instead. If I’d left the room, I would’ve punched a hole in the wall down the hall, and we can’t be having that.

Although we were talking about being non-judgmental that evening, I couldn’t help judging the hell out of that woman. My automatic thought was, “she’s so fucking ignorant!”

Within moments, however, I shifted to, “perhaps she’s new to her diagnosis and doesn’t know much about BPD, much less bipolar. She’s obviously never heard of rapid cycling, and probably doesn’t know anyone who’s bipolar, nor the differences between mood disorders and personality disorders.” Ignorant? Yes. But I shouldn’t be judgmental because I don’t know the facts.

I felt better about being less judgmental, but it didn’t make me any less angry. The group leader caught on – we actually discussed it in front of everyone in a way that completely was over their heads, because the group members all assume that because Linehan designed DBT for borderlines, everyone in the group has BPD.

Wrong.

If you don’t want to be judged, don’t judge others. If you want to learn to be nonjudgmental, start by examining your assumptions. And by all that’s good in this world, people, please take the advice of the immortal Kurt Vonnegut:

There’s only one rule that I know of, babies—God damn it, you’ve got to be kind.

DBT Week 24

Tags

acting opposite, bipolar, borderline, DBT, emotion regulation, group, group therapy, workbook

This was an odd week for DBT; one of the group leaders was absent, so we only had the secondary therapist there – she’s nice enough but seems like a frowzy grandma. And only four of us attended, so there was a lot more “sharing” than usual. No one could get out of saying something at each turn.

The material we covered was more emotion regulation, but having finished up the Linehan module, it was actually a chapter from a book I recently purchased, “The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder” ($15 on Amazon.) It reinterprets the original content in presentation and with some specificity to the condition.

That alone sparked interesting conversation. Another group member said, to the effect of, “The doctors always diagnose me bipolar, but I read books about it and think, that’s not me. But when I read about Borderline Personality Disorder, it was like I was reading all about myself.” So I replied that I’d had the exact same experience with one doctor, except reversing the two conditions. I have to wonder how often that happens…

Anyway, it was the first time anyone openly discussed diagnoses in group, although some were easy guesses based on things they said. I once saw some of the Dx codes on the receptionist’s check-in sheet, and I’m the only bipolar in the group.

The main things we went over were from chapter 7, “What to Do About Your Emotions.” The first topic was how to stop avoiding emotions, with yet another handy acronym, which seems much less tortured than Linehan’s embarrassingly contrived acronyms.

• Watch: Observe and note the experience of the emotion.
• Avoid acting: Don’t act immediately – it’s an emotion, not a fact, and you don’t have to do anything about it.
• Think: think of the emotion as a wave that will eventually go away on its own if you don’t struggle against it.
• Choose: choose to experience the emotion; even if it’s hard, it’s in your best interest and over time you will get better at handling emotions.
• Helpers: emotions are helpers that serve a purpose.

When we discussed that point, I said that I take issue with the assertion that all emotions have a purpose. What, hypomania’s purpose is to tell me to sleep? Depression’s purpose is to remind me to keep popping my pills? Or make sure that I notice it’s October or February? This is where pretty much every emotion regulation thing falls apart for me; they assume that all emotions are somehow reactive and meaningful. I’m sorry, but I think that sometimes emotions are biological misfires that do not serve any purpose, or at the very least, are physiologically amplified so far beyond their original purpose as to be destructive.

The other part of the chapter that we spent some time on was the Opposite-to-Emotion Action worksheet. It’s a table with columns for a situation, the emotion experienced, the urge to act attached to the emotion, the actual action taken, and the aftereffects. This is a substantially clearer presentation than in the original DBT content. Much like the big grid I filled in that made me think about how I experience each different emotion – autonomically, thoughts, reaction urges, actions taken, etc – this way of analyzing the ways I’m trying to use the DBT skills is far better for me. It’s better aligned with the way my mind has been trained to work as a researcher; a structured self-analytic approach tends to bring the most catharsis.

I’ve been working through the emotion regulation section on the DBT-for-bipolars book alongside the DBT-for-borderlines version in group and find it much more useful for me. I’d suggest that anyone who needs DBT skills go look for a workbook that fits their needs – don’t pay too much for Linehan’s workbook just because it’s the grandma of them all, especially if you’re not borderline. I saw versions for anxiety, bulimia, and depression; there are probably more, and they are likely more usable than a workbook focused at a completely different disorder than what you’re dealing with. Besides which, the newer workbooks are a lot more appropriate for self-guided use. The one I’ve got makes more sense, has clearer descriptions, is less hokey and dated, and a number of the worksheets are substantially more useful to me than anything in traditional DBT.

So, anyone want a practically new copy of the $40 “Skills Training Manual for Treating Borderline Personality Disorder” for say, $15?

Time is Flying

Tags

birth control, coming out, DBT, medical records, meds, perfectionism, progress, safety plan, update, Wellbutrin, work

Random floral arrangement at the NY State Fair. My Debonair has a light leak. Obviously.

I’ve not been able to keep up my usual queue of posts recently due to travel, med changes, and trying to catch up at work from a low period. I have 14 drafts in the hopper and lots of good stuff coming your way, when I get to it.

In the meantime, here’s a general update on the state of things. Overall I’m doing much better now that I’ve escaped the annual October/November Slump. Don’t worry, the drama of human misery will probably return in February…

More meds changes…

• I had genetic testing for medication sensitivity, and it was very enlightening. I can now make more informed decisions about what to take with a much lower likelihood of bad reactions both from the wrong drugs and the wrong dosages.
• Switching from generic to brand Wellbutrin XL has been practically miraculous. I feel a lot better in several ways that are directly related to that.
• I’m also enraged about the negligence of Teva and the FDA regarding the budeprion debacle. Suffice it to say that the next person who tells me that brand and generics are equivalent will get punched in the face. I hope there will be a class action suit.
• I’m frustrated with wading through health insurance paperwork. I have to pay out of pocket until I can submit evidence that we’ve paid our part of the deductible. And they rejected the prior auth request for Wellbutrin XL, so now there’s a second round of paperwork on that. It never ends.
• I discontinued hormonal birth control. It didn’t shrink the ovarian cysts and completely dysregulated my otherwise clockwork cycle. I’ll miss the reduced cramping and diminished acne, but it’s better than several random periods a month and constant spotting.
• I’m reducing sertraline bit by bit and have my hopes up to wean off it entirely soon. Side effects are already reduced, but not entirely gone.

Other news…

• I came out to one of my supervisors about being bipolar! More on that to come.
• I’m working on writing a safety plan to improve accountability and clarity about what to do in an emergency situation when I can’t make decisions for myself.
• I’m collecting up all my medical records I can get my hands on. Having a copy of my own records helps me understand things better and communicate with my providers more clearly.
• I’m planning to follow through with the second cycle of DBT – it’s starting to pay off.
• My head is spinning with recent revelations about issues with perfectionism and its underlying nasties. I guess there will be some work to do on that in therapy…
• I nominated Canvas for the WEGO Health Activist Awards – I think in the category of Best Ensemble Cast – and someone else has also nominated Canvas for Best in Show: Twitter. Go Canvas go!
• I got nominated for the WEGO Health Activist Award for Best in Show: Blog!!! I’m delighted just to be nominated, but Natasha Tracy is in the running, after all, so I figure I have a snowball’s chance. But apparently multiple nominations may be meaningful? In any case, they get too many nominations to review fully, so I’m not holding my breath. But it was really nice of whomever made that nomination.

I know I’m trying to do way more than I can handle at the moment. Some of that can’t be avoided, but I can’t continue to ignore the constant messages that I need to be far more aggressive about managing my illness and addressing related issues. It’s so overwhelming. I have no idea where to start – and I know progress will be painful and frustratingly slow.

It’s gonna be a tough 2013, folks, but I expect to come out of it on top.

DBT Weeks 22 & 23

Tags

acting opposite, DBT, emotion regulation, group therapy, justified, mindfulness, perfectionism, skills, therapy

I just plain didn’t get to writing up separate posts for the last couple of weeks of DBT, so today you get a double-plus emotion regulation extravaganza! This module has been pretty helpful for me so far as I struggle with emotion regulation more than I ever understood.

Week 22 focused on mindfulness of the current emotion. Some of this goes against instinct, but it works. Step one is to observe the emotion – notice that it is there and try to view it objectively. You can’t do anything to change the emotion if you don’t know that it’s taken over.

Second, experience it. Instead of blocking or suppressing or holding on to the emotion, let it come and go without making more of it than it is. That’s where you have to get totally zen and it’s going to take some practice for anyone to get there. Personally, if it’s a panic attack or worsening anxiety, I do this until the Ativan kicked in. There’s a reason I have that stuff, and no reason to let the pain go on longer than necessary.

Third, remember that you’re not your emotion and you don’t have to act on it. The instructions say to remember when you’ve felt different, but I also find it helpful to think about when I’ve felt the same and everything turned out OK, e.g. the panic attack didn’t kill me the last time, so it probably won’t this time either.

Finally, the kicker: practice “loving” your emotion. There’s a cheesy “dandelion” story that goes with this, but I’m not going to perpetrate it upon you here. The instructions say not to judge the emotion, be willing to experience it, and  radically accepting your emotion. You feel what you feel, not what you’re supposed to feel or what you want to feel. Admit it and reduce a little suffering in your life.

A random quote about mental illness that I particularly like.

This sparked an interesting conversation about the difference between pain and suffering. An enlightening comment was that pain is the problem of the moment, but suffering is letting the problem cause pain for longer than necessary. It’s an interesting perspective that I think merits a little thought. It certainly justifies the occasional PRN anxiolytic.

The homework was to repeat the worksheet for reducing painful emotions. I think the repetition, each week adding a new section, is really helping. I’m being more conscientious about trying to take care of things like sleep, exercise, and eating (of course, the better I feel, the easier that is.) I’m trying to do things that make life a little more pleasant, forcing myself to recognize that I’m making progress, admitting that I’ve been pretty isolated, and owning up to avoidant behaviors that inevitably worsen the situation. As for mindfulness of the current emotion, well, I’m trying. Experiencing difficult emotions and just sort of surrendering to them is challenging when I work so hard to try to control them.

On to week 23. This is more effort than I expected. But here we go…

The new strategy for the week was changing emotions by acting opposite to the current emotion. That’s not a fake-it-til-you-make-it proposition, however. We watched Marsha Linehan’s own video lecture for this content (on a VCR, can you even imagine?) which had a lot of good details.

There were specific strategies for four categories of emotion: fear, guilt or shame, sadness or depression, and anger. An important concept is that each emotion has a related action. With fear, it’s avoidance; for guilt and shame, it’s hiding. Withdrawal is the in/action of depression and sadness, and anger goes with attacking. I’m not going to go into a lot of detail here, but basically all of the strategies involve approaching the cause of the emotion and facing whatever triggers it, except for anger, in which case it’s better to avoid whomever/whatever is pissing you off.

The steps that Linehan outlined for “acting opposite” are:

1. Identify the emotion
2. Identify the action associated with the emotion
3. Decide whether you want to reduce the emotion
4. If so, figure out the opposite action.
5. Do it.

This was followed by discussion of what makes an emotion justified or not. The video discussed what justifies fear and anger and the group leaders provided their own handout for guilt/shame. Then I had to open my big mouth. I pointed out that some of the criteria and strategies focus on relationships, but what if the person you’re angry at or harm by your actions is yourself? I had to clarify by saying how Hippie Dude says I’m too hard on myself and that I’m a perfectionist to a fault (a lot of people say they’re perfectionists but have no idea how far that can go…)

After the session, one of the group leaders slipped me a note with a book title on it, I Thought It Was Just Me (but it isn’t): Making the Journey from “What Will People Think?” to “I Am Enough”, by Brene Brown. That sort of hit a sore spot. I actually convinced myself that I wasn’t a perfectionist for years, but let’s admit it. I filled in a few assessments and am unquestionably guilty as charged. Although it seems related to Imposter Syndrome somehow, perfectionism wasn’t something that I recognized as an “issue” until only recently, so I ordered a couple of books from Amazon. Seems I’ve found yet another issue to work on in therapy. Yeeha.