It’s Not Pretty

It’s not pretty. She’s not pretty. She’s not a thin, wistful girl with large tragic eyes. There’s no staring into space while smoking a cigarette and drinking Diet Coke. She’s overweight and plain. Her facial expression matches whatever situation she’s in and does not reveal how she feels. Her apartment is a disgusting mess. She doesn’t manage to still be beautiful with messy hair and circles under her eyes. Her hair is greasy and her pajamas ill-fitting. There’s no getting sent to inpatient where she has a crush (who likes her back) and leaves filled with promise and hope. There is being sent home from the ER after a few hours because she doesn’t have a specific plan for suicide, so it doesn’t matter than she can’t function. She fakes her way through work and eventually gets fired for calling off too much. She eats cereal from the box that she bought from Walgreens at 3 am since she hates leaving the house when it’s light outside. There are cuts on her thighs and sores on her scalp from compulsive picking. She doesn’t turn her misery into haunting music or captivating artwork. She can’t finish a book, watches TV without following the plot. No one notices; no one reaches out. Her friends don’t rally around her. No one wants to rescue her. It’s not a girl looking fragile and crying while indie acoustic plays in the background. It’s her slamming a cabinet door on her arm over and over after looking at photos of her cat that ran away just wishing she could cry. It is slow and heavy and terrible. It’s not like a movie. It’s not glamorous. And it’s not pretty.

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I Find My Lack of Progress Disturbing

When it comes to BPD there are so many symptoms and issues to work on that it can be hard to know where to start or where to focus your energy. Besides the main areas of DBT (emotion regulation, mindfulness, interpersonal effectiveness, and distress tolerance) there’s my intense self-loathing and self-esteem issues, sleep problems, sensory issues, chronic pain, dealing with the consequences of my symptoms/poor choices, and just life skills/existence. I know that a lot of those things will improve by working on the DBT stuff, but sometimes things need to be addressed separately.

I’ve been so stagnant lately that I decided to go down to the very basics, make some progress there, and work my way forward. It took a long time, a lot of spinning my wheels in the mud, and a lot of failing at my goals for me to realize I need to lower my expectations.

I don’t know if other people are like this, but often things don’t click for me until I come around to them on my own.  I can see something in articles or books or have it suggested to me by others and it just doesn’t resonate with me, but after I’ve gone through my own little experiences or thought process it will suddenly make sense. It’s not that things have to be my own idea or only on my own terms; I just have to see them in a light that works for me.

Visual goal trackers are one of those things. They aren’t a new concept by any means, and I’ve definitely seen them before in articles about productivity, getting things done, etc. I’ve halfheartedly scribbled some out in notebooks before but never kept up with one. A few weeks ago at work I was helping one of the kids use her snack board to choose a snack and it occurred to me that a visual aid would probably be helpful for me. I stare at the things on my walls a lot when I am daydreaming and I do find crossing things off a to-do list to be satisfying. So I picked very basic goals to track and made this.

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The picture on the left is from Allie Brosh’s blog hyperboleandahalf. I tried to find a source for the unicorn picture and couldn’t find a definitive one.

I laminated this so I can write on it with a dry erase marker and use it repeatedly. The goals are pretty self-explanatory and are centered around building routines. I think that building routines is one of the most important and fundamental things I can do to facilitate my progress. I think my inability to keep a routine and make things like taking meds and exercising a habit is part of why I am not making progress in most areas.

After a few weeks, I still wasn’t making any progress. I would do okay on some of the goals for some days but miss others. My performance was really spotty across the board. I got very discouraged and hopeless about the whole thing. It seemed pointless because it wasn’t working and I was really disgusted with myself. I kept thinking, “There’s no point in trying anymore. I always get excited and say I’m going to do shit, then I fail. It’s the same thing every time. I’m a lazy, stupid loser.” Blah blah.

Then I started thinking about it from a behaviorism perspective. When a person goes to do something, the benefit of the action has to outweigh the cost. Satisfying your hunger is worth the effort of cooking (or buying or otherwise procuring) food. Not being cold is worth the effort of putting on clothes or pulling the blanket over yourself or turning on the heat. Even stuff we really don’t want to do, like going to a social event we are dreading and will get no pleasure from, is somehow worth it (avoiding guilt, preserving a friendship, etc).

At work we are constantly thinking about whether our reinforcement is strong enough for whatever we are asking the kids to do. Is macaroni and cheese worth the effort of trying to use a utensil? Is the Mickey Mouse puzzle fun enough for the kid to be okay with sitting at the table to have it? Are bubbles worth imitating a b sound? If not, it’s our job to ramp up the reward and make it worth it for the kids to try. If we can’t do that, we need to decrease what we are asking for.

So I decided to do that for myself. I decided to decrease demands first. I thought about which goals were most important to me. I picked meds (obviously), exercise, no money at convenience stores, and oral hygiene. I chose oral hygiene because I have gingivitis right now, thanks to not flossing. This is embarrassing for me to admit, but I think it’s important to talk about the embarrassing things, especially because it directly relates to my mental illness. It’s hard to floss when everything seems pointless, when I can’t picture being alive in 5 years. When waking up and getting to work on time is a fight every morning the 3 minutes it takes to floss seems like a lifetime. But it’s affecting my self-esteem and since oral health can affect your heart health, I need to fix it. I set my exercise time for 10 minutes a day; my concern right now is building the habit.

My reinforcement/reward is that when I hit all of the goals for a week straight I will get $5 toward whatever. In addition to using my goal tracker I’m working on a sort of collage of pictures of things I want to save for, mouths with really nice teeth (my teeth will never be perfectly straight and white, but the pictures will remind me of healthy mouths), and people exercising. It feels kind of corny, but I’m trying it anyway.

I’ll see how this goes. I hope I’ve reached the point where I’m tired enough of stagnation that I will be more motivated to try, or that I will do it even if I don’t feel motivated.

Balancing Self-Compassion and Self-Discipline

I’ve been a self-improvement nut pretty much since I hit puberty. There’s a journal entry from the summer before I started 7th grade (so I’d just turned twelve) in which I wrote detailed plans for mastery of several virtues. I was going to focus on one each day of the week. I’m not sure how long that whole thing lasted, but the mindset remains.

I’m also pretty hard on myself, like a lot of people. It seems like people have always told me to quit being so hard on myself. Mental health professionals tell me to practice self-compassion. One of the social workers at the partial hospitalization program repeatedly told us all to give ourselves grace.

It wasn’t until fairly recently (like the past 6 months or so) that I recognized and accepted that I can’t just push through my mental illness. In some ways I knew that. I’ve always known that just snapping out of it wasn’t an option and that it couldn’t be cured by sheer force of will. But I think I sort of thought that if I attacked it hard enough–got therapy, took meds, used coping skills at home–that I could annihilate it without having to alter my life in any significant way. I didn’t have a realistic idea of exactly how much practice and work it was going to take to recover from borderline personality disorder.

The past 4 months in particular have shown me that I have to make recovery my top priority even if that means sacrificing some other things. I had to take time off work. I’ve put the process of applying to/selecting a grad school on hold. I’ve adjusted my expectations of myself.

I think that this is a good, smart thing. But I don’t want to stop moving forward. I want to give myself space to rest and not expect too much of myself, but I don’t want to quit accomplishing things. Right now I’m working 30 hours a week, and I’m happy about it. I’m making enough money to pay for stuff and I get to keep my insurance. I also don’t feel overworked. However, most days when I get home I don’t feel like doing anything else that I feel like I “need” to do. I don’t want to exercise, make good eating choices, or clean up around the house.

I don’t know how to balance giving myself grace and making progress. Am I taking care of myself by deciding to read, play video games, spend time reading about/talking to people online about recovery instead of exercising or cleaning? Or am I just being lazy? Would I be protecting myself by staying home from a close friend’s wedding because it’s 5 hours away and travel and crowds make me very anxious? Or would I be a shitty friend to miss it?

I don’t want there to always be a reason I can’t do things. But I also want to take care of myself, focus on recovery, and not drive myself into the ground.

BPD Stigma in Psychology Today

I recently read an article on the Psychology Today website that made me pretty angry. I’m not in the habit of reading Psychology Today. I prefer to get information about BPD (and mental illness in general) from peer-reviewed scientific journals. I came across this while looking up something else.

Here’s a link to the article for those interested, but if you’ve got BPD this will probably make you angry (the comment section is even worse).
https://www.psychologytoday.com/blog/matter-personality/201109/the-family-dynamics-patients-borderline-personality-disorder

This article ticked me off because of the way the author, David M. Allen, MD, talked about people with borderline personality disorder. I found his language to be stigmatizing and some of the things he said were just flat out wrong. I tweeted angrily about this but then I decided I should write a thoughtful response. After all, I’m trying to fight stigma, and if someone who buys into the stigma just sees a pissy tweet about the article, that’s not going to change their mind.

First of all, Allen refers to BPD as the “‘jack of all trades” of personality dysfunction.’ I think that’s a bit of an overstatement, but whatever, bro.

In the fifth paragraph, he talks about splitting. He gets it wrong.

They engage in behavior referred to by therapists as splitting: Everyone else is treated either like a god or a complete pile of manure, with nothing in between.

This isn’t exactly accurate. Splitting doesn’t occur 100% of the time with 100% of people. In my experience, and from what I understand, the experience of many others with BPD, splitting often refers to the way we feel about another person, not the way we treat them. So he’s simplifying it in a way that makes it sound more negative than it is. This contributes to misconceptions about BPD because it creates an image of us arbitrarily treating people in irrational extremes. That’s not what happens.

Next comes the “borderlines as manipulators” trope.

Interestingly, patients with BPD are often described by therapists as being superb manipulators.  One must wonder how anyone who cannot simultaneously evaluate another person’s strengths and weaknesses could possibly be a good manipulator.  Simple answer:  They could not.  While the tendency of thes individuals to “split” others into all good or all bad does derive from the bewildering contradictory behavior of the patient’s parents or primary caretakers, usually it is just an act.

Okay, so right there he says that splitting is usually just an act. An act. I’m not even sure how to address this. Why would someone pretend to experience splitting? What could be gained from that? I guess one could argue that maybe it’s easier to categorize people into groups of “all bad” or “all good,” but if a person were doing it for that reason, I think it would be because they genuinely thought that way, thus making it NOT an act.

Another thing: the thing he says about a person who can’t evaluate a person’s strengths and weaknesses at the same time not being a good manipulator? He’s right, and that’s EXACTLY what happens. People with BPD often think in black and white; it’s very difficult for us to see multiple truths in the same situation. We have problems with interpersonal effectiveness, and that makes it difficult for us to be good manipulators. Are there people with BPD who are manipulative? Yeah, I’m sure there are plenty. But it’s not an inherent part of having borderline personality disorder.

One of the crappy things about this myth that all borderlines are manipulative is that people who believe that aren’t going to believe us when we say that we aren’t. That’s why articles like this make me so angry. This guy has an audience and gives the appearance of credibility (by being an MD and a published author) and he’s spreading the stigma.

In the seventh paragraph, Allen says that people with BPD can turn most of their symptoms on and off very quickly.

I noticed that patients with BPD could turn most of their symptoms off and on like a faucet – and at a moment’s notice.

Nope nope nope. Maybe borderlines can hide/alter behaviors in public or in the presence of certain people, but that is NOT the same as turning off symptoms. And this ability is not exclusive to BPD. If everyone with a mental illness were incapable of hiding symptoms/behaviors, the world would be a very different place. People wouldn’t wait until they got home to binge and/or purge. People with depression would no longer be able to force smiles or fake happiness around co-workers or classmates. The majority of those suffering with mental illness have the burden of trying to hide our symptoms and change our behavior in certain circumstances.

If he’d given an example of what he’s talking about, that would help, but he doesn’t. He says “most” symptoms. Which ones? The unstable sense of self? The chronic feelings of emptiness? Recurrent suicidal attempts and/or self-injurious behavior? A pattern of unstable relationships? Those by definition can’t be switched on and off because they chronic and persistent. So does he mean the impulsive behavior? The mood swings that might last only a few hours? Well, it makes sense for those things to change in a matter of moments. That takes care of 6 of the 9 diagnostic symptoms there.

I’m not even going to get into this guy’s whole “spoiler” role theory. I’m not interested in that. However, I do want to point out that he refers to the movie “Thirteen” as “almost an instruction manual on how to create patients with BPD without abusing them.” I’m sure he was being a little tongue-in-cheek when he was saying this, but it comes across as unprofessional to me.

Also, later in the post when he is discussing the “spoiler” child he says that the child “will figuratively piss all over everything the parent does for them.” Again, pretty unprofessional.

This whole piece reads like an op-ed to me. It’s not based on real research, just on the guy’s interactions with patients with BPD and their families. If it were just posted on his blog, it would be annoying and I’d still think he’s wrong. But it’s not on his personal blog; it’s on Psychology Today, where the impressionable and uneducated masses are going to read it.

We got a long way to go, stigma-fighters.

Shame

I’ve been in a partial hospitalization program during the day for the past 2 weeks. Most of the day is spent in group therapy. Today is one of the groups we talked about shame. The therapist said that research suggests that shame makes things like depression, alcoholism, addiction, eating disorders, etc. worse.

Then we were instructed to pick something that is a source of shame for us and write a little bit about it in our notebooks–how it makes us feel, where we think the shame comes from, behaviors related to the issue that causes us shame, etc.

After that we picked a compassionate figure (a person in our life, a famous person, an imaginary entity, a ball of light, whatever) and write a letter from them to us. The letter was supposed to offer encouragement, love, acceptance, and compassion in regards to the source of shame we’d picked.

I chose my shame around being fat and hating my body. I didn’t think it would be difficult since I spend a huge percentage of my waking hours thinking about how fat and ugly I am. However, I got extremely agitated by the first part of the exercise. Just writing about my shame around being overweight and ugly made me angry, sad, humiliated, and ashamed, of course. I had to leave the room and pace in the hallway for a little bit.

When it was time to write the letter, I couldn’t imagine a human being saying compassionate words to me on this topic. People are so weird and uncomfortable with fat. They either tell me I’m not (when I know I am) or act like it’s a horrible thing about me that I can change and that they are willing to look past because they are so amazing and kind. So I just thought about one of my cats and how he loves me no matter what. What I look like is of no consequence to him. I imagined him lying snuggled up to me and radiating love. That calmed me down a little.

Next the therapist asked people to share. I was already kind of irritated because there are two people in the group who derail the discussion in every single group. And they were doing it again this time. Also, since I’ve been tapering the lexapro all my emotions seem a lot closer to the surface and I’ve been getting pissed about things I normally don’t.

When the therapist asked me to share it caught me off guard because it didn’t seem to follow the flow of the discussion. When I said that I’d been unable to imagine a person saying compassionate words to me on the subject, she asked me what I would say to someone I love if they were in my position. I might share my response in another post. Next she asked what emotions I was feeling and I said, “Embarrassed and mad.” She asked what was there if I tried to peel back the anger. I realized that I was sad and hurt because there was no one in my life who would say those compassionate words to me. I was also irritated because I wanted to cut myself and couldn’t. I was getting teary and choked up at this point. She asked what I could do instead of cutting and where I could find my strength. I started crying harder and said I didn’t know and didn’t want to talk about cutting. She said I didn’t have to. I covered my face and was curled up in the chair and had my hands squeezed into fists. She asked what the emotion was then and pointed out that I was making myself very small. I said that I was mad that people were in the room and that I didn’t want anyone to look at me. She asked how old I felt right then. I thought about it and pretty quickly realized I felt 7. I told her that and she asked what I wanted to hide from when I was seven. I said, “I don’t know and I don’t want to talk anymore.” Then she said I didn’t have to but that I might want to explore that with my individual therapist.

I cried for the rest of group. I used my hair as a curtain around my face and wrapped my arms around my head. I wanted to leave the room so badly but I didn’t want anyone to look at me. It was so painful–the whole thing.

When the group was over and people left the room to take a break I went to the bathroom and cut my arm. That kind of helped.

So I feel like I realized/figured out some stuff during the group and maybe let out some pain. But I don’t know what I am supposed to do with that information. It doesn’t fix my body image issues or my shame. It doesn’t provide me with compassion from others. It just brought all this hurt to the surface. Now what?

Whatever It Takes

I’m starting a partial hospitalization program tomorrow. I was in the same program a little over 6 months ago. It was helpful then and I’m sure it will be helpful again.

I will be there from 830 am to about 4 pm each day. I’ll be assigned to a social worker and see a psychiatrist. Most of the day will be spent in group therapy.

I think it will be great to go back there. But I feel like I don’t have the energy/motivation to drag myself out of bed in the morning and drive there. So weird how my thoughts and feelings don’t match. But that’s like 90% of my problem, right?

Last time I didn’t have a great attitude when I started. I was scared and miserable and my only experience with group therapy had been negative. My boyfriend and closest friend were both out of town so I was kind of without support. But after a few days, I was fully invested. I felt safe with the other people there and was ready to work hard on getting better. I was not ready to be done when I was discharged. It felt like I belonged there, like that was where I needed to be–in a place where the only focus was getting better for 7 straight hours.

I hope that this time will be even more effective since I will be going in with a more receptive attitude. I also have a therapist already so I’ll have follow-up appointments. Plus I think I definitely need a med change and I really liked the psychiatrist on staff last time I was there.

I know that my life over the past year, especially the past 6 months, has shown me that I have to make my mental health my top priority. That might mean scaling down to part-time at work after that partial hospitalization program. It might mean putting off applying to grad school. But I can’t keep going the way I have been lately. I can’t put a band-aid on my illness until I’m okay enough to go back to work only to fall apart again in a month or two.

I want to get better so badly. I’ll do whatever I have to.