Tuesday, 5 June 2018

Emotion Regulation Therapy: Session Four

(See Session Three to catch up)

At the start of the session, my Support Worker told me about her discussion with the Nurse Prescriber re: my psychiatric medication. Apparently, because I'd said I didn't want to go on the Mirtazapine (because of the weight gain risks), she'd decided I was to stay on Sertraline and she had cancelled the follow up appointment. I was quite shocked about this, especially as the nurse hadn't phoned me to say anything about this. I obviously wasn't happy about her decision, so my Support Worker said she'd have another word, to see if they could put me on something else and rebook the follow up appointment. I'm still waiting to hear back about this.

I was feeling quite numb on the day of my therapy appointment. I struggled a bit with concentrating too. I did ask whether this was my last appointment as well, as I was worried that I hadn't improved enough to be discharged. Thankfully, she said that although this was the last booked session, she and my CPN had a discussion and decided I needed another two sessions before considering discharge. I was really relieved about this. I told her that my moods had been all over the place again, and although I was coping today, I don't know how I'd be the next day and didn't want to be discharged, only to be in need of referral straight after.

She seemed a bit concerned about my mood swings, and wrote some notes down. One thing she did mention, that has been getting my mind going a lot, was that even though I seemed quite low in session three, overall she hasn't noticed Depression in me on the whole. I wasn't sure what to say to that. The first mental health diagnosis I was given was Depression, and that diagnosis has followed me for years. I'm not actively suicidal anymore though, and my low points aren't quite as low as they used to be. I do self harm more than I used to though. I've found a change in the symptoms I have too. After the appointment, I did look into Depression with BPD and an article did talk about how depressive symptoms tend to be different. Of course not everyone with BPD will experience exactly the same, but the article said that the symptoms are more to do with anger, loneliness, guilt/shame, and boredom, whereas with Depression alone, the symptoms are more to do with sadness (understatement I know), feeling like a failure, lack of energy etc. I definitely felt I could relate more to the BPD depression than the standalone Depression diagnosis. It could be that the article is inaccurate but I could relate to what it said.

Anyway, back to the session. The topics we spoke about were more of a follow on from session three. We went through parts of the "Living Like You Mean It" book, and some more worksheets too.

The first worksheet was entitled "Life is Like a Wheel". It explains that life is always changing but eventually goes back round to the first point of the wheel. This is usually because of things happening in your life. For example, you could feel happy or successful at stage 1, a traffic jam could make you very stressed at phase 2, a bad comment from your boss could make you feel worry and suffering at phase 3, a compliment from a colleague could make you feel hopeful at phase 4, then back to happy at phase 1. It says that feelings are temporary and that they can change from hour to hour even.
It also states that certain feelings can take longer to change. For example, grief. A loved one dying can make us feel a huge sense of loss. Sadness and sometimes anger may follow. Anxiety may occur; worrying how to cope without our loved one. Denial may come next; where we may try to hide our feelings and block out memories of the person who has died, eventually allowing the tears and sadness to come, remembering the person in good and bad times, visiting their grave etc will start the healing process, then hope and happiness should follow. This can take years but the grieving process will be completed.

The next worksheet was entitled "The Assertive Option". It gave examples of certain feelings. On the right hand side would be unhelpful things we often feel or do, on the left hand side are better, more assertive behaviours, feelings etc. For example, acceptance rather than denial, and sharing feelings rather than hiding feelings.

The last worksheet (quite a wordy one!) explained acceptance. It defined it in 3 parts. Firstly, to accept something is to acknowledge it exists, secondly to believe there is no reality that should not exist, and thirdly, to see it as bearable.

The worksheet gave examples of accepting certain realities, e.g. that there are no certainties in life, utopia doesn't exist, and we cannot change others. It also explained that accepting something does not mean you have to like or be indifferent to it, and that acceptance is vital for stress management.

I find this very difficult, although I acknowledge it's important to accept things. I have strong views about being compassionate, equal rights etc and I do find it hard to accept when I come across people who believe certain people don't deserve the basic things in life for survival (food, shelter etc) just because they don't work for example. I guess I find it hard to believe someone could be that callous, and I want to have enough courage to debate their opinion and get them to see my point of view. I cannot change anyone and I cannot control the opinions they have. I can educate and maybe even persuade, but I can't completely change them. So I have to try and accept this reality, no matter how much I may dislike it.

In order to accept realities, the worksheet says we need to be mindful of our thoughts and beliefs about other's opinions. These can include believing someone should be different to who they are, the need to make them admit they are wrong, and the feeling of anger at being unable to do anything.

It also includes challenging our demands by asking certain questions of ourselves. "Can I really change this person/situation?", "Why must this situation etc not happen?" for example.

Lastly, the worksheet asks us to practise acceptance in order to improve stress management.

My homework is to do read through the worksheets again and practise acceptance. I think this will be the most difficult task so far, but maybe it'll help my stress levels?

Tuesday, 29 May 2018

Emotion Regulation Therapy: Session Three

(TW: Discussion of weight, medication, self harm, and suicidal ideations)

My third Emotion Regulation Therapy session was the day after my medication review. Because of this, a lot of how I was feeling related to it. I was also feeling very low, and therefore was putting a very negative spin on things.

We started off by discussing my medication review. My Support Worker wanted to know how it had gone, how I felt about the Nurse Prescriber's decisions etc. I wasn't sure what to think of it really. I think it went well, in that I was listened to, my antidepressant would be changed, and I would be seen again in 6 weeks. The antidepressant I may be put on though, is Mirtazapine. I was ok with that at first. A few of my friends take it and find it very helpful. Unfortunately, one of the most common side effects is weight gain. I'm trying very hard to lose weight at the moment, I struggle with comfort eating, and I'm honestly terrified of putting more weight on. I don't feel any benefits of Mirtazapine would be worth it, as the potential weight gain would worsen my depressive symptoms enough to cancel that out. I told my Support Worker this, and she said that when she'd been told by the nurse about the medication, alarm bells rung for her because she knows I'm trying to lose weight. She then told me that she would get the Nurse Prescriber to talk to the Consultant Psychiatrist (who is in charge of deciding the psychiatric medication I should be on) to see if he will consider prescribing something else. I've no idea what exactly will be considered, but I'm a bit more reassured that it'll be something that won't/is less likely to cause weight gain.

We then moved onto how I'd been feeling, besides the medication changes. I said that I'd been numb the day before, and was worried I came across as if nothing was wrong with me. I told my Support Worker that I'd overexplained this to the Nurse Prescriber and was worried about how I'd come across. Apparently, I'd explained myself well though, phew! I'd gone from numb to very depressed this day though. I felt like a failure, like nothing would work out ok, and honestly I felt lonely. It's been a while since I've been in a real loving relationship, and I missed it so much. I didn't feel very lovable anyway, and was nervous about trying to meet anyone new. I started crying a lot when I spoke about this. I just felt so worthless, as if no one could ever feel I'm worth staying with for the long run. I know I tend to take things personally, and the last person I met couldn't make his mind up about whether he wanted a relationship or not. One minute he'd be talking about meeting me, the next he would decide he'd rather stay in and smoke weed. I didn't know where I was with him, and although I understood he was addicted, I had to put myself first and stop seeing him. This made me feel very worthless as well. To me, it felt like smoking meant more to him than continuing to see me, as if I was worth less than a joint. I know with addictions it's complicated though, and it's not right for me to take it personally. I just hope he is able to get help at some point.

Next, we went onto the worksheet for that session. This was about becoming aware of emotions. It named eight main emotions as anger, sadness, happiness, love, fear, guilt/shame, surprise, and disgust.
The first task was to think about six of these emotions and, for each, try to remember a time I was in a situation where I felt this emotion. These were what I put:

Anger: When a PIP assessor lied on their report; saying I could walk much further than I could

Sadness: Losing a close friend to suicide

Happiness: Getting a good result on my research project at university

Love: When an ex told me he wanted to marry me

Fear: When a huge wasp flew into the classroom at school (I have a phobia of wasps)

Guilt/Shame: When I had to pull out of moving house with a friend, and they took it badly

The next section of the worksheet described each of those six emotions, in terms of their physical manifestations. It also reminded me that "feelings are felt in the body", "thinking distances you from your feelings", and "how you experience your feelings is neither right nor wrong, it just is"

The last task was to be mindful of my feelings; using the worksheet's descriptions to help me identify how I am feeling in that moment. I found this difficult, but one thing I noticed was how often I tend to feel anxious, without a particular cause. I'd always been unsure of my Generalised Anxiety Disorder diagnosis, but maybe it's right?

Just before the end of the session, my Support Worker recommended a book to me, that might help with identifying and managing my emotions. "Living Like You Mean It" by Ronald Frederick. It's a very cheesy title, but apparently it's a useful book. I've ordered it and if I manage to concentrate enough to finish reading it, maybe I'll write a review! (I'm not making any promises though).

For now though, I will be writing about Session 4 of Emotion Regulation Therapy. This is my last session, and I'm not sure if I will have another CPN appointment, so I'm not sure what will happen next. I'll keep you posted though!

Saturday, 26 May 2018

Medication Review

(TW: Discussion of Medication doses and weight gain)

Last Monday, I had my medication review with the CMHT Nurse Prescriber. I was worried about how I'd come across during the appointment, as I was feeling numb and tend to look absolutely fine when I'm like that.

I was quite calm during the appointment, and explained how I'd been feeling, the kinds of mood swings I have, as well as the times when I'm numb. I sort of over-explained how I was feeling too, and told the nurse that I worried I was coming across as if there was nothing wrong with me. She took that into consideration thankfully, and understood the problems that I had.

She asked me what I hoped would come of this appointment, and I said that I wanted the Sertraline to be changed to a different antidepressant (as it doesn't work for me anymore) and my Aripriprazole dose to be raised (as I felt I needed a stronger dose to control my mood swings).

She said that, because I have BPD (Borderline Personality Disorder), my symptoms were mainly linked to the relationships I have, and medication wouldn't help as much as therapy. I worried that she would stop my mental health medication altogether, but luckily she didn't.

The Nurse Prescriber told me that what she thought would be best was to put me on a different antidepressant than Sertraline, in a different category (SSRIs, Tricyclic, SNRIs etc) as a similar one probably wouldn't work. She didn't want to put me on a higher dose of Aripriprazole however, as 10mg was the appropriate maintenance dose for my needs. It is technically an antipsychotic, and as I don't really experience Psychosis, it wouldn't be suitable to raise the dose.

She asked me if there were any antidepressants I wanted to try. I wasn't sure, but she did suggest Mirtazapine. At the time, I knew nothing about it apart from that a few of my friends found it helpful, so I agreed.*

She said she would have a word with the Consultant Psychiatrist and then would write a letter to my GP (CCing me in) with the medication I was to be put on. She also wanted me to see her in 6 weeks, to see if the new medication was helping. After asking if I had any other questions or concerns (I didn't at the time) she ended the session.

*The session went well, but the next day, I looked up Mirtazapine and was shocked to find it was one of the worst antidepressants for weight gain. I am desperately trying to lose weight and putting on weight makes me very depressed, so I was worried about this! I've since had a word with my Support Worker**, who will talk to the Consultant Psychiatrist to see if I can be put on something that doesn't cause (as much) weight gain.

** I will talk about my latest session with the Support Worker in the next blog post.

Wednesday, 23 May 2018

Emotion Regulation Therapy: Session Two

Emotion Regulation Therapy

(See session one to catch up)

I don't think I was very sure how I felt during this session. I found it hard to connect to any emotions, which I sometimes find quite disturbing. Sometimes being numb is a relief (especially after days of really intense mood swings) but other times, I want to feel *something*.

We went through the homework I'd been set; which was to finish the worksheet about pros and cons of acting on impulses, and using distress tolerance skills. In the next sheet, I had to go through the STOP, TIPP etc skills and see which ones I wanted to try, what I'd do specifically, and what I expected the result to be.

I also stuck up the different skills sheets in my room, so I can see them clearly and be reminded whenever I see them. It's still early days, but I did manage to use some of the skills and I hadn't self harmed too much/badly that week.

The next thing we went through was things we do/think when we are avoiding emotions. I don't always realise I avoid emotions (especially negative ones) but I could relate to almost everything on the list on the worksheet. I ticked things such as:

  • Avoiding situations that might be emotional - (I hate crying, so avoid watching sad programmes or listening to sad music)
  • Feeling discomfort or nervousness with sharing a silent moment with someone - (I always feel the need to fill silences, as I find them very awkward. I also feel it's my responsibility to talk)
  • Feeling afraid of being or seeming vulnerable - (I find it very hard to "let go" especially with people I don't know or trust. It takes a while for me to fully open up and then I worry about oversharing)
  • Never allowing yourself to get angry - (I worry so much about hurting people, even if they've hurt me emotionally. I have had some times where I have lashed out at people I love, and it has made me feel like I'm a bad person)
  • Feeling uncomfortable accepting compliments from others - (I never feel like I deserve the compliments, so tend to dismiss them, or say thank you then quickly change the subject)
The second worksheet spoke about emotional and physical things that may happen when feelings are suppressed. These included things such as anxiety, irritability, teeth grinding, angry outbursts, and depression. I could relate to some, including teeth grinding (which I'm aware I'm doing while I type this!)

The next step was to take action. This involved becoming aware of our feelings, finding ways to manage them before they become overwhelming, feeling the emotions through (including physical sensations) and accepting those feelings as they are. The last step was to choose whether to open up or not. Some situations of course aren't suitable for opening up, but other situations call for being open and assertive. This is a difficult thing for me.

Homework - My homework was to read through the steps for accepting and dealing with emotions, and to try to open up. 

Friday, 11 May 2018

Emotion Regulation Therapy: Session One

Trigger Warning: Mentions of Overdose, Self Harm, and Medication

Since my last post, I've had another appointment with my CPN. This appointment mainly consisted of going over what I'd told her at the assessment, how I've been coping since, and what had been decided at the meeting.

My self harm urges haven't been too strong recently, although they have still been there. I decided I felt safe enough to take control of my medication again and so far have not had any more overdoses. I think this is due to the reassurance that I will get some help. I'm holding out for that, so don't have such a strong urge to do things that could potentially severely harm me. I have self harmed, but only very superficially.

I told her this, and that things have continued to be difficult with my Nan's health (her possible Dementia is definitely worsening). I've made up with the friend who fell out with me over me pulling out of moving house. There's a little less pressure from certain things, but I'm still struggling to cope with the pressure that is still there. I've found recently that my moods have been swinging between feeling numb and feeling very low.

She was pleased that I hadn't self harmed as badly, but she was still concerned at how extremely I tend to react to things. She noticed that I spoke very negatively about myself and put a lot of responsibility on my shoulders when I didn't need to/as much. She told me that she'd had the meeting about me now, and what had been decided was that I will have Emotion Regulation Therapy sessions with my old Support Worker, and that I would have a medication review. I'd already received the psychiatrist appointment for the medication review, but my CPN was concerned that it was too long a wait, so we've decided that my appointment would be rearranged for a much sooner time, with a nurse prescriber instead. I'm quite happy with that. It seems that the Sertraline isn't working anymore, and the Aripriprazole dose is too low.

Emotion Regulation Therapy

Earlier this week, I had my first Emotion Regulation Therapy session with my Support Worker. At the start of the session, she explained that this type of therapy takes skills from Dialectical Behavioural Therapy (DBT) that of course focuses on helping to regulate how someone reacts to certain situations, stressors etc.

My support worker told me the CPN had said that I did want DBT, but unfortunately it isn't offered with my local mental health team. She seemed disappointed that there weren't many therapy options offered (with this team) for people with BPD. She told me that unfortunately, the goalposts kept being moved so it was very hard to get onto things such as pathways that may offer suitable support. I told her that I was just glad to get some support and some parts of DBT that were relevant to me.

We went through how I view and react to things, as well as how I treat myself and others. My Support Worker said that what she could tell from me was that I have strong opinions, but due to fear of backlash, arguments, lack of self confidence etc, I find it hard to voice them. I tend to stand up for others and (in her words) "rescue" others but tend to sacrifice my own wellbeing to do this. I agree to be honest. I wouldn't call myself selfless or anything like that, but I do tend to put others before myself and I'd rather help others than help myself.

We then moved onto the worksheets. The first sheet asked me to think of a situation where I reacted in a quite extreme way. I thought of a recent event, which of course involved my fear of losing friends. This was the time that I was looking to move house with a friend of mine, and due to becoming quite unstable, I had to contact my friend and pull out. He took this badly and (after a few days of silent treatment) sent me a long angry text. Although this has now been resolved, at the time, I was very distressed. I panicked, I cried, I dissociated, and I had very strong urges to self harm/overdose. I felt like I was going to lose my friend of 10 years and I felt very guilty. I knew I'd made the right decision for me, but I'm not used to putting myself first (especially if it meant hurting someone else's feelings) so I felt like a terrible person.

Of course, I had to break this right down into what happened (I put something like "friend fell out with me after I couldn't move house with him). I then had to write down how I reacted (I cried, panicked, asked friends for reassurance, had strong urges to self harm) and then what the consequences were. In this instance, nothing bad happened as a result of my reactions. I got the reassurance I needed from friends, and although I still had urges, my friends talked me out of self harming.

The next skill sheets suggested ways of controlling/delaying acting on my urges, ways of distracting myself, noticing my changes in mood, physical sensations etc, and ways of self soothing. I'll explain each worksheet below:

STOP: This sheet mainly focuses on delaying/stopping acting on your impulse. It reminds you that you are in control. It suggests physically taking yourself away from the situation that is causing these urges, noticing how you feel, how others are reacting, and considering the consequences of acting on urges.

TIPP: This sheet suggests ways to calm physical sensations and emotions (such as using ice to cool yourself down if anxiety or anger raises your temperature).

Distraction Skills: This sheet consists of different types of distraction suggestions, such as activities you can do, helping others, keeping your mind busy or having something physical to concentrate on (different textures etc)

Self Soothing Skills: These involve focusing on stimulating the five senses. This includes stroking a pet, looking at photos, listening to music, smelling perfume or eating a nice treat.

We started on the worksheet that asked me to think of pros and cons of acting on my impulses, and of using the distress tolerance skills. With my Support Worker's help, I filled in the pros and cons of acting on impulses. 

Homework - My homework was to finish the previous sheet, as well as a worksheet where I had to say what skills I wanted to try, what I specifically planned to do, and what the outcome was likely to be. After filling in those sheets, I was to stick up the skills sheets in my room, somewhere I can't ignore them.

Overall, I found this session very useful. I'd already tried some skills, but there were other suggestions I hadn't thought of. I am determined to get my homework done and practise these skills. I'll just have to see how I get on!

Wednesday, 11 April 2018

CMHT Assessment and Possibly Some More Help?

This post follows on from Another Crisis and an Urgent CMHT Referral

(TW: Mentions of Overdose and Suicidal thoughts)

The past couple of weeks have really dragged and it's taken a lot of distractions and talking to friends to stop me from looking for my medication. I've tried, I've struggled, but I managed to keep myself busy (mostly with gaming). Unfortunately, I've found it hard to focus on anything but ODing.

I finally had my assessment on Monday. I was nervous, but had written down some notes and knew what I wanted to say. I arrived 15 minutes early (as the letter said to) but, due to the CPN being busy with another patient, I wasn't seen until 15 minutes after my appointment time. I was really agitated at this point, but apart from ringing CMHT again to see if I'd be seen soon, I bit my lip.

The CPN I saw was the same one I saw last time I had an assessment. Luckily, she had a lot of my details, so we mainly focused on how I'd been feeling and what had been happening recently. She still asked me a fair amount of questions, however. These included questions about the overdose , whether I was suicidal, how my appetite, personal hygiene, concentration levels etc have been. We also discussed the medication I was on right now, whether I'd had a review of them, and if I'd had a blood test recently. I was exhausted by the end! One thing I noticed was that the CPN wrote a few notes and mentioned it a few times when I said that my parents have been looking after my medication. I thought this might go in my favour when it comes to deciding if I should get extra help from CMHT.

We also spoke about the things going on in my life right now, and possible things that have triggered my mood swings and depression. There were a couple of things I mentioned, which were the stresses with planning to move house with a friend, and my nan's declining health.

Nan has been showing more and more signs of Alzheimers/Dementia. She is starting to become verbally aggressive and more confused over quite simple things. It's making it very difficult to have a conversation with her or explain anything to her, as she cannot process it properly and tends to shout over us. Since the CMHT assessment, Nan has had a cognitive assessment which she only just passed. There's no diagnosis yet, but the GP is very concerned and wants to keep an eye on her.

As for moving house, as I'm not stable or safe at the moment (I'm still constantly thinking about overdosing) I have decided not to move just yet. I felt so guilty about telling my friend, and he's not happy with me at all, but I had to make this decision and put my own health first.

Soon after this, the CMHT assessment came to a close. The CPN made sure we'd covered everything then told me what she wanted to happen. She wants me to have a blood test, to rule out any physical causes for my mood changes etc. She also wants me to have a medication review and some more Self Compassion therapy. She is having a meeting about me today, where she will suggest this and hopefully she will contact me later to let me know what has been decided.

Friday, 6 April 2018

Another Crisis and an urgent CMHT referral

(TW: Self Harm and Overdose mentions)

In the past few weeks, I've felt very low and noticed I've had strong urges to harm myself. I spoke to one of my best friends and she suggested ringing CMHT. This is also something that my care plan suggests when things are going very badly, so I rang them.

I eventually got through to someone from CMHT, but because I wasn't under their care, I was then told to ring the Access Team (This is the main referral team). I was told by them, to ring the Primary Care Team. When I rang them, instead of being connected to someone I could talk to, I was told to leave a voicemail and I would be called back. My voice was quite shaky at this point, it'd taken a lot for me to make just one phonecall, let alone three! I didn't get a callback, so eventually I text my therapist (at that point, my foggy mind had finally realised I had her mobile number). She text back quite quickly, asked me some questions about the urges to harm myself, what I wanted to do, how likely it was that I'll do it etc. I told her that I had very strong urges to overdose, and had the boxes of all my medication right by me, ready to take. She then said she would call me in half an hour.

I was trying so hard, but as the minutes ticked by, the urges became far too strong and I took my first overdose. Granted, a small one, but an overdose nonetheless.

Soon after this, my therapist finally called back. I told her that I had actually taken some medication, and that I wanted to take as many as would make me unconscious. She asked more questions, then said she would get in touch with the Access Team. She told me to expect a callback, possibly from a CPN from CMHT. It took a couple of hours (talking to my best friend prevented me from taking more of an overdose) but a CPN called me. I explained everything to her and she booked me in for a "priority assessment". Unfortunately, the earliest she could fit me in was 9th April. I accepted that appointment. She then wanted to check I'd be ok, and had distractions as well as people to talk to. She told me to get my parents to hide my medication from me, and only give me a day's worth at a time. She also told me about an app called Calm Harm (which is supposed to use various methods to help you resist self harming).

I was happy about the assessment, but not about the waiting time. I couldn't see how I'd make it through the two weeks. I ended up taking another overdose in the night, so I could sleep. One particularly disturbing thing that happened afterwards was that I had some visual hallucinations. I told my friend the next day, and she explained this could be caused by Serotonin Syndrome (something which can occur when you take too many antidepressants).

Since then, I have had to ask my parents to take care of my medication for me, as every day I've been having thoughts (and sometimes urges) to take another overdose. I find it hard to explain why and what I actually want to happen. I'm not sure I'm very suicidal, but I do want to be unconscious and to be able to escape from all the pressures I'm under at the moment (potentially moving house, nan being unwell to name a couple of things). Another thing I want is help. I think my mental health medication has stopped working and I need to finally get therapy for BPD. I worry that I won't be considered ill enough though.

Either way, I will mention all this at the assessment. I've now been discharged from Primary Care as I'm "too complex" for them to deal with. Ideally, I'd love to have a CPN for a while, as well as a medication review, and to be put on the waiting list for DBT/another therapy for BPD.

My negative mind is telling me not to keep my hopes up however. I'm worried that I will be discharged back to my GP with nothing more than advice to distract myself. The thing is, distractions aren't working anymore and I am not safe.

I had to tell a friend today that I could not now move house with them, as mentally I'm just not stable enough. I can't keep myself safe on my own, and I'm just not sure I could cope with the stresses of moving. I need help to get through this, and I'm so worried that I'm not going to get it.