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!