Interpersonal Therapy (Take Two) Session 3

(TRIGGER WARNING: Mentions of Suicide, Self Harm, and Childhood Bullying)

 This session, we were to speak about previous depressive episodes, in order to create a "timeline" of events and declines in my mental health. We were also going to start to draw up a diagram of my key relationships (family, friends, any romantic partners etc).

In the week leading up to this session, I had a lot of times where I felt quite on edge and irritable. I do tend to have a hatred of sound sometimes, usually when I'm overwhelmed. It tends to be more sounds of people's voices rather than inanimate objects (the washing machine, music etc). The technical term for this is Misophonia, although I am not actually diagnosed with this. I find sounds of voices can instil anxiety in me, or even rage. I go into a fight or flight mode, where I want to either escape the sounds or yell at them in order to hopefully make them stop.

We did the usual PHQ9, GAD etc questionnaires in which I scored more severely for Depression than Generalised Anxiety (which makes me a good fit for this type of therapy, as it is specifically for Depression). We also went through my Symptom Review; where I picked out 5 most prominent symptoms for me in that past week.

As explained above, irritability was one of the main symptoms of my Depression in that week. I explained examples of conversations that had set me off, and how I reacted. I told my therapist about how I find it hard to process information when there is more than one voice speaking at the same time as well. It does either make me very anxious, or very angry, and people don't tend to understand that.

As well as irritability, I found the following symptoms had been either very strong or very frequent recently:

• Always tired: I believe this could be a mixture of fatigue due to mental health problems, as well as the fatigue I experience with my Fibromyalgia. The weather tends to make my Fibro flare up too. Either way, I struggled with my energy levels and felt relieved on any occasion I could get into bed and nap. I found it hard to do much else really.

• Think other people don't like me: I think I've mentioned this before, but I find it difficult to reassure myself that my friends still like me. I look for clues that they are drifting away from me, or simply don't like me anymore. It could range from someone cutting off contact online (unfriending on Facebook for instance) to something as silly as not being one of the friends tagged in a post I can relate to. I keep having recurring dreams about a friend who cut contact with me around 8 years ago. In the dream, I am asking her why but never getting a clear answer. I believe some of this paranoia around friends stems from the times I was bullied. Part of the tactics they used were to pretend to be my friend, then leave me out of things. It made it hard to trust who was my real friend, and whether they actually liked me

• Down on myself: My homework for this session was to play some music on one of my instruments, or to sing. It was supposed to be an "antidepressant activity" that I could enjoy and feel a sense of achievement from. When I struggled to do this more than once or twice in a week, I felt very down on myself. I enjoyed it when I did do it, even though I was quite rusty, but I was very self critical afterwards. When I didn't do it, I felt guilty, as if I was letting myself and my therapist down by not trying hard enough to ease my Depression.

• Worrying: Although my Generalised Anxiety score on the GAD questionnaire was lower than my Depression score on the PHQ, I still found I worried a lot about things in that week. Various things got to me, and I was apprehensive about when I would get my Gastroenterology appointment through, when I would get my PIP decision, would my therapist be annoyed at me for not doing my homework "enough" etc.

I explained all these things to my therapist; trying not to go off topic too much, and having her guide me back on topic when I did. She also reassured me that she was glad I'd at least tried to do my music practice, and that my struggle to get going with it was something that needed addressing. 

We then went onto the topic of a Depression timeline. This is a recollection of past depressive episodes, what caused/triggered them, how you felt at the time, how you noticed you were depressed, and what happened. I find it hard to split my Depression into clear cut episodes, as it mostly feels quite constant, but I tried my best to recall times it had flared up and the symptoms I noticed first.

My most recent episode started about 4 or 5 months ago and coincided with my stomach and bowel issues. (I will do a separate post about my Gastroenterology journey soon). I had been experiencing pains and severe constipation that was making me miserable. Alongside this, family disputes had come to light, and I finally decided to get help when I had a sort of public breakdown on social media. The symptoms I noticed that made me think my Depression was flaring up, were lack of appetite and sleep problems. I usually sleep fairly well (for a chronically ill person!) and my appetite is usually moderate-large. Waking up in the night many more times, and not feeling like eating had become disturbing symptoms for me. 

The episode before this, I don't remember very clearly. It may have been about a year ago; involving losing a few friends. My Depressive episodes are very interpersonal (hence why I feel optimistic about this type of therapy!) and disputes, anxieties, lack of contact etc can set them off quite badly. I deeply fear rejection, and I constantly seek reassurance. My emotions can feel very unstable too, especially when it feels like things around me are falling apart. I suppose I noticed the start of this episode, when I began to feel out of control with my emotions, and I started tweeting a lot about losing friends. 

I struggled to recall details about previous episodes, and tried to explain how I mostly remember episodes from years ago, when I was suicidal. My therapist then asked if I remembered my first ever Depressive episode.

I was about 13, in my most hated year of Secondary School; year 8. I remember I had strong suicidal feelings, due to the constant bullying I experienced. I confided in a friend, who broke my trust and told the bullies about my urge to attempt suicide and why. They ganged up on me, and I could not trust anyone with my deepest darkest secrets for a while after that. It also helped shape my ideas about people; whether I could trust them, how I expect them to react, how I always felt inferior to them etc. I never sought help for my mental health at that age, partly because I didn't know it was available. There was a school nurse, but you had to be physically unwell to see her. I just didn't feel I had anyone to talk to and my only outlet was to self harm. This is when I started, and it carried on for many years, whilst I was being bullied. I didn't know a lot about Depression at the time, but I knew it wasn't "normal" to feel suicidal or to want to harm myself. I also knew I felt desperately low, and motivation went out of the window. I strongly believe it was music that saved me. I engaged in extra curricular activities, such as junior, then senior band and choir. None of my bullies were in those groups, and I enjoyed music so much that it became my saviour. 

After we had gone through all this, there was only a bit of time left in the session. We were yet to go onto my key relationships. My therapist briefly explained this task, and how it would be presented on paper. I was to use my time before session 4 to have a go at starting the task, and we would go through it properly in this next session.

So far, I think my therapy sessions are going well. I have wanted to explain about various traumas in my life (as they still need addressing) but my therapist hesitates to let me, as this type of therapy doesn't deal with that. I will have to stay on topic and hope that what I can talk about, and address, helps my Depression in the long run. 

Resources

What Is Misophonia?: https://www.webmd.com/mental-health/what-is-misophonia#1

Fight or Flight Response: https://www.psychologytools.com/resource/fight-or-flight-response/

Patient Health Questionnaire 9: https://www.mdcalc.com/phq-9-patient-health-questionnaire-9

GAD 7 Anxiety Test Questionnaire: https://patient.info/doctor/generalised-anxiety-disorder-assessment-gad-7

Fibromyalgia - NHS: https://www.nhs.uk/conditions/fibromyalgia/

Interpersonal Therapy (Take two) Session 2

(TRIGGER WARNING: Mention of past trauma, and an abusive relationship)

Leading up to session 2 of Interpersonal Therapy, I thought I would have to talk about past trauma and previous episodes of Depression. I spent the past week ruminating over this, feeling much worse by the time session 2 came around. I even had a horribly triggering dream; the night before therapy. It involved confronting my abusive ex about everything he'd done, and him denying everything. His friends, and some of my ex friends didn't believe me either. It made me feel so invalidated and unsafe. I woke up paranoid, and unable to do much. It took a while to get out of bed, as I wanted to stay away from everyone. I just felt that no one around me was a safe person (even though the people I live with, my parents and my cat, are extremely safe). 

Even before this dream, I spent the week depressed most days and unable to motivate myself to do much. I tried to do enjoyable things; activities my therapist refer to as "anti-depressant". The one thing I could get myself to do was play casual games. I found this had become more of a habit than something enjoyable though. It distracted me from awful thoughts and feelings, but it didn't do anything to lift my mood as such. 

As it turned out, session 2 of IPT was mostly about my most recent depressive episode. At first, we went through the PHQ, GAD etc questionnaires (to assess and quantify levels of depression, anxiety, and daily functioning/lifestyle), then we went on to the symptom review. I will list below the 5 most prominent symptoms for me:

1. No motivation - I had to go back to past trauma to explain how it linked to my feelings now. I felt stuck in one place. Memories of the past seemed to hold me back. I guess I was triggered by thoughts of past trauma, and they held me in one place when I ruminated on them. I felt like I couldn't move on, especially as I anticipated talking about my past yet again. I know I need to address things, but I'd really rather avoid them.

2. No energy - The energy that constantly worrying about the past takes is exhausting. Thinking about what I need to talk about takes all my energy as well. I think we forget that just thinking can take its toll on our energy levels. Even if all we're doing is sitting and remembering, we are still exerting ourselves. A phrase I used to describe my frame of mind is that I felt the weight of the world on my shoulders.

3. Feel guilty -  I am taking a long time to do things, because of the symptoms of my depression. I am slowed down, and motivation levels are low. Because of this, I may take ages in the shower, planning things, getting dressed, cooking etc. I feel guilty because people may have to wait for me, or wait to use the bathroom. The way I behave has an impact on others, it doesn't happen in a vacuum. I also worry that my problems have an impact on others; such as my frame of mind, my feelings, the way I talk etc. I also assume that my mood has an impact on others. I suppose I'm an empath because of the way a room's atmosphere or a person's mood affects me. I understand other's emotions a lot too. I'm like a sponge to be honest! Not everyone is like that though, and I have to remember that me being sad won't always bring others down. I'm allowed to feel how I feel without guilt!

4. Think other people don't like me - I read into everything! I look for clues that someone doesn't like me, or is drifting away from me. I talk about it on Twitter, because I want that reassurance even though deep down I know it won't help me in the long run. I need to reassure myself and trust others. My lack of trust, my paranoia, and the things I type, I feel are pushing people away. This is a big big part of why I decided to try Interpersonal Therapy. As I said in Session 1 , it involves addressing problems in relationships, role changes, disputes etc. Part of my Borderline Personality Disorder symptoms involves being terrified of rejection and abandonment. I do things to avoid that rejection or maintain that friendship, even if it has turned toxic. In the past, I have begged bullies to stay "friends" with me, so I don't end up alone.

5. Can't make decisions - Due to lack of energy and motivation, I have been finding it do hard to come to a decision about simple things, such as what to eat, what to do to entertain myself etc. It takes me ages to decide, I talk myself out of it, or I spend so long thinking about it, or flicking between activities etc, that there is simply no time left to actually engage in the activity. Alongside this, my concentration levels have been low, so I haven't been able to focus on things, or I worry that I won't be able to focus on or enjoy something. I may have mentioned this before, but the thought of being bored/not enjoying something becomes unbearable rather than slightly disappointing. I think it is part of the extreme mood swings and emotions I get, especially with BPD.  

After going through the symptom review, my therapist noted that I take on so much pressure from assumptions about other people's thoughts about me, how my moods/behaviour impacts others and so on. It's no wonder I have no energy! She then asked about my most recent depressive episode.

I explained to her that I believe it started during lockdown, about 4 months ago when my physical gastro symptoms developed. I have experienced chronic constipation, moderate/severe abdominal pain, appetite changes, bloating, and bloody mucus in my stools. Because of all these symptoms, I started off fed up, then my appetite changed even more, and I noticed something wasn't right when my sleep changed. I would wake up many times in the night (not just because of pain) and I would be deep in thought for a while before I could settle down to sleep again. I would get more tired, much earlier, and therefore would wake up much earlier. I usually take a nap halfway through the day, to try and replenish my energy slightly (it never fully replenishes, due to the nature of my chronic physical conditions such as Fibromyalgia). I found recently that I needed more and more, or longer and longer naps however, and I was desperate to sleep all the time!

My moods were low anyway, but I wasn't sure how low exactly until it affected my sleep first of all. 

As well as having physical gastro symptoms which frustrated and worried me, I had conflicts with some family members I used to be close to. I won't go into details, but it involved some nastiness that I wouldn't tolerate. Trying to make the peace didn't work, and because I saw certain people in a different light, it affected how I expected others to be and therefore affected my moods further. My support circle seemed to be getting smaller and smaller.

Another thing that kept this particular depressive episode going, was my worries about pushing friends away. I wrote some fairly bitter things on social media, that didn't go down well. What I was looking for was support and reassurance, but quite understandably, it was misinterpreted and now I worry that others are drifting away from me, or beginning to see me in the way I see myself (i.e. as some kind of horrible monster who craves attention constantly).

I told my therapist that I do tend to be extremely self critical, and it's something I'm trying to work on, but not getting very far with. She said that I am very critical of myself and conflicts with relationships seem to be a big part of this latest depressive episode, but she would explore other reasons too. Conflicts in relationships need to be addressed first though.

We finally moved on to antidepressant activities. The gaming needed to be put to one side really, as it served no real purpose other than as a slight distraction. She asked me what else I enjoyed doing, and I mentioned my musical side. I play flute, guitar, and keyboard. I also enjoy singing and writing lyrics. Apparently, when I said this to her, my tone of voice became much brighter and happier sounding. She set me "homework" to do more musical things, then tell her how it went in the next session. 

Again, time went on very quickly, and we had been speaking for over an hour, so we had to leave it there. Next session is 1pm on 18th Jan. 

Resources

Interpersonal Therapy for Depression: https://www.healthline.com/health/depression/interpersonal-therapy#how-ipt-works

Amy's Mystery Illness: "I'm a Survivor": https://www.amysmysteryillness.co.uk/2018/07/im-survivor.html

PHQ 9 Score Interpretation: https://www.efficacy.org.uk/therapy/phq-9-and-gad-7/

Amy's Mystery Illness: Interpersonal Therapy (Take two) Session 1: https://www.amysmysteryillness.co.uk/2021/01/interpersonal-therapy-take-two-session-1.html

About BPD: Mind: https://www.mind.org.uk/information-support/types-of-mental-health-problems/borderline-personality-disorder-bpd/about-bpd/

Interpersonal Therapy (Take Two) Session 1

(TRIGGER WARNING: Mentions of Self Harm and Suicidal Feelings)

 After a major Depression and mood swings relapse, and encouraging words from loved ones, I decided to ask for help again. Initially, I thought I just needed my medication/dose changing but when calling Access/Crisis team, I was told I would probably benefit from therapy again, and my GP should be able to review my mental health medication. I reluctantly called Primary Care/IAPT to book an assessment and see what therapies were available (thinking they would just put me onto CBT again) but luckily was assessed by a wellbeing practitioner who realised that I had been through CBT many a time; resulting in some help for my anxiety disorders, but no improvement of my depressive episodes. The Primary Care team decided that I would be a good fit for Interpersonal Therapy instead. 

Interpersonal Therapy is intended as a treatment specifically for Depression (whether as a condition in itself or a part of another diagnosis) and focuses on how relationships can have a significant impact on our mental health. It could be things such as role changes (becoming a parent, carer, taking on a new job to name some examples), a loss or bereavement, arguments within relationships of any kind, or a major life event. This type of therapy aims to look at these factors and help the client to build up skills around them in order to improve their symptoms of Depression. There are 16 sessions to this type of therapy. The first 4 aim to get a picture of how Depression manifests for the client specifically, the middle 8 sessions aim to help build up skills to help improve symptoms, and the last 4 aim to conclude the therapy and get the client ready to continue practising those skills once therapy has ended. 

I had a few sessions of Interpersonal Therapy with someone prior to my diagnosis of Borderline Personality Disorder. I was very unwell at the time, however, and due to some things my therapist said as well, the therapeutic relationship broke down and I was unable to continue. I am looking forward to going through the process of this therapy with a different therapist though. 

My initial phone call with the new therapist went very well. I felt she was easy to talk to, and listened well to my problems. We decided that my diagnoses, symptoms, and issues would be a good fit for this type of therapy, and I was happy to go ahead. 

Before the first appointment, I had the PHQ/GAD/Phobia etc questionnaires to fill in, as well as a therapy agreement, consent for my therapist to record our appointments (she is a trainee IPT therapist, so her supervisor needs to monitor the sessions), and a symptom review sheet. 

The Symptom Review worksheet is a grid containing many different possible symptoms of Depression. My task was to tick each symptom I felt had been a problem within the last week, then pick 5 that specifically needed addressing. I did tick a lot of the symptoms, and found it hard to pick just 5. I put a star next to the most pressing symptoms, but through talking to my therapist in our first session, I found that each of those branched out into the other ones, were very similar in the way they manifested, or were linked quite closely together. What looked like a simple task, became a more complex one, the more I tried to explain each of the symptoms!

I felt like I was rambling throughout the conversation, and I worried that the therapist would not be able to organise what I'd said into cohesive notes. I should've had more faith though, she was very helpful and understanding. She would bring me back on topic when needed and would focus on the symptoms that seemed to bother me most. Between us, we decided that I was struggling with the following issues most in the past week:

• Irritability - I would find conversations and too much noise overwhelming, with led to a type of sensory overload which resulted in irritability. I may not always have made this apparent to the person/people I'm around, but I coped with it by turning on myself and either punishing myself (self harm) or isolating myself (going in my room). Generally, this is something I do if conversations online become too overwhelming or difficult. It's as if I'm suffering an emotional pain and I either want to escape it or turn it into a pain that I find easier to deal with. 

• Always tired - I experience extreme fatigue, due to my physical health problems, but I know that Depression plays a big part too. I find this symptom links in with lack of motivation and lack of energy (other symptoms on the symptom review sheet). This week especially, I have found I am constantly exhausted and want to stay in bed for longer and longer. I know that this is partly due to the Depression because my moods affect my levels of energy, and the worse I feel, the more sleep I need. Unfortunately, although sleep can have a positive effect on mood, oversleeping can have the opposite effect. I felt as if I hadn't achieved much at all in my week, I saw myself as lazy, and I worried others would see me as lazy too. 

• Mood swings - These are problems I have experienced a lot recently, which is why I think my mood stabilizers (Aripiprazole) have stopped working. I feel things in the extremes, to a point where I can feel as if I can't cope or I am out of control. The extremes weren't as bad as they could have been this week, but they were bad enough for it to be a problem. I didn't get the hypomanic emotions this time, but I did swing from considerably depressed and down, to irritable/angry, tearful, anxious, and even numb. I explained the numbness further, as my therapist said that it wasn't written down as a particular depressive symptom (which I found interesting, as a lot of people I know with Depression do feel numb quite a lot!). It's something I hadn't realised in myself until I connected with others with similar conditions and symptoms. When numb, my self awareness of how ill I am tends to decrease, and I'm not sure how to respond to the question "How are you?" because I simply don't know. When numb, I can dissociate too, although not always. I explained how I experience dissociation, to my therapist. She found that interesting too. We discussed how some of my symptoms had become coping mechanisms, as my numbness and dissociation can occur after days/events/conversations that I had found overwhelming. Again, it was a matter of extremes. I either felt too much, or not enough. 

• Feel worthless - I am often very self critical, although this is something I am trying to work on. I try to say more positive things about myself these days, but I do worry about coming across as arrogant, or just being wrong. When I'm not able/don't have the motivation to do much in my day, then I feel worthless and pointless as a person. This can lead to the suicidal feelings, as, in order to feel like I should be on this earth, I want to feel I have some sort of purpose, I am doing something to improve myself, or I'm doing some good for other people. It's a bit of a chicken and egg situation, as if I feel worthless, I lack motivation, but if I lack motivation and therefore don't do much, I feel worthless. I'm never sure which started first, but it seems endless! 

• Bored - As a symptom, this seems like a very mild one, but boredom can be unbearable for me. When I lack motivation and are not doing much, obviously I get bored. I have things I could do, but the thought of being disappointed if I do not enjoy them, or struggle to progress with them, can be very hard to deal with. Being bored can lead to becoming frustrated, angry at myself, extremely low and self critical, and even lead to suicidal feelings if I feel everything is going wrong. Doing something I enjoy (seeing a friend, not possible at the moment of course! Playing a musical instrument, cross stitch, a TV show etc) can lift my mood, but overthinking the possible result (not enjoying it) can make me talk myself out of even starting. I can usually push past this worry and do the activity anyway, but when very low, any disappointment feels like a big risk. 

As you can imagine, going through the symptom review took up most of the time in the therapy session. I was very apologetic and nervous throughout, but my therapist tried to put me at ease by saying she could understand what I was saying/what I meant, and she felt she had learnt a lot about me that day. She confirmed that, going on the questionnaires and what I had told her, I was still suffering from moderate to severe Depression. Apparently this type of therapy expects a diagnosis to be made and for Depression to be the main problem that needs addressing in order to go ahead. I know labels aren't useful for everyone but I like to have a name to put to the problems I experience, so I know what I am dealing with and what is likely to be helpful for me. 

She then told me what the other sessions would cover (possible past trauma/events, key relationships, arguments, role transitions etc) and asked me to complete the PHQ etc questionnaires and symptom review for next session as well. 

This concluded the session, and after checking there was nothing else I needed to discuss, we booked in for the same time next Monday. 

Resources

Interpersonal Therapy for Depression: https://www.healthline.com/health/depression/interpersonal-therapy#how-ipt-works

About BPD: Mind: https://www.mind.org.uk/information-support/types-of-mental-health-problems/borderline-personality-disorder-bpd/about-bpd/

PHQ 9 Score Interpretation: https://www.efficacy.org.uk/therapy/phq-9-and-gad-7/

Therapy Agreements: https://www.umcpt.co.uk/questionnaires/therapy-agreements/#:~:text=A%20Therapy%20Agreement%20is%20a,abide%20by%20throughout%20your%20sessions.