Society's Influences and Stigma: Counselling Session 5

(TRIGGER WARNING: Mentions of self harm and sexual assault)

Leading up to this latest session, I'd been very low, anxious, and lacking motivation. My physical health isn't great (which affects my functioning enough already) but my mental health is quite poor at the moment, and the lack of motivation that forms part of my Depression, really affects my ability to do daily tasks.

I managed to wash and dress, as well as feed myself, but this exhausts me enough. I want to be able to do more, more often, but I'm not on sufficient medication for my pain, so it becomes quite debilitating. I feel like I'm constantly having to balance looking after my mental and physical health.

Anyway, back to the counselling session. My Anxiety and Depression scores were high again, and I told my counsellor that the main things bothering me at the moment were my lack of motivation and worrying about my mum's mental health. I won't go into detail about mum, as it is her business to tell who she needs/wants to. I just want her to get the help she needs to make her life easier to cope with.

We ended up talking about all sorts of things, including how certain things that have happened affect my moods at the moment.

We did an exercise where I had to write down the big events that I think have affected my mental health. These were the termination, the bullying at school, and the abusive relationship at university. Underneath, I put the moods that have resulted from these things. Finally, I wrote down the behaviours that these things have led to. Here is what I wrote:

Termination:
       Moods: Panic, Guilt, Shame, Low Mood, Anxiety
       Behaviours: Avoidance, Releasing anger by venting online, self harm to punish myself, making myself read/watch triggering things, as I feel I deserve to feel that way.

Bullying at school:
       Moods: Identity Problems, Low Mood, Low Self Esteem, Anxiety, Paranoia, Loneliness, Feeling useless.
       Behaviours: Seeking Reassurance, Avoiding Group Conversations, Self Harm when I feel myself acting like I used to, Lacking Motivation

Abusive Relationship: 
       Moods: Low Mood, Low Self Esteem, Anxiety/Panic
       Behaviours: Seeking Validation, Second Guessing Myself, Hyper-awareness, Being Suspicious of Men, Being Promiscuous in the past - seeking comfort, but with risky behaviour

The moods and behaviour from the termination are very complex and contradictory. I either avoid everything, or flood myself with everything. I show self-destructive behaviour; where I am constantly punishing myself, whether that's physically or mentally.

I'm the same with the bullying and the abusive relationship. All the comments and judgments made about me have formed part of my identity and made me feel suspicious of some people. I worry that people have ulterior motives and don't really like me/just as a friend.

I remember a time a friend of mine and I were thinking about meeting up. He'd been quite flirty and I had my guard up, so I kept putting him off. One day, when my parents were on holiday, he turned up out of the blue. Suddenly my safe place (i.e. my flat) didn't feel as safe. I let him in as I wasn't sure how he'd react if I didn't. We watched a movie together, but then he started playing with my hair. I felt like alarm bells were going in my head. I thought he'd try to have sex with me, without my explicit consent. I also worried I'd just let him because I wasn't sure what he'd do if I rejected him. As far as I was aware, he never did anything violent, but my mind instantly thought he might.

I've been sexually abused (by a stranger in a bus station) in the past, when I was a teenager. I didn't discuss this with the counsellor, but thinking back, I think this also fueled my suspicion of men who are flirty with me. If I'm not attracted to them, I find it very hard to reject them and I end up feeling violated, and disgusted in myself if anything happens.

We didn't have time to go through everything, but from what I explained to my counsellor, she spotted a pattern. I was very influenced by society's views, as well as possibly wanting to influence society with my own views. She said this was very interesting and important. This is something she wants us to discuss and unpick in subsequent sessions.

Although my moods have still been pretty awful, I'm at least feeling like I have a good therapeutic relationship with my counsellor, and it helps to talk about how I've been feeling. She gets me to explain certain things I say, gives her view when appropriate, and helps me to understand and pick up on things. I do feel positive about these sessions and I'm hoping in time I will be able to talk more freely about the things I've been through.

There's no "homework" as such, for the next session, but I am continuing my journal and at the very least, it is helping me monitor my moods and fill in the PHQ etc questionnaires.

Mental Health Questions Asked at Work Capability Assessments

(TW: Suicide)

Since my first Work Capability Assessment, my mental health has definitely declined. Throughout the process for claiming Employment and Support Allowance, claimants are treated as if they are faking/embellishing their disabilities. Letters from GPs, specialists, therapists etc are given little or no consideration in deciding whether someone is "fit for work", "fit for work related activity" or not fit for either.

There's a lot of pressure from filling in lengthy forms, gathering evidence (in the hope it will be considered), sending sick notes in on time, sending assessment forms in on time, being able to explain your disabilities to an assessor & hope they will not twist or completely disregard your words. This is all before a decision has been given, and already it is not surprising that someone's mental health will suffer.

A particular issue with Work Capability Assessments is how the assessor asks mental health-based questions; primarily suicide-based ones. Claimants are asked questions such as; "Have you ever tried to harm yourself or take your own life or needed to go to hospital?"¹, "do you have any intentions or plans to hurt yourself currently?"², and "what is it that stops you from acting on the thoughts that you have?"³ These questions are asked in a hostile environment; where the claimant is observed right from the moment they arrive in the car park of the assessment centre. To be asked such personal questions in that context is extremely distressing and has led to worsening of people's health conditions.

At my first Work Capability Assessment, I was asked if I have had thoughts of suicide, why I had those thoughts, whether I had attempted suicide, and what stopped me from attempting. It took a while for me to really open up about my suicidal thoughts to my own therapist, so being asked those questions so brazenly, by a stranger no less, was very distressing. I found it very hard to answer, and I burst into tears as I was made to think about my darkest times. The assessor was barely sympathetic, and was more interested in getting me to answer these questions.

Maximus has been criticised for the types of suicide-based questions they ask claimants, but their response has been that "Every healthcare professional we employ is trained to ask people with a mental health condition a series of clinical questions to assess how their condition affects their daily lives."

A spokesperson for the Department for Work and Pensions (DWP) said "If an individual has mental health issues or there is an indication of suicidal thoughts or intentions, this will be given careful and sensitive exploration to establish the circumstances"

According to a Freedom of Information request in 2014 (I haven't been able to find anything more recent unfortunately), WCA assessors get approximately 17 days' training if they are nurses or physiotherapists, and less than 17 days if they are doctors. I've looked through the PDFs released as part of the response to the request, & it appears that actual mental health training is only covered in just over 4 of those days for nurses, 7 days (including overviews of some mental health conditions) for physiotherapists, and just 2 days for doctors.

The British Association for Counselling and Psychotherapy (BACP) have ethical frameworks for working with suicidal clients. According to this, factors such as the following determine the best way of approaching the topic of suicide and what action to take:

• The context in which therapy is taking place
• The relationship with the client
• The boundaries of confidentiality agreed
• The confidence of the practitioner to explore the meaning of suicide

In the Risk Factors section of the BACP ethical framework document, it is stated that "Practitioners need to be aware of factors that might suggest their client is in a high-risk category" (for acting on suicidal thoughts). This doesn't mean that those in statistically non-high risk categories are unlikely to carry out any plans, but gives a guideline that can determine "the dialogue that then needs to take place with the client". Sources of information on high-risk category clients can also provide vital tools that support risk assessments. 

When exploring how to word questions based around suicidal thoughts & plans, the ethical framework document says "The wording of such questions is important and needs to be treated sensitively. Much will depend upon the setting in which the therapy takes place, the age, understanding, or emotional capacity of the client, and the individual approach of the practitioner" "It is important for practitioners to think about how they might ask a client about suicide. However, best practice suggests asking clearly, openly, and empathically"

This document goes on to explain that it is also important to explore protective factors with the client, and encourage them to use those support networks etc. If the client is at high risk of attempting suicide then specialist mental health services may need to be involved. 

And this is all within a therapeutic setting. A work capability assessment is by no means a therapeutic setting, & the vital resources for dealing with suicide risk are not there; which makes approaching the topic of suicide with the claimant potentially very risky. This could quite easily lead to the worsening of suicidal thoughts and even plans. As for the discussion of protective factors, this is only very briefly touched upon in Work Capability Assessments, so is very unlikely to counteract the impact of asking a claimant (for e.g.) if they have considered suicide, and what methods they would use/have used. If risk of suicide needs to be explored, as part of someone's assessment, surely the healthcare professionals involved in the monitoring/treatment of their mental health (therapists, psychiatrists, GPs even) should be contacted? This could also determine whether a face to face assessment would be necessary, or whether it would be likely to cause a significant deterioration in the claimant's mental health. 

Resources:

¹, ², ³ DNS Article - "Maximus 'admits' using brutal and dangerous suicide questions": http://www.disabilitynewsservice.com/maximus-admits-using-brutal-and-dangerous-suicide-questions/

Article in the Independent - "DWP's fit-to-work tests 'cause permanent damage to mental health' study finds": http://www.independent.co.uk/news/uk/politics/fit-to-work-wca-tests-mental-health-dwp-work-capability-assessment-benefits-esa-pip-a7623686.html

Freedom of Information Request: https://www.disabilityrightsuk.org/news/2014/september/wca-assessors-how-much-training

Nurses' training documents: https://www.disabilityrightsuk.org/sites/default/files/pdf/nurses.pdf (see pages 6-7)

Physiotherapists' training documents: https://www.disabilityrightsuk.org/sites/default/files/pdf/physiotherapists.pdf (see pages 7-9)

Doctors' training documents: https://www.disabilityrightsuk.org/sites/default/files/pdf/doctors.pdf (see page 8)

BACP "Working with Suicidal Clients" - Introduction: http://www.bacp.co.uk/ethical_framework/documents/GPiA042.pdf (see page 6)

BACP "Working with Suicidal Clients" - Risk factors: http://www.bacp.co.uk/ethical_framework/documents/GPiA042.pdf (see page 8)

My Mental Health Timeline

Childhood: When I think back to my childhood, I believe I had some mild mental health problems back then; which were probably brought on by the bullying I experienced. I have always had a low self-image, and been critical of myself. I've always had anxiety in some form or another as well. I'd feel anxious about eating in front of people, being in busy places, and catching the bus. I still managed to do all of these things, but I constantly worried about embarrassing myself, seeing one of my bullies, or having a panic attack. I self harmed fairly frequently as a way of releasing my emotions, and as a way of punishing myself for not dealing with things as well as I thought I should.

As I moved onto secondary school and the bullying continued, I became very self conscious & blamed myself for anything that went wrong. I started carrying out certain routines (praying 3 times, exactly at midnight) and carrying "lucky charms" in specific pockets. I truly believed that, if I did this, the bullying would lessen or I'd cope with it better. If I didn't carry out the routines, or forgot to bring certain "lucky charms" with me, I believed my day would be awful & that I wouldn't be able to cope with anything. If I did have a bad day, I believed it was because I hadn't done my routine properly or at the right time. I started to have violent intrusive thoughts, that led to violent dreams. I worried that I'd carry out those violent acts and that I was a terrible, evil person.


University: When I finished school, I decided to go to a university where it was unlikely I'd know anyone. I needed a fresh start, and felt I was a bit happier and confident enough to make new friends. I think this was one of the best decisions I made. I was independent, popular, enjoying life! I was also very impulsive and a bit of a risk taker when it came to certain impulses.

In my second year of university, the physical health problems started and I think this is what led to the anxiety relapse and depression. It certainly didn't help that I was in an abusive relationship at the time, and lost friends thanks to my fluctuating physical illness. I blamed myself for everything again and felt I had to explain why I was well enough to go out some days, and not others. I felt very trapped and isolated by my illness, as well as by my partner at the time. We broke up, but I still felt isolated & I struggled with making plans. As well as feeling too physically ill to attend most lectures, I became very anxious with being in busy lecture halls. I spent more time in my room & became fairly paranoid about friends. I wondered what they thought of me, whether they believed me, whether I was losing them.


Work: After university, I had my first full time job. I was in a relationship at the time, and was fairly happy. It was lovely to come home from work to my partner. He made me feel wanted, and encouraged me to be more sociable. Although not as good as university, I became a little more sociable; catching up with old friends. When it came to work, I often felt as if I wasn't good enough. I struggled with phone-calls, as I worried that the customer wouldn't think I was competent. I still had anxiety with busy situations, and found meetings made me panicky. Whenever I could, I would avoid meetings.  Eventually, my physical health had worsened so much that I had to give up working. My anxiety had worsened a lot too.


Breaking Up: The paranoia I had, the anxiety, and the fact that I wasn't well enough to go out much, I think led to my partner breaking up with me. I struggled with being single, and felt completely worthless and broken. Finding out that he'd met someone else just two days later didn't help either. Was I that easily replaceable? I'd moved back to my parents' flat and away from old friends. Most of my social interactions were online, and so I didn't go out much. I lost more friends, and ended up breaking ties with the rest of one friendship group, before they broke ties with me. It hurt a lot, and I still have times where I dwell on it now.



Unemployment: Once I'd moved back home, I had to decide whether to force myself to work again , or to try claiming Employment and Support Allowance. I was really worried that I'd be thought of as "faking it" or just not being ill enough to qualify. After a horrible assessment, I was accepted for ESA. Stories in the tabloids of "fakers", "scroungers" etc made me paranoid that maybe I'd be accused of this if I was seen outside, or walking one step further than I should be. If I saw a strange car or van outside, or if someone looked at me for longer than normal, I instantly thought they worked for the government.


Starting Therapy: I noticed my moods had been so low, and finally decided to open up to my GP about this. (You can find my blog post about this here). I was given the number to self refer for Cognitive Behavioural Therapy. My first lot of CBT was at a low intensity level, and I saw my therapist every fortnight. We talked about my home situation, physical health (and how that had an impact on my mental health) as well as things that'd happened recently and how to re-examine my thoughts. I liked the therapist, but wasn't finding therapy very beneficial. It seemed too simplistic, and I wasn't sure I really fit the boxes that come with mental health questionnaires etc. I didn't know how to explain it so thought that maybe I just wasn't trying hard enough. I started to have very strong suicidal urges, and was soon in crisis. My therapist at the time contacted crisis team, and I had assessments but nothing else could be offered for the diagnoses I had (Generalised Anxiety Disorder, & Depression). I got very panicky at my last low intensity therapy session, and was then referred on to high intensity CBT. I was also prescribed Amitriptyline by my GP, to see if this would help my moods.

I didn't seem to have such a good rapport with my second therapist. I felt she was repeating a lot of what I'd already learnt about CBT, and I wasn't given much opportunity to talk through how I felt. It seemed more about going through worksheets. If my suicidal thoughts were more frequent, my therapist would instantly go to contacting crisis team. In the end, I told her not to, and I began to hide my darkest feelings and just comply with the worksheets. I ended up finishing this lot of CBT early, partly because I couldn't get transport there any more (and was too anxious to use taxis/buses), partly because it just wasn't helping me.

My third lot of CBT (again at high intensity level) was carried out at home. I was far too anxious to travel, and had then been diagnosed with Agoraphobia, which helped a lot with getting a therapist to come to my house. I got on well with this therapist, and was opening up a bit more. I still didn't find much benefit from the worksheets, and found that I was just going through the motions with homework. It seemed I wanted the therapist to think they'd helped me a lot. I felt like I was failing otherwise. Apart from this, I found a bit of benefit from having the odd walk outside, with the therapist. She wanted me to get a bit more confident outside, and I liked how we didn't have to always be indoors for therapy. I knew I needed help for my agoraphobia, and having someone accompany me outside and build up to me being a bit more independent, would be a good idea. Unfortunately the sessions came to an end before I could make any noticeable progress.

As well as going through therapy, my latest crisis also led to some appointments with a psychiatrist. They changed my medication to Sertraline (with Diazepam as a short emergency prescription). They also suggested I have Psychodynamic therapy, as CBT didn't seem to be suiting me. Unfortunately, I was not given that therapy. I'm not sure any available therapists were trained to carry it out. My third CBT therapist did say, however, that due to the trauma I'd experienced in the past, she may be able to offer me EMDR, as she was training in it. She wanted me to have a break from therapy for a few months first though.

Moving: My parents and I moved house quite quickly, a couple of months after the third lot of therapy. Unfortunately the area we moved to was not under the same mental health team, so I was discharged and told to approach my GP and get referred to the team in my new area. I struggled to get up the courage for quite a while, and took longer to phone the self referral number. I wanted to avoid mental health services altogether, and be left alone. I felt that I wouldn't be reliable and would be discharged for cancelling so many appointments; due to (physical) ill health. When I did eventually call the number, and soon after got my telephone assessment, I found myself rambling a lot to the therapist on the phone. I wasn't sure where to start, and was already very nervous. It felt as if they listened though.

Interpersonal Therapy: I was very pleased to be offered a type of therapy that wasn't Cognitive Behavioural Therapy. I needed to talk about things in the past, and how I formed/maintained relationships, so Interpersonal Therapy seemed like a more suitable one for my issues. At my most recent session, however, I lost trust in my therapist after they dismissed my concerns about my self harming getting worse, as well as a diagnosis I thought I might have. This condition is Borderline Personality Disorder. I explained some of the reasons why I thought I had it, but I didn't feel listened to. The therapist just told me that BPD was something that psychiatrists diagnose you with, if they don't know what's wrong with you. This made me really angry, as I know this condition is real. I couldn't listen to what he said for the rest of the session, and spent most of it wondering whether to just walk out. It was a good job I stayed until the end though, as he suggested I get referred to Secondary Care services (CMHT). I went to my GP the next day, who contacted my therapist to confirm this referral was right for me. After a quick phonecall with the therapist, later that day, I was referred. I was contacted the following day by CMHT; who gave me an appointment for 3rd February.

Community Mental Health Team (Secondary Care): On Friday, 3rd February, I went to my appointment. In the room there was a Community Psychiatric Nurse (CPN). and psychology assistant observing. The CPN explained about my referral and gave me a Wellbeing questionnaire to fill in rather than the usual Depression (PHQ9) and Anxiety (GAD) ones. This questionnaire included questions about coping, making decisions, whether I've felt close to people etc. I've found this questionnaire, with similar questions. I was ticking rarely or none of the time for a lot of them; so I'm guessing my "wellbeing" isn't great!

The CPN then went on to asking why I think I've been referred to the Secondary Care Team, what my main struggles are, and what sort of help I think I need. I spoke about mood swings, the intensity of my moods, how I would be full of emotion (to the point where I feel I'll burst) or feeling nothing at all. I told him how I found it hard to cope with how quickly/extremely my moods can change. I mentioned the numerous crises I've had, suicidal thoughts (which became plans at one point) and frequent self harming that's getting worse. I said I was feeling less in control when it came to my moods and self harming. I can get very irritable and angry, but tend to turn this anger on myself. I also mentioned the times where I've been hypomanic, quite impulsive, agitated etc and how I find that strange; given my diagnosis.

I spoke about the many years of psychological bullying I experienced, as well as an abortion I had at 19, and a controlling, abusive relationship I had, not long after.

Finally, I spoke about my last therapy session, where I felt I could now open up about how, for over a year, I've wondered if I have Borderline Personality Disorder.  I can relate to pretty much all the criteria, although some were more prominent when I was a teenager/ very early 20s. The CPN didn't confirm or deny a BPD diagnosis, but did say that (looking over what I'd told him) he believed I had a long-standing trauma related disorder. He wasn't entirely sure if secondary or primary care would be more suitable for me, but he would have a word with my therapist and give me a call next week.

So this is where I'm at now. I'm not entirely sure what to think about the CMHT appointment. It was a shorter appointment than I expected, and not quite as thorough either. The CPN did ask some specific questions, but it was mainly left to me to explain how I'd been feeling. There were things I forgot to mention to him (and he has given me contact numbers to ring if I do need to talk about them) but I think he got a fairly good picture of my problems. I guess I'll just have to wait and see!

I hate my skin.

TW: This post includes details of self harm. Please take care reading it. 

I pick my skin. A lot. Several times a day. I've done it at least since my teens, but it has got a lot worse in the past year or so. I absolutely hate my skin at the moment and even though it's mainly because of my picking, It also give me the severe urge to carry on picking. I've been trying to think of why I do it, what my triggers are etc. I tend to do it much more when I'm stressed, anxious, or very depressed. This can be to distract myself from the thing/s I'm stressed about, or can be as a form of punishment if I've been too anxious or depressed to do something. I also find that if I see a flaw (a spot, bit of dry skin etc) I just *have* to sort it out. I will do this for hours on end; as if I'm in some sort of trance. It's like an itch that gets worse, the more I leave it. I cannot concentrate on anything else, and all I can think of is "fixing" that flaw. Of course, it rarely helps my skin. Quite the opposite in fact. The more I pick, the worse it gets, and I have marks that I don't think are ever going to go away.

It's got to a point where I don't just use my fingers, I use pins as well. I've come to realise that this has become a form of self harm. Although it hasn't required medical treatment, I've caused myself to bleed a fair amount, and have needed to use plasters. Small parts of my body have reduced/no feeling now as well. 

I've admitted (some of) this to my parents, and think it has worried them. I try to conceal the wounds and make excuses for why I've been out of the room for so long. It is something I guess I feel ashamed of, but the more I hate myself for it, the more I do it!

I've been trying very very hard to reduce how often I do this and have so far managed up to a day with no picking. I just about managed yesterday, and I'm trying to make it two days without picking. It is so difficult, because I'm having to try to ignore those intrusive thoughts and urges. I'm trying to find ways to distract myself, by keeping myself as busy as I can. This of course isn't helping my physical health, but sometimes I have to compromise in order to help my mental health a bit. 

A while back, I bought one of those fidget toys. It was some little wooden blocks strung together with elasticated string. You could make different shapes by twisting and moving the blocks. Unfortunately, I found it didn't really help. It kept my hands busy for a bit, but it just wasn't the same. I wasn't "fixing" anything, just adjusting it. 

I've tried adult colouring books too. It helps a little, and can be a good distraction sometimes, but it doesn't require much focus so doesn't really help keep my mind off intrusive thoughts and urges. 

In order to calm my skin down a little, I've used ice cubes on the worst marks. Although it took some of the redness away, I ended up using this as a way to harm myself; by holding the icecubes on my skin until the pain was too hard to bear. 

At the moment, I'm using cross stitch to distract myself and keep my hands busy. I struggle with concentration, but on my not-so-bad days, I can focus on this and push those picking urges back a little. I game a lot as well; casual gaming when I can't concentrate for too long. 

I'm feeling so restless right now, but I'm trying to hold it together and not give in. Can I make it to two days without picking? Wish me luck, I need it!