CBT is over - you're on your own

So I've managed the 12 weeks and I've learnt  loads of things that are actually very useful.  At the last weekly session, all of my mental club chums turn up looking as nervous and concerned as me. It's been lovely having somewhere to come each week and share about the madness. Now we have to go out into the world alone and practice our techniques and survive the world alone. The general feeling is one of fear as we won't have the group to fall back on, and most people are terrified of a depression relapse. The worst thing in the world is feeling well, then having your joy snatched away from you, not knowing when it will return. We all dread it on some level. There are no guarantees of wellness.

The therapist uses the analogy of doing your driving test. You have your block of 12 lessons, pass your test and then you have to go out and drive all on your own. You know intellectually that you can, but you're going solo and its a little bit scary to say the least. Its exactly the same as CBT. You have to go and put it into practice. Some poelple will have a car crash, some will have a few scrapes and some will drive aorund, blissfully unaware of any trouble whatsoever. Its a case of suck it and see.

I've done my score sheets that compare to my first week session feelings to my final week session, and they show that although I'm still depressed, my social functioning and anxiety are much improved. For me, this is fabulous as I know depression won't just go away, but I have a deep need to be able to function and get on with my life. Giving up is not an option. And I have been getting on with it. I am managing to juggle 3 days at work and 1 at home, looking after the kids, having more fun and generally being more involved in my own life and relationships. Its good news.

However, I now have to face another recovery hurdle which is deeply rooted and not easy to shift. Friends, I introduce you to low self esteem. "Low self-esteem means that you think you are a lesser person than others. It can often be traced back to early childhood experiences, such as heavy criticism, being abandoned, feeling unloved, or being ridiculed or abused. It can also be a symptom of depression." (www.thesite.org) In short, whether or not I am depressed, happy or otherwise, generally I think of myself as the dirt, which is on the turd on your shoe. And I am going to do another course which will help me to overcome this. Its going to be uncomfortable (which really means excruciating) , last 10 weeks (A bloody lifetime), but it will help (yeah right, but not for me, which I'm told is a typical low self esteem remark!).

Welcome to hell.

A gift from my CBT chum

..and this is what she gave to the group:-

Autobiography in five short chapters - by Portia Nelson

1.
I walk down the street.
There is a deep hole in the sidewalk
I fall in
I am lost...I am helpless
It isn't my fault
It takes forever to find a way out

2
I walk down the same street.
There is a hole in the sidewalk
I pretend I don't see it
I fall in again
I can't believe I am in the same place
But it isn't my fault
It still takes a long time to get out

3
I walk down the same street.
There is a deep hole in the sidewalk
I see it is there
I still fall in...its a habit
My eyes are open
I know where I am
It is my fault
I get out immediately

4
I walk down the same street.
There is a deep hole in the sidewalk
I walk around it

5
I walk down another street

Absolute genius!

Did I mention I'd been discharged?

After a year of support, my lovely CPN feels I am well enough to be let off the leash. I am well enough mentally,  and have successfully reintegrated into the real world. Apparently I am a mental health success story. Sadly you don't get a certificate of sanity but I'm just happy to be well. I cry when she says goodbye - its been an emotional journey and she's been amazing.

Although I am free from regular mental health team scrutiny, I am still seeing other professionals. Sadly I'm still not typically "Normal" in the brain area. I'm to see my psychiatrist every 3-4 months and my psychotherapist on a one-to-one basis to do some exposure therapy. This doesn't mean I get forced in front of a pervert in a rain mac to stop me feeling unhinged, but means I get to learn a new technique that'll help me with the intrusive thoughts. I'll explain more later.

I feel like a grown up, healthy person at work, and in my flurry of wellness, I decide to work and extra day and a half a week. I have told everyone with whom I work that I am of a slightly disordered mental disposition and explain that I will be doing certain things that keep me centred. For example, sharing some inspirational quote cards around the office, not doing meetings after 3pm, dispensing joy in amongst the stress to lighten the mood and working from home one day a week. Most people embrace my eccentricity and realise that although I'm bonkers I'm quite good at my job and let me get on with it. There are a few who tell me off for talking in the office and laughing (God forbid I should have fun at work) and the odd one or 2 that look at me as if I were a big lump of dog poop on their shoe. These people I learn to accept and ignore. Get me with my CBT techniques!

I have begun to live a again and the hopefulness continues. I go to my appointment with the psychotherapist and talk about my intrusive thoughts. What I learn is that ALL people experience intrusive thoughts. She gives me a sheet of data relating to 100 people and a list of the intrusive thoughts that pop into their head. Most people, and I mean ordinary folk, have the odd thought that is not really acceptable. You know stuff like, "Shall I let go of the steering wheel?", or thinking you've not locked the door or left the cooker on, thinking about someone else whilst making love to your partner, thinking you might yell an obscenity in a quite place or have an odd sexual thought at what you would deem to be a completely inappropriate time; you know like when you are cleaning out the guinea pigs or something.

When non OCD people have these types of thought intrusions, they ignore it, probably give it a few seconds reflection, think, "That was odd" and carry on. Not so for us with an overactive amygdala:

Amygdala: "a small area hidden within the temporal region of the brain. In humans, the amygdala is the size and shape of an almond (amygdalum is Latin for almond).  [...] this area is the heart of the emotion system. It is "able to process the emotional significance of individual stimuli as well as complex situations. The amygdala is, in essence, involved in the appraisal of emotional meaning"." (The Emotional Brain: The Mysterious Underpinnings of Emotional Life by Joseph LeDoux, Simon & Schuster) Keeping it simple what this means is that an almond blob in my head is responsible for my flight or flight reactions. And mine is overdeveloped, and overstimulated, so my brain, hormones and emotions are all out of kilter. I told you I was a bit on the broken side. Maybe this is where the term "She's nuts!" comes from?

Basically me and my brain overreact. Which is a pain as it means I spend a lot of time being over stimulated by normal day to day things and being hideously anxious. It also gets worse when my mood is low. In classic OCD, people will try to make the anxiety go away with rituals, that make the person feel free from the anxiety. When you speak to about OCD, people will ask you if you clean and wash your hands obsessively. I feel that the thought intrusion side is left out and people don't really get that part. Apparently the overstimulated amygdala can be a result of traumatic childhood, a serious stressful incident, that type of stuff.  Spending too much time on high alert makes you over sensitive.

I remember having a bad depression week and my mood was really low. WHAM the nasty thought pops in and because its hideous, I immediately feel frightened, and worried that I might actually act out on my thought even when I don't want to (That's the compulsive bit), I become incredibly distressed and go to pieces. Most OCD people are conscientious and quite perfectionist in nature. The thoughts are usually massively removed from the values and ethical choices of the person suffering, so the thoughts feel even more disastrous. So for me the thoughts are usually around hurting myself in savage ways. Stuff like swallowing bleach, pouring boiling water over myself, chopping off my arm with a bread knife. My core belief is about living and not death or suicide, celebrating life, gentleness and love, looking after my family and surviving my mental illness. So if I were actually to do those horrid things, it would go completely against my moral code. That is why it feels so awful. And the stimuli is centred around day to day things - making a coffee, loading the dish washer, cleaning the house. Its not like I'm stood in front of an axe murderer and I'm fighting for my life. When I shared about the intrusive thinking in group, they all looked appalled and sympathetic. None of them could identify with my experience, so I felt incredibly vulnerable.  The therapist god love her, explained it by saying,"Its like a devout Catholic sitting in church, suddenly wanting to shout out a swear word, or wanting to flash her breasts at the priest". Its unthinkable that she'd actually do it. 

So the exposure stuff is about retraining my almond blob into what is really terrifying and what is not. The homework is to walk around the house holding glass, putting sharp knives in the sink whilst washing up (Only for me not the rest of the family), putting the nail polish remover next to my coffee cup whilst I'm drinking, and standing near to a boiling kettle for an extended period of time poking fun at it. The plan is that after doing these things over and over again, my brain will learn that I'm not going to do what the thought intended. I'm not going to hurt my self and the anxiety level then reduces dramatically. I also learn that the thought is a lie and I don't need to panic. 

I also get superstitious thoughts too, things like if my husband is late home from work, the almond blob places the, "He's died" thought into my head. If I act out on the thought, I panic, have to ring everybody and ensure that he's not dead in any way, shape or form. Now, I remember its folly, ride out the panic and breathe. I don't phone, I don't imagine horrors and I calm down.

Its hard work but it works. The following few weeks I have to look at my rituals. I thought I didn't have any. oops!

Apparently I have TRAPs

Don't worry, its not a STI or another mental illness. Avoidance apparently has been my best friend. TRAP stands for TRIGGER, RESPONSE, AVOIDANCE pattern and CONSEQUENCES.

So, a mega twat from work says something really nasty in a meeting. I either become sad, angry or fearful, I revert to an avoidance behaviour and then I feel rubbish. Apparently I do this a lot. Getting stuck in TRAPs exacerbates low mood and TRAPs joined together like a sick Christmas paper chain result in being depressed even more. Avoidance behaviour for me usually involves crying, zoning out, eating, sleeping, avoiding conflict, being subservient, emotional fatigue (where you lose interest in everything and just can't get going), running away, or anything else that will shut off the feelings that make you uncomfortable and shatter your joy. Run for the hills, hide under the duvet,deny all knowledge, look at the floor - I could go on.

I am so damn sick even I am beginning to wonder if there is any hope for me. Thankfully, the CBT group mirror reflects 9 other emotionally unbalanced friends, so I will carry on regardless. Bless them all. We all look tortured after this session, realising that we are actually going to have to push out of the comfort zone, and expose ourselves to our worst nightmare. Dealing with other people.

So, I have to implement TRACs ( Sorry about the acronym overdose), which means TRIGGER, RESPONSE, ALTERNATIVE COPING mechanism. So when twat colleague says something that makes me wither, I have to take a deep breath and say, "I disagree with your comment and your behaviour is unacceptable." When the therapist tells us this, we all giggle and do the opened mouthed and prolonged, "Nooooooooooooo!" It feels liberating to think I am actually allowed to do this. Even if I don't actually carry it out, the knowledge alone sends my happiness soaring. I am also told that guilt is a waste of time so I have to bin it. Apparently normal folk do this stuff all the time and think nothing of it. They dismiss rubbish and resolve conflict, and walk freely through the maze of day to day life. I find this fascinating.

What I also have to learn is that a new bag, or top, or scarf, or all of those things will not resolve the conflict or make the terrors go away. Hiding is not a solution. This behaviour lulls me into a false sense of security and doesn't challenge the fear. Really a TRAC is throwing the bucket of water over the wicked witch. I am required to turn up at work in my magic red shoes, banish all negativity and focus on the wizard and finding my way home! My colleagues will now be the munchkins and my therapist is Glinda. This does mean that every now and then the flying monkeys will try and get me but really, all will be well. The witch is my nemesis - she is my TRAP. When I am finally well, I will return the the normality of the farm, and realise it doesn't hold the fear and control it once did. Life will no longer get the better of me.

um.....

The Social model of disability

"The social model of disability proposes that systemic barriers, negative attitudes and exclusion by society (purposely or inadvertently) are the ultimate factors defining who is disabled and who is not in a particular society. It recognizes that while some people have physical, sensory, intellectual, or psychological variations, which may sometimes cause individual functional limitation or impairments, these do not have to lead to disability, unless society fails to take account of and include people regardless of their individual differences.

The model does not deny that some individual differences lead to individual limitations or impairments, but rather that these are not the cause of individuals being excluded. The origins of the approach can be traced to the 1960s and the disabled people's Civil Rights Movement/human rights movements; the specific term itself emerged from the United Kingdom in the 1980s".  (http://en.wikipedia.org/wiki/Inclusion_(disability_rights))

So what this actually means is that society, my environment and my illness play a huge part in how I am treated or understood. Its about you as well as me. Some people embrace mental ill health; some people call you a nutter or a psycho and either fear you or persecute you. Its a bit of a gamble when you decide to share your truth with someone.

So lets explore the social model a little further. Now I am back at  work its suggested that my employer makes, "Reasonable adjustments" to my working day in order for me to have optimum functionality. This can actually be quite difficult for depressed individuals, as their symptoms and triggers are all completely different. And being mentally ill is very different from being physically ill. If I'd have broken my leg it would be pretty obvious how to help out. But my brain is a bit broken so I have to try and figure what works and what doesn't. Sadly some things I cannot avoid, like senior members of staff that have had a personality bypass and think shouting louder means things get done quicker.Or those idiots that refuse to see your humanness and attack you with academic brutality just for kicks. Work for them is an arena to dispense pain and misery to the masses and get paid for it. They probably kill bunnies in their spare time or get beaten up by their wives. In these instances I have to re-engage that whole zoning out thing that I do to avoid any outburst and subsequent repercussions.I can also call on sarcasm and/or Socratic irony in an emergency . Sorry.....Socratic irony means:

• n.( a pose of ignorance assumed in order to entice others into making statements that can then be challenged.) Basically its a very good way of making someone who thinks they are clever look very stupid in a very gentle but cut throat way. I didn't say I was a nice person all of the time did I? 

 Anyway, what my boss and I agree to do is stick to half a week, create a stress action plan and see how it goes. I'm allowed to go off to a quiet area if I'm feeling overwhelmed, sometimes I can work from home and I need to structure my time to minimise deadline chaos. I have to implement CBT techniques, keep to my sleep hygiene plan (That's the one where I sleep at a regular time, in a cool dark room, with no excess noise etc) and try not to have a mental breakdown. They also let me pop out to mental club every week and to see my CPN and Psychiatrist too. All in all, they are quite accommodating and for that I am truly grateful.

Its quite a hard balance to strike with people.  I don't want to become a total fruit cake so I  have to pick my way through the situations as they arise and not get too done in if I get it all wrong.  I am responsible for my own well being and although my employers do what they can, ultimately I'm the one who has to call the shots. And this will almost certainly be my downfall.

Less black dog, more gorgon with sprouting snakes for hair

The reason I'm saying this, is because my lovely depressive illness is a multi-faceted demon of despair. My general symptoms I learn, trigger secondary behaviours. So if I'm feeling isolated, tearful and forgetful, I'll hide in the house and eat. Or, I'll zone out whilst watching a DVD and procrastinate until it's bedtime. Rumination is another offender - chewing the useless cud of unsolvable problems, over and over and over. The thinking spiral dips and then low self esteem, doubt and fear kick in, and all is lost for another few hours, or days, or weeks.

The enormous universe inside my head is intricately structured and is nicely honed with habitual behaviours that are really quite bad for me. For example, I'll compulsively shop for at least half an hour before I get to group to stem the anxiety. I feel like my mind has been doing this to me whilst my back has been turned and I never even noticed how complex and controlling it had become. Certain types of people can also trip me up. I realise that those persons who are aggressive and dismissive cripple me emotionally and I shrink into my shoes and want to run away. Also, between 2 and 3pm every day, my energy level dips and I cannot concentrate for toffee - my vocabulary chip goes wrong and all my words come out back to front. I'll call a dressing gown a wardrobe, or just go completely blank for minutes at a time. Quite frankly, I am a total shambles!! How the hell I've been functioning in the grown up sane world is beyond me. Oh yeah, I've been off work for 6 months, so I haven't! I have an epiphany, and realise that most people are simple, uncomplicated folk who just turn up on the day, and plod joyously and freely around the world, blissfully unaware of the nightmare some of us live through. Jealously is an ugly character defect although at this point I may nurture it for a while until I feel better. Its fuels my sarcasm, which is another finely tuned coping strategy.

So every week I go into the room full of depressed souls, and share my inner most fears and talk about how my learning journey is impacting on my life. It is like a bad soap opera, and truth is definitely more bizarre than fiction. Our resident CBT cynic is starting to get on everyone's nerves too. "I just don't get it" is the phrase that triggers resentment and rolling eyeballs from all of us. We even try to do intervention and cross examine him as to why he's struggling so much. To be honest, I think its a case of  not being willing or able to change. The moaning gets on my nerves so much I actually complain to the therapists who also bemoans the lack of willingness but they don't want to throw them off the course just yet.  If I was in charge I'd be more cut throat.

And after the 2 hour soiree into the murky depths of the dysfunctional mind, I actually have to go back to work.  I've given up being coy about my whereabouts, and tell them I've been at mental club. I seriously think some people just tolerate me and the rest think humour is definately a good way of dispelling the harsh reality of my situation. Part of me wishes I had a T shirt that I could wear that states, "Menatlly ill and fragile - Handle with care" on it, so I can negotiate around the difficulties. Sadly I'm not allowed to be treated as special and different so I just have to make do. Admitting I'm a bit bonkers isn't so bad and actually I am begining to accept my disability. That in itself is a huge shift in thinking, and maybe one day, I will actually be ok. I won't need to tell you I'm mad because I'll be just like you.

Parachuting into therapy

You really do have to throw yourself into therapy, or nothing will change. I begin to realise that my depression has been around for much longer than I imagined, and what first triggered my depression is not what perpetuates it. New incidences or traumas keep it going. So for me that would mean childbirth, more childbirth, inter dispersed with massive change, a dead grandparent and the nightmare work scenario. Its really been piling up. Also, events leading up to the birth of my first child were also guilty of causing more problems - another dead grandparent, a miscarriage and 2 relocation's in 4 years. I think I've been on automatic pilot, functioning to the best of my ability but, mired so deeply in the illness, I've not seen the depth of it or how incredibly unhappy I've been. Its definitely an eye opener. I'm more broken than I first thought.

In the second week of mad club we talk about our depression patterns. Does my mood dictate my reactions and behaviour? Do I give in to emotional fatigue? Do I try to think myself out of my problems and then get stuck inside my own head?  What habits do I have that act as coping mechanisms? What I'm learning is that my mood and my social  environment have a massive impact on how depressed I feel. I've been living in my own head far too much and giving power to people, places and things far too much. I need to grab the black dog by the neck, put a collar on it and muzzle its face. I must be alpha dog! No barking necessary, although howling at the moon might be acceptable at some point!

What is interesting for me is that I realise I have been absolutely terrified of the illness. Scared of what it might do next, how it will sabotage my happiness or oppress me so much that I will just give up. I also learn that I cannot think myself out of depression. Intellectual gymnastics, reading and wishful thinking won't do it. I have to take action. The depression won't just go away and I have to learn how to live with it. I need to give it it's place, which is not the centre of everything, and not my singular defining characteristic. For some unknown reason, I have these skills for other issues in my life, but when it comes to depression, I appear to have a massive blind spot.

We are given a piece of homework called a "Mood diary". We literally have to monitor our mood every hour during the day for a week and write it in a diary. It feels like an overwhelming task but it will help to identify what our behaviour patterns are like. When I return to group the following week, we all look like we've been run over by a bus. I personally feel so vulnerable and raw that I think I might just lay prostrate on the floor and weep. This is a course for those people who will do anything to get better. Lesser mortals would hide in denial and despair. I have to accept that I am feeling resistant to change and I am going to have to dig deep with my willingness.

When we feed back to our fellow group members the following week, we are all sadistically pleased that everyone is feeling shite. It means that all of us are finding it tough so we can all relax. We all begin to realise that there is no magic feeling of constant happiness. Normal people have fluctating mood and they just get on with it. With depression the moods feel magnified, so we have to learn to recognise what the mood is, and then choose how to respond to it.  We also see how moods link together and take you down the plug hole of despair. We are told that in the coming weeks we will learn how to behave in a way that can halt the marching army of maudlin demons and rise above the insanity. We all breathe a sigh of relief - the discomfort will pass and normal service may well be restored in the coming weeks. I've got to learn to live outside of my head and give the depression the view of my rear end!