So, the inspiration for this post has come from a very recent, disastrous first therapy appointment and so initially I was just going to concentrate on that experience, but I found myself thinking of so many more bits about therapy that I want to talk about too…
When the first Psychologist (as far as I can remember) became involved in my care/treatment, I was very much in agreement with the us vs them culture when it came to psychiatric service users and certain professionals (most often the Police and Crisis Team though).
That mindset mostly stemmed from instances where I had been a psychiatric inpatient, because I think that it can be incredibly easy to build relationships with others on the ward and then see them in a number of different situations that could lead to intense thoughts and feelings towards the staff. I mean, it could vary from seeing someone being restrained and being angry that they were being deprived of their freedom and choice, to seeing someone self-harm or attempt suicide and ending up full of resentment for the staff who had been ‘useless’ in protecting and helping that person.
So, needless to say, I saw cooperating as a sign of weakness and defeat, and I developed a fear that engaging with professionals would make me more vulnerable. After self-harming, so many people would ask why I hadn’t called for help before doing it and I’d say that I hated the thought of seeking help and then those I’d spoken to, responding in ways I didn’t want or expect. I mean, there were numerous occasions where people – in general – have voiced that someone can’t genuinely be suicidal if they’re asking for help; but then you’d make a suicide attempt, and the first question would be “why didn’t you ring such-and-such?!” And that ironic sense of being unable to do anything ‘right’ no matter what you do, can really add to the frustration and contribute to the us vs them outlook.
But I think that the truth is, besides being dramatically under-funded; one of the largest challenges mental health services face, is that sometimes, you can throw all the help and support in the world at a person, but if they don’t want it, won’t accept it, and refuse to engage with you; they’ll continue to drift away from any hope or chance of obtaining stability and entering ‘recovery.’ And it’s so much more straightforward – and definitely, often true – to say that sometimes the help and support actually isn’t anywhere near good enough; but I think that how cooperative a person is with services should be viewed as equally important. And sometimes that level of cooperation can be influenced by the actual state of the person’s mental health, and sometimes it’s about so much more…
For me, the majority of my disengagement and reluctance to follow the advice and guidance of the professionals, was about viewing them as the opposition. Which meant that for me to do a one-eighty on that – to completely change my thinking and see that they were trying their best to help and that they were only human, so they got it wrong sometimes – it took coming incredibly close to killing myself. I mean, waking up from life support in Intensive Care was terrifying. It, ironically, kind of gave me more hope in that I questioned whether I was even meant to die yet because surely if I were, it would have happened by then? And with that realisation came the recognition that if I didn’t start cooperating with the mental health professionals who still believed I had the potential to recover (and there weren’t many left by that point – most have given up on me by then), I wasn’t going to get anywhere. Things weren’t going to change, and I knew that I couldn’t do it by myself. Having spent years causing myself harm, it felt as though that was all that I could do. That was all I was good at. And without help, I couldn’t haul my body out of the hole I’d dug.
The two years prior to the first Psychologist (that I can remember) becoming involved in my care/treatment in 2011, were so unsettled, impulsive, and irrational. I mean, I was constantly in and out of hospitals – both medical and psychiatric – for self-harm and disassociation, the hallucinations were escalating, and I had made a few suicide attempts.
As unwell as I was though, I was still becoming more and more aware of the fact that things were just getting worse and that they would continue to go downhill unless/until something changed. I guess my Community Psychiatric Nurse (CPN) also realised this because arranged an appointment (I don’t think there was any real referral process then or if there was, I don’t know/remember it!) with a Psychologist.
Over the space of a few months, we did two of the greatest pieces of therapy work that became absolutely instrumental in my mental health and safety at that time.
On one occasion none of the hospital staff could agree on whether I had the capacity to refuse treatment, and, in the end, it took them five hours to decide; by which time, I was even more poorly. So, the Psychologist recommended that we write up an ‘Advanced Directive’ which would state and advise what hospital staff should do if I were to present to A&E due to my mental health. The most helpful part of it was the recommendation that staff be aware that when I was feeling well, I wanted to be alive; so, if I was refusing treatment that could help me, it should be assumed I didn’t have the capacity to do so. It meant that there were no real arguments between professionals which helped because usually when they were disagreeing with one another, I was directly blamed and treat horribly because of that blame.
The second positive step in my work with the Psychologist was when she created my Schemas document. This was basically about talking through all the different thoughts and feelings that I felt influenced me to almost become a different person, and then recording the behaviours and attitude I would exhibit, and the ways I should be treat depending upon them (you can read more about the Therapy here). The Psychologists theory here was that since the abuse happened to me when I was young, my mind had almost separated off all these different child-like parts that varied from ‘Vulnerable Child’ to ‘Impulsive Child’ – and everything in between!
These two pieces of work, were so helpful in leaving me feel that I had been listened to, validated, and understood; and these were all very important notions for my mental health. It makes me sad to think that those very simple qualities – which are arguably completely necessary aspects for any psychiatric professionals to exhibit – led to my most stable period in the community. I think it was enlightening for me to see that I actually wasn’t expecting too much from mental health services and that those very simply things were enough to leave my thoughts to self-harm or attempt suicide silenced.
Unfortunately, though, the amazing Psychologist did nothing to help me with the hallucinations and when I began experiencing visual ones, I was left so scared and hopeless that I made my first most serious suicide attempt.
After being in a psychiatric hospital down South, one of the staff called my Mum and just, in passing, mentioned Dialectical Behaviour Therapy (DBT) and when my Mum voiced having never heard of it, they explained that DBT is actually the recommended treatment for someone with the diagnosis I had held for two years; Borderline Personality Disorder (BPD). And why hadn’t we heard of it? Well, regardless of the number of people my local mental health service was diagnosing with BPD, they still didn’t have any specific help and support for those people! So, when I returned North, my Mum – being the mama bear that she is! – fought for me to have DBT, but it became apparent that the only way to do so would be if I were admitted to a specialist psychiatric hospital miles away from home!
When the assessment for the private hospital in Bradford revealed that going there would mean so much more than being just one weekly DBT session as I had imagined; I refused to go. Initially, this was seen as my decision that I was both capable and allowed to make, but when the hallucinations worsened and my third suicide attempt became the most life-threatening, that decision was taken away from me. Which meant that when I woke up from life support in Intensive Care, I was told that I’d be going to the Bradford hospital with or without my consent and cooperation.
So, I agreed to go because as honestly suicidal as I had been when an Anaesthetist in A&E told me that I was about to be sedated and treat under the Mental Capacity Act and I said “I hope something goes wrong and I die anyway;” the entire situation had terrified me. It’s kind of like this episode in Greys Anatomy(!) where a prisoner on death row is taken to the hospital and he refuses treatment for his injuries, but when he’s actually about to die; he says he doesn’t want to and asks for help. One of the Doctors says that death is a scary thing and he’s allowed to be afraid of it. And I guess that’s sort of what happened to me… I felt suicidal, but when I actually came close to death, that seemed to disappear and was replaced by an intense and overwhelming terror.
But that ‘terror’ was so much about dying as it was about living… Months before my mental health went downhill, I was given too much morphine in a medical hospital, and I went into respiratory arrest (I stopped breathing). It’s well over a decade later and I still vividly remember the sense of serenity and the bright white light that filled my vision and left me inexplicably desperate to reach where it was at its brightest. I wasn’t afraid of death – in fact, I quite liked the idea of it… The memories of that blissful, peaceful feeling made the idea of dying kind of comforting.
The fear during that situation was mostly about the fact that if I had died, nothing would change. My local NHS Trusts would likely continue to fail people they were diagnosing with a Disorder they lacked the resources to treat, and all the professionals who had treat me so horribly, would continue to do so with others. If I died, I wouldn’t have a voice. I wouldn’t have the potential to influence change and improvement. And this passion and determination to change things so that no one else was so failed and mistreat that they ended up on life support, was really boosted when the staff in Bradford commented that had I been in their locality, I likely would’ve been admitted after one suicide attempt. Not three and – as my records state – over SIXTY hospital admissions.
So, when I finally went to the specialist hospital in Bradford in the summer of 2012, I was told that you actually don’t just immediately start DBT once you’re admitted. No, instead, you have to complete a lengthy (in my opinion anyway!) period of stability first. I guess that the thinking behind that is that if DBT makes anything ‘worse,’ chances are you’ll be in a better position to cope with that than you would if you started the therapy whilst at your absolute lowest. And I suppose that actually makes sense. (It’s probably also worth noting that even some therapies in the community require a period of stability before beginning.)
I think that finding the correct timing for you starting therapy is also not only about how you cope with it if things get tough, but also how you engage with it in general. I mean, sometimes a person (not just someone with a mental illness)’s level of cooperation and engagement are dependant upon their mental state. I mean, if you’re struggling with thoughts to self-harm or suicidal feelings, how are you meant to sit in a room and focus on completing worksheets and reading through your DBT diary? If you’re experiencing hallucinations, how are you supposed to stop them from taking over absolutely all of your attention long enough to sit through a few hours of teaching of even just one DBT skill?!
Those months it took to stabilise my mental health – mostly through medication – were also really important in influencing my opinions of the Bradford staff. I mean, I don’t think I was even there for twenty-four hours when I tried to escape and was promptly sectioned under the 1983 Mental Health Act! And of course, that filled me with anger and resentment towards the staff who – in my opinion at the time – were only prolonging my suffering by stopping me from killing myself. I wasn’t at all grateful to be saved. I wasn’t excited to start DBT. I didn’t see the admission as the one that would change everything. To be honest, a huge part of my motivation to go to Bradford was that I’d be further away from the people who knew me the best and that could heighten the potential for me to be able to attempt suicide again.
Ironically, though, it had the opposite impact because being surrounded by staff who didn’t know me very well turned out to mean that they always aired on the side of caution – in the most (in my opinion) drastic ways! But equally ironically, this stopped making me hate them! I mean, when the professionals back North would make decisions like the Bradford staff, it always felt like a misunderstood punishment. As if they were desperate to stop dealing with me and sectioned or sedated and restrained me, out of frustration and not care or concern. Whereas the Bradford staff seemed to be a whole lot more kind, thoughtful, and better motivated. And I think that developing this trust and appreciation in the staff was really influential when the time came to start DBT.
I used to really frequently feel sad at the thought of how bad my mental health got before I got the right help and it started to get better; but not anymore. I’ve learnt to deal with that frustration and sadness by using the mind set that perhaps all those years and hospital admissions before Bradford, just weren’t the right moments for it. I mean my Nana and my Mum always talk about everything happening for a reason and perhaps I just had to get to the point I did in order for me to develop the passion and dedication to claw my way back.
Mindfulness: I like to utilise this when engaging in a distraction activity (found in the Distress Tolerance module) that is helping to make any unsafe thoughts and feelings bearable:
Distress Tolerance: I like to use the radical acceptance skill in this module when I’m feeling completely powerless or resentful around a situation, and the grounding skills when the hallucinations are overwhelming or disassociation is creeping in:
Emotion Regulation: I’ve found the self-validation skill in this module really useful when I’m feeling dismissed, ignored, and patronised by the people I’ve looked to for help and support:
Interpersonal Effectiveness: I typically like to use, the FAST skill when I’m feeling overly critical of myself, experiencing low self-esteem, and falling back into old thoughts that I was deserving of hardship and destined to die: