Category Archives: Depression

Starting a Mental Health Blog: Insights

I’ve put together a few tips of things I really wish I had known before starting this blog in hopes of providing a little useful information for anyone leaning toward starting their own.

I’ve been writing the bi[polar] curious blog now for five years and there have definitely been some big lessons I’ve had to learn along the way. I wanted to put together a list of a few of those lessons to share for anyone in the early stages of blogging or thinking about starting their own mental health blog. Of course, keep in mind that I’ve remained relatively unstable over the last five years because of the treatment resistant nature of my bipolar symptoms so you may find that your approach to navigating some of these issues may be a lot different than the way I’ve gone about dealing with them. Really I just thought there were several things I wish I had known ahead of time, things I could have coped with before starting this blog that might have helped me remain more stable through this process.

The spam is real.

WordPress does a pretty good job of helping filter out spam comments from real ones, but sometimes spam comments show up where they shouldn’t. Early on it would be a little heartbreaking to think I’d received a comment only to find that a robot was trying to sell male enhancement products on my page, and while most of these spam comments are harmless (just annoying to clear out when they happen) every so often I would get one that would throw me into a fit of paranoia because it would use a jumble of words nearing something rational and related to something I was experiencing (hello psychosis!). I’ve had many situations where I’ve had to sit down and remind myself that spam is just spam, it is meaningless, and it happens.

The comment commentary.

Five years ago I convinced myself that I would respond to every comment a real-life human posted on my blog. That seems like common courtesy, right? Of course, that was when I’d have a comment or two a week, and they were nice, fluffy sort of, “you did it!” comments. Unfortunately, negative comments are something that happen, and sometimes they are a product of someone failing to understand the point of a post, or not liking the content, and sometimes they can just be random, cruel turds someone left behind for no apparent reason. For a time I even had a commenter who liked to point out every spelling and grammatical error in every post. Negative comments happen, and it took some time for me to be able to take a step back from them and understand that they didn’t mean my blog sucked. They didn’t mean I sucked. They didn’t mean I wasn’t doing a good job, and choosing not to respond to them (because doing so would send me into a fit of panic) wasn’t the end of the world. In fact, these days I find I can’t respond to most comments because I simply don’t have time, and I’ve reached the point where I am ok with that, even if it means looking somewhat aloof or elusive.

The real trick here is having a plan for what to do when these negative comments occur, because living with an emotional disorder makes responding to something that pisses me off or is making me cry very difficult when it occurs in a conversation with someone I love, let alone a random stranger who can’t hear my tone in my comment and may not have understood me in the first place. Ultimately, creating some distance to keep from taking comments personally has been a really, really important process for me in terms of blogging.

Da emails.

Having contact information available on the blog was important to me because I envisioned helping people who needed it. I’ve had crisis intervention training in regard to speaking with people who are very suicidal, but I am by no means a doctor or therapist or any other number of licensed professionals who deal with that sort of thing on a regular basis. I hoped people would contact me if they had questions because I am a peer, and because emailing me might be a less-intimidating intermediary step between not seeking help and seeking it.

I set up an email account dedicatedly specifically for this blog because it was also important to me that people not have my immediate personal contact information. This was really important in helping keep a boundary between readers and solicitors and me, but sometimes it has been really hard to cope with emails from people in crisis, a constant barrage of emails from people wanting to post “guest posts” for my blog (with my blog name obviously copy and pasted into their email), and those asking me to promote their products or services on my blog. These last two categories were completely unexpected, and having to “act professional” when I’m actively in the middle of a depressive or manic episode has been outrageously challenging –especially when some companies have been pushy or rude about promoting their products.

One of the ways I have gotten around this has been to formulate my own “general response” email template. It hurt my soul a little bit at first to do it, but the more I noticed the emails I received being written in general terms and sent to hundreds of bloggers the more ok I felt with doing the same thing to reply to them. Obviously I haven’t relied on a template to reply to those in crisis or those with genuine questions, but I’ve always been the sort of person who has a hard time saying “no” and having a template to fall back on that does that for me in a polite but firm way has been extremely helpful.

Overall, the number of emails I receive on a daily basis can be overwhelming, given I have a condition that leaves me having a hard time just getting through the basics of taking care of myself at times. Knowing that would be an issue ahead of time would have really helped me out, and I think I wouldn’t have worried so much about saying no to people, especially those who offer to write “guest posts” for the blog. Honestly if you are interested in writing a guest post for a blog, I’d expect to see an email without typos. An email that talks about why you want to write, and potentially a link to something that you’ve already written. A blog is only as good as its content… and while there is nothing wrong with finding guest authors (in fact it is great if you’re out of town or need more content) I think it is worth finding ones who can write.

Keeping it regular.

When I started the bi[polar] curious blog I told myself I would write regularly. At first that meant five days a week. Then eventually three. Then eventually one. Did I get on my case about not being able to keep up with the pace I set for myself (when I was hypomanic, I might add)? You bet! But as I’ve continued on I’ve found that writing one good post has sometimes meant writing three or four that weren’t as good, and then a few drafts of the one I’m posting before I put it out there. I guess along the way I found that I favor quality over quantity (though the level of quality is surely negotiable) and I had to realize that my blogging habits really mimicked the patterns I saw in myself in the workplace. When I am depressed I don’t want to write. When I am manic I want to write constantly.

One of the things we pride ourselves on in the bipolar community is that ability to produce in elevated periods, and I found that instead of posting everything I wrote in those periods all at once I could use a little tool in wordpress called the scheduler to pick a date and time in the future to unveil a post I’d already finished. I’ve had many people comment on the relative regularity of my blog and the answer is not rigorous training or pushing through my periods of depression, it pretty much has everything to do with the scheduler. I write as many posts as I can when I feel inspired, then set dates for them to be posted.

Best shortcut ever.

Everyone can see it.

There is something very freeing about being anonymous and writing about a topic like mental health and there are certainly some good reasons to go that route. My goal with this blog has been to be more open, to take some of that “scary” away from mental health, and to help both people I know and don’t know understand what living with mental illness is like.

Ok, so creating a blog and telling everyone I know about it was absolutely terrifying. When it happened I felt quite ill honestly, and though I didn’t vomit profusely it took a while for me to get used to the idea of people I know reading the things I was writing. Even after five years I’ll hear someone say something about this blog to me or a friend and feel wildly embarrassed as I realize that they have been reading it, but that’s ok. Ultimately the people I know have responded quite well, given some of the things I’ve written about.

The flip side of that coin is that if your email address is linked to your blog or if you real name is associated with it people you know (and potentially ones you don’t want to read your blog) can still find it. Social Security (if you’re applying for SSDI) can certainly find it (they found mine in a heartbeat) and they really tried hard to use it against me in my hearing.

In many ways, even if you blog anonymously, it is important to remember that the things we write, like the things we say, have weight. Writing something privately is much different than writing something others can read, our words effect other people and they effect ourselves, so taking responsibility for those words (whether you are writing anonymously or not) is something that will ultimately benefit you in the long run. Choosing to post things while in a crisis situation may be helpful if you feel unable to reach out to your support network (your doctors, therapist, psychiatrist, friends, family, support group) however be prepared to expect that in the mental health community these sorts of crisis posts are taken very seriously. Many of us have lost friends to suicide and find ourselves quite despairing when someone leaves a trail of suicidal breadcrumbs without any way for us to help. Trust me, talking to someone in person is much more highly recommended, and when in doubt reaching out to an organization like the crisis clinic (like this one: 1-800-273-TALK) is much more likely to provide support in the moment when you need it.

I guess I’m just saying, please do not rely on the mental health blogging community for all of your mental health support needs. Connecting to other bloggers and feeling a sense of community is great, but it is no substitute for having a real-life support system in daily and crisis situations. Having someone you can reach out to in times of crisis who can respond immediately is very, very important.

Initial uncertainty.

There was a lot of uncertainty when I started. A lot of obsessing over how many followers I had and over how many comments I had. I didn’t know how to come up with ideas for posts so I started brainstorming odd lists everywhere. I didn’t know what I wanted my blog to be, I just knew I wanted to write something. That’s normal.

Maybe you have a plan or no plan at all, and maybe you’ll find that you love blogging or maybe you’ll hate it. Maybe you’ll find that you don’t care as much as you thought you did, or maybe you’ll find that a blog is a stepping stone to something else. Ultimately there are many ways it could go but you’ll never know unless you give it a shot.

There are certainly a lot of positive things that have come out of this blog for me but most of that reflection will come in next week’s post (and some was already discussed in last week’s post as well). In the meantime, I would say that if you’ve considered writing or look to connect with others through writing, or even just want to get to know yourself better blogging can be a really helpful way to do those things!

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Writing for Relief

I don’t know about you, but there are times when I feel that going a week (or two, or three) between therapy sessions is far too long.

I don’t think it is because I have an extraordinary amount of drama in my life, but there are some subjects and issues I only really discuss with my therapist. I’ve found that there are things I’ve brought up with friends or family that really weren’t constructive because nobody could relate, so short of therapy (or group therapy) I have a vat in my brain where all those thoughts just kind of slosh around in holding until I have the opportunity to wash the tank out each week.

A full and sloshing vat of pent up confusion or sadness or anger or whatever is hardly ideal. It can get so full that things start to spill over into my daily life, and that’s not cool. Sometimes it can get so full the structural integrity of the vat can’t hold it all and it blows up in my face. Squishy thought fragments get all over the floor, everything gets warped… it’s a nightmare to clean up.

Lately I would say I’ve been exploring some rather complex issues and thoughts and they aren’t things that I can easily talk about with the people around me. Sometimes I feel like things are just too abstract to be able to talk about in a way that will make sense to people, and therapy really helps me take pieces of an idea and mold them into something coherent.

Words.

But, as I’ve pointed out, that isn’t always an option. Sometimes I need my brain to form words sooner rather than later, because once these bits are formed into pieces that I can understand they become solid. I can take them from the vat and file them wherever they need to be filed in my head.

I learned pretty early in my life that writing is one way I can form those bits into full words and ideas on my own without waiting for the vat to overflow.

In my youth having a journal was (pardon my nerdiness here) kind of like having my own personal horcrux. It was someplace I could turn those thought fragments into words and store them to save space in my mind. At the same time negative thoughts and imagery could live in the journal safely without having to constantly nag at me. Looking back at these journals has showed me that they were really a stream-of-consciousness word barf sort of situation, and that’s fine (now where did I put that basilisk fang?). They weren’t meant to be on the top of the New York Times bestsellers list. Writing that way helped me cope with the sheer volume of everything inside my head and allowed me to have a little more space to concentrate.

As I got older writing and journaling began to allow me to ask questions of myself and the world and brainstorm what they might mean or what the answers might be. It became a tool for me to organize my thoughts more than just dump them.

Things progressed even further when I began writing this blog and used the writing process here to take questions or ideas I had about mental health, put them into words, and then try to arrange those words in ways that made sense to other people. I’d say this not only satisfied my desire to understand things better, it has also meant working toward being able to communicate better in general around the topic of mental health.

Writing is incredible that way, it is a form of expression I really think I took for granted but didn’t realize for a long time how many ways it has helped me. Writing in journals, writing poetry, writing blogs, there are a lot of options to try depending on what you might hope to get out of it. Some of the biggest takeaways I’ve encountered are:

  • Organizing thoughts
  • Purging negative thoughts or ideas for relief
  • Expressing hidden emotions I may not express otherwise
  • Better understanding (of myself, my illnesses, my issues, my situation, etc.)
  • Seeing things from another perspective (great with writing prompts)
  • Taking the terror out of something I’m afraid of (by exploring what is so scary about it)
  • A place to practice “positive self talk” (letting myself know that I am awesome, I’m doing a good job at life, and I’ve got this handled)
  • An outlet for conveying difficult ideas to other people (blogging, for example)
  • A way to become familiar with words that go with my emotions, being familiar with this vocabulary has made it easier for me to express them in situations outside of writing.
  • Perspective on a past version of myself, seeing how far I’ve come (only if I’m willing to go back and read it)
  • A sense of relief and release should I feel inclined to write about something I’m holding onto and destroying the writing later (shredding, burning, etc.)
  • You never know, something you wrote could be comedic gold in 20 years (check out Mortified for some super amazing adults reading their teenage journals aloud, I love it)

I’m sure that is just the tip of the iceberg there.

I wanted to share this topic this week because I’ve been dealing with some difficult topics in my life that are hazy. They remind me a lot of when I first started trying to write about mental illness and I found I didn’t have the words to describe what it felt like, or how it worked in me. Back then I didn’t even know what my emotions were, I was so used to pushing them down that I couldn’t readily identify one from another.

Likewise I’ve found myself opening all kinds of old boxes in my brain only to find that there are things that are still very relevant. They may not pertain to mental health, but they are things that, like my emotions, I’ve been cramming in boxes and throwing in deep storage for the past 30 years. As I’ve delved into all of this I’ve also started feeling some depression, I’ve felt confused and overwhelmed and quite a lot like I don’t believe I can handle it.

That’s the thing though, isn’t it? Mental illness isn’t going to wait for me to clean out the freezer and the garage before it rushes in to greet me, at least, not with the kind I have. Having treatment resistant Bipolar Disorder means having to multitask sometimes, even when what is in front of me doesn’t seem to have any baring on my illness specifically. Of course, I am more than willing to admit that the prospect of repressing any important memory or issue is probably depressing to anyone, but with my diagnosis I can pretty much anticipate that reaction in a very certain way.

One of the ways I’ve been coping with this has been to write. I’ve been writing non-stop for the past three weeks and then had to ease up the past few days because my hands were swollen from typing (which has meant not being able to play xbox either, rough!). Writing has become a place where I feel comfortable with my thoughts and feelings, and it is great because I don’t always feel that in social situations.

I would attribute writing (though I am self-soothing, getting outside, eating regularly, all that jazz) to the relatively level amount of depression I’ve been having. Yeah, it isn’t ideal… but being able to write enough to keep this vat from overflowing (ugh, and I just stained the new hardwoods too!) has helped keep me more rational and able to deal with the depression as it comes and has seemed to keep the depression from becoming totally consuming.

Whether I am writing something private or public it is comforting to know that I have complete control over what goes on the page, but the best feeling is to allow myself to step over the line of control, to allow myself to write anything and everything I feel. It can be an act of rebellion, it can be profound, it can be silly, it can be unidentifiable. In the end it doesn’t matter to me because it is the act that defines it, not the finished product.

Total Eclipse of the Gut

For many years now I’ve been avoiding my gut instincts. Maybe avoiding is the wrong word, I’ve been wary of them and I haven’t been implementing them when they come up. I guess that is probably one definition of avoiding, but for whatever reason it feels important to me to add that part about feeling wary.

I’ve been thinking of my gut feelings as the product of an inner-office anonymous comments box and I’m the poor sap who has to sift through the comments that have been left there.

“This is a place to leave comments,” the box says, “ideas, and suggestions on how to make the office run more smoothly. They will be reviewed by management in the consciousness department.”

Of course, I haven’t been able to take the program very seriously when many of the comments have read things like:

Absolutely trust that guy who is inviting you inside his house and says there is free taco bell inside.

or

Can we please collect more roadkill? The IT department won’t even notice the smell.

or

Make Fridays “casual werewolf” day.

In the beginning I followed through with most of the suggestions in the box only to realize there are one or two A-holes in the office (damn you Psychosis! Mania! And don’t think I don’t see you sneaking around over there too Depression!) who keep leaving these bizarre notes they expect me to follow through on.

Without a filter to keep the odd comments from the important ones the results historically turned out poorly.

But that’s always the story, isn’t it? One or two bad apples ruining it for everyone. As the manager of the office inside my brain I’ve had to stop allowing comments from within myself simply to keep from doing some totally stupid and irrational things. The trouble is… all of the good, useful comments have also been discarded in the process.

In the meantime I’ve worked to try to improve the comments program. It has been temping every time someone has told me “just trust your gut” I feel like I ought to give it a second chance, despite constantly winding up in situations where I’ve taken away all of the pairs of scissors and staplers in the office during a busy week or deprived my employees of contact with the outside world for days until they go on strike and say, “you know, we really aren’t getting any work done at this rate.”

As someone who wants to manage this office well I’ve taken it upon myself to try to find answers. To research and test through trial and error what I could do to keep the team running. I’ve scoured the anonymous comments with handwriting analysis in hopes of being able to pull Psychosis’ notes from the rest (and the rest of those who love to throw a wrench into things) with no luck. I even hired on a new employee (Rationalization) to help manage the comments department but ultimately it didn’t seem to make much difference. Before long Rationalization seemed willing to justify why casual-werewolf-Fridays would be great and I had to halt the project over again.

While I was searching for a solution I wasn’t expecting things to get worse. One of my employees, Sexuality, began leaving notes in the comment box in an effort to make the break-room more LGBT friendly. I discarded all of those comments with the suspicion that they may have come from Psychosis playing a prank. Denying all of the comments meant denying the legitimate ones too, and before long Sexuality was upset and launching a full scale mutiny, bringing all of her closest co-workers on board. Depression wailed, Energy dropped dramatically and wouldn’t come out from under their desk, and Self-Worth made a very rude gesture at me during my 3 pm coffee break.

When Intimacy made a request to work harder on relationships in an effort to feel more connected I ignored it. I was certain it was Psychosis again, and even though I hadn’t seen them in weeks I thought for sure it was some game of misdirection. Pretty soon Anger snapped after a paper jam and ripped the feeder tray off the unit and Productivity simply stood up and said, “I can’t work in an environment like this, I’m going home.”

I watched chaos erupt from my cubicle and that’s when my phone rang.

“Yes, Department of Consciousness here,” I answered.

“This is HR,” a voice said. “It has come to our attention that you’ve denied a request to make the breakroom more LGBT friendly and I’m afraid Sexuality has come to us to file a complaint.”

Sexuality filed that comment?!?” I asked astounded, “Are you sure it wasn’t Psychosis?

“Sarah, Psychosis hasn’t been in in weeks, hasn’t even booted up to work remotely, there hasn’t been a need. I’m afraid the issue at hand is bordering on discrimination at this point so it needs to be addressed immediately. If you can’t take care of it, we’ll find someone who can.” The voice said.

“Of course!” my mind reeled, horror struck that I had ignored something so important. “Right away!”

“Good day.” The voice added.

“Wait!” I quickly cried upon realizing I’d never encountered anyone from HR, “Who is this?” But all I heard with a click followed by a dial tone.

 *

I’ve gone through years of therapy trying to figure out how to discern which piece of my internal dialogue to listen to, how to pinpoint the difference between when my gut says something to me and when it is mental illness pushing me in a specific direction.

Ultimately I reached the point where I felt the need to scrutinize everything that ran through my head before making any decisions. It didn’t keep me from having manic episodes, or depressive episodes, or psychotic episodes or doing wildly irrational things. All it did was create a backlog of personal issues that built up and began contributing to my anger and depression and paving strange avenues that I’d find myself trying to take to solve those issues when I was psychotic or manic. In some ways it seems as though Psychosis was trying to help me, attempting to take back doors to solve issues I wasn’t solving directly.

That is part of what has made everything so blurry. I was so worked up and emotional about some issues when I was psychotic (or depressed or manic) I couldn’t see how important the same issues were to me when I wasn’t. I simply didn’t feel the same level of intensity about them when I was feeling stable, even though they still mattered.

All this time I’ve considered psychosis to be like a bubble, like I could discard anything that happened within the bubble in which the episode took place and discount any aspect as being useful or informative (though usually a good story later). The psychosis bubbles that arose eclipsed my gut instincts entirely, or at least discounting anything within those bubbles often also meant discounting real and important instincts. Really, the more time I take to understand the issues I’ve been avoiding, the more it seems that my episodes have acted more like a magnet drawn intensely to those same issues rather than provoke or direct me toward new useless ones.

I’m sure all that is confusing, and it is to me too. Even so, this has been a huge revelation for me because it means the eclipse is ending. I’m realizing that there is value in every comment in that comment box, even the ones I considered to be a joke.

“You mean, you’re listening to yourself again?” My therapist asked last week.

*

I imagined myself in that office, smeared with printer toner and covered in paper cuts climbing on top of my desk and waving my arms.

“Alright! Alright!” I shouted at them. “I’ve been a terrible manager, I can see that now. Ignoring you isn’t helping us get things done and the box,” I kicked the comments box off my desk onto the carpet littered with remnants from the three hole punch and paper clips, “screw the box. The box isn’t working! From now on we’ll have an open door policy and if you need something you can come directly to me. Even you Psychosis,” I added as a fit of giggles came from over one of the speaker phones.

“I’m sorry I went behind your back,” Sexuality said to me as the last of the internal raging died down and we began cleaning up.

“I don’t blame you,” I replied, dumping the old comments box into the trash. “I guess I was so wrapped up in working on communicating to the outside world that I forgot the importance of communication here.”

*

“Um, yes,” I replied to my therapist, blinking for a moment. “I am listening, and I expect I have a hell of a lot to say.”

 

Big Picture Mood Charting

I’m sure those of you that have been reading a while know that I am a big mood-charting enthusiast and for those of you who haven’t, well, I get a real thrill from any kind of chart or graph in general. Don’t even get me started on those that can convey something as mysterious as the inner workings of living with bipolar disorder… that’s my jam.

I’ve spent a lot of time messing around with different charts and graphs as a result and ultimately I’ve found that there is one type of mood chart in particular that has been very helpful in providing a big-picture look at how my symptoms operate. I call it the “color band mood chart” and it is a way to visualize what types of episodes I have and when they have taken place over a period of time.

I’ve spent some time sharing about this type of charting before (here) but I wanted to revisit the topic because with nearly five years of data now on my chart it becomes very easy to see the comings and goings of my episodes. I live with mood swings that can occur over a long period of time (months) but also swings that can happen several times in a day so this method of charting is really useful for seeing my episode length and severity of symptoms in a single glance.

20160908_105507

This type of charting is done on graph paper and the key above denotes how the element of time is displayed in the chart. I have opted to leave out any mood swings taking up less than 3 hours in a day (even though they are often present) to chart the moods that encompass the longest period of time each day. I also limit the mood swings represented in a single block to 3, any more than that and I typically just consider it a “mixed episode” day.

20160908_105446

The key above shows what each colored box represents. Green areas are periods of stability. Blue represents depression, but darker blue signifies more severe depression (generally with some symptoms of suicidality). Yellow denotes hypomania with red representing full mania. Brown represents mixed symptoms and black represents more severe mixed symptoms (usually with psychosis or suicidality).

The chart below begins in 2011 and I’ve been compiling data every day (with the exception of a short period in June, 2011) since. Looking back and looking at the chart below I can certainly say that 2011 and 2014 were both pretty hard years for me and both required psychiatric hospitalizations. There have been other times I may have benefitted from hospitalization that I only really recognize by looking back at the chart as well.

20160908_105349

Sarah’s Color-Band Mood Chart showing bipolar episode length and severity  from 2011-2016

 

If you have been reading the past few months you might remember I had a pretty severe mixed episode in June and part of July and if you look here at the bottom of the chart you can see the dark shapes that represent that period as I fluttered between depressive, mixed, and elevated symptoms.

The information on these two pieces of graph paper have been huge in helping me convey my symptoms to my doctor and also to avoid undergoing treatment that isn’t potentially helpful to my own personal brand of bipolar disorder (as not all types of treatment are useful for all types of bipolar symptoms). I began the chart because I really wanted to find the patterns in how my episodes work, but as you can see there is really much more to my illness than experiencing symptoms at a specific time of year or alternating back and forth between depression and mania specifically. The chart has also been great for seeing how the medications I have tried have effected me and since my symptoms are treatment resistant it has been really important to have this tool to convey the way many medications have triggered (or worsened) episodes for me (like during the past few months) instead of quelled them.

It has been encouraging too to see episodes that were initially big chunks of depression or hypomania become smaller fractured chunks. Even without a medication to stabilize me everything I’ve learned about how to cope with the mood swings themselves has helped me bounce back out of them at times instead of staying locked in. Even though there are times I find there is little I can do to shake my way out of an episode, the smaller daily mood swings are something I’ve learned to cope with somewhat more effectively.

Just something fun to share and maybe some inspiration for those of you living with mood swings (bipolar or unipolar too). Being able to quantify the periods I am having problems has made living with my illness much easier to accept and try to treat.

For more information on mood charting (including other charting methods and tips) you can read “why chart?” as well as a number of other posts from Chart Week like “Personalizing Mood Chart Rating Scales or  “What else can I chart?”

 

Redefining My Urges

Trigger Warning: topic includes some discussion on self-harm, suicidal, and homicidal urges.

Lately I’ve been trying to do a better job of understanding the urges I feel and how they fit with my symptoms. Living with treatment resistant bipolar disorder has meant that even though I find myself having the sorts of urges everyone else seems to (though as human beings we all seem quite reluctant to talk about urges) I also experience urges brought on by my illness. On top of that, my ability to respond to these urges can be quite compromised based on what my symptoms are doing as well… but let’s back up for a second.

Urges are impulses. Strong desires. They are those feelings inside of us that scream out to “just do it” in certain situations. Sometimes my urges come only in the form of a feeling like gravity taking over and I act on them without thinking, sometimes they’re accompanied with thoughts that can encourage or discourage following an urge.

To break it down, here’s an example of a relatively healthy urge I have. A simple craving.

Urge: make eggs.
Thought: I do like to eat eggs.
Action: made eggs.

You can substitute chocolate in for eggs, chocolate is good. Or you could substitute tea, in which case the urge and actions become blurrier for me because I have dietary restrictions. In that situation having a chai tea latte, for example, becomes something I shouldn’t do. I will get sick if I have dairy, so the urge has a negative consequence –it becomes unhealthy.

Urge: drink a chai tea!
Thought: holy yum batman, but this will make me sick (Reminder: I can’t have milk or caffeine).
Action: urge denied, drank juice.

Even though drinking a chai tea is unhealthy for me, there are times when I am run down or worn out where the negative consequences of drinking one sort of fade out. In that kind of situation I find my thoughts work against me.

Urge: for pumpkin spice’s sake, drink a chai tea!
Thought: It is fall, I do like chai, and even if I get disgustingly bloaty and gassy and can’t leave my house for two days I don’t have any plans anyway.
Action: 20 minutes of sweet, sweet chai tea action, 48 hours of intestinal horror.

Finally, there are those situations where thinking doesn’t even come into play (I swear, I have a point here). If someone put the chai tea in my hand and told me to drink it, the impulse becomes much easier to carry out.

Urge: drink this chai tea in your hand!
Action: yes, thanks.

Alright, so this seems perfectly reasonable to understand when I am thinking about something mundane but delicious, like breakfast… but these same scenarios are true for most types of urges I encounter. As human beings, we come up against a lot of kinds of urges, but the ones I want to look at more specifically are the negative urges, the ones that we know will have (or are likely to have) negative consequences. Things like lying, cheating, stealing, violence, sexual attraction to inappropriate parties, overeating, overuse of drugs or alcohol, self-harm, and suicide (to name just a few).

Most of the things I’ve listed are not things people talk openly about despite how commonly we find ourselves feeling urges to do negative things. I’m sure there are people who excel at shooting down these urges, but I don’t think it is very clear cut. If my chai tea was now an act of violence (let’s say slapping someone in the face who had done something inappropriate), even a totally rational person might not deny the urge after several drinks.

Urge: that bitch just threw a drink in your face! Slap her!
Thought: I’m the bigger person here… she looks ridiculous, I can let it lie.
Action: deny urge, stand around dripping.

(But after several drinks, or a bad day, or after something particularly offensive like groping your partner…)

Urge: oh no she didn’t, slap her!
Action: slapping.

I’d say that, more than anything else, is why I don’t drink anymore. My mind, for whatever reason, seems fully capable of jumping from urge to action without being intoxicated.

Anyway, last example. Living with treatment resistant bipolar disorder has often meant living with suicidal urges on a regular basis, and this is one aspect of my illness that I think people understand least. You see, these urges are something I can typically rationalize away.

Urge: you should kill yourself.
Thought: I might not feel good right now but I’ll bounce back. Plus that sounds like a lot of work. Plus what about my dog? Plus I think people might get upset.
Action: still alive, despite lack of chai tea lattes.

But, as I mentioned with my chai example above, if I find myself in a position where extreme stress or a particularly long depressive episode has eroded my ability to think clearly, the urge becomes harder to contradict.

Urge: you really should kill yourself.
Thought: you’ve been pushing that nonstop for months, and I’m sure there is a reason I have resisted that urge in the past even if I can’t quite remember it now. I’d better call someone.
Action: call my therapist, she acts as a rational brain for me when mine isn’t working.

Then there are situations that I call “level 3” suicidality, and that is when hospitalization becomes required because the urge has consumed any ability to contradict with thought.

Urge: kill yourself.
Action: jaywalk, check into the ER.

I know it isn’t a pretty topic, I’m sure that is why it goes unmentioned most of the time. Just the fact that I spent so many years not knowing where the urges I felt were coming from or that they did not mean immediate suicide, or violence, or self-harm, that I still had a choice as to whether I would act on them or not, was exceptionally confusing and wildly detrimental to my sense of self-worth. On top of that, not knowing what kind of situations (alcohol, mania/mixed episodes, high stress) led me to jump from an urge to an action without thinking made it really hard for me to stop acting on the urges I felt.

Being unable to separate the urges I felt from the totality of who I thought I was meant years of trying to punish myself for urges I could not control in an effort to curb them because I assumed that “getting better” meant not having those horrible feelings anymore. Besides, urges that provide harmful consequences are not generally seen as normal in our communities despite how often people experience them because the topic is typically taboo. Needless to say, when I was sixteen and experiencing psychosis with homicidal urges I immediately assumed I was a terrible person who probably didn’t deserve to live, given the fact that I wanted so desperately to hurt other people. Even though I worked hard to deny those urges I still felt wildly ashamed for having those urges in the first place.

I still catch myself sometimes, telling myself that the urges I feel to self-harm or commit suicide mean I am something less that others, that it doesn’t matter how many worms on the sidewalk I frantically save from being walked on because overall I’m a terrible person.

But that simply isn’t true. (And I’m sure the worms do appreciate it in their own way.)

I can’t judge myself based on the urges I feel because doing so is like judging an entire library because one book doesn’t seem to get shelved properly on a regular basis. To discredit the entire system and collection because of one book seems absurd, especially once I’ve learned that there are many creative solutions for where to keep that book in the catalog.

As I’ve gotten older I’ve started to understand that everyone feels urges and that urges are outside of our control. We might not all feel the same ones, but I’m sure we’ve all felt an urge now and again we have felt ashamed of. Being able to take a step back from that shame has meant feeling better about myself and even though I don’t expect those urges to go away anymore, I just try to focus on the way I view the urge and how I choose to act when it comes up.

…and if I slip up and drink a chai tea now and again, I’m only human.

How DBT is Changing the Game

I have been celebrating all week because as of last Thursday I have officially completed all of the sections in the DBT workbook and group. Apart from high-fiving myself (alright, so that’s just a clap really) for seeing this through I’ve been reflecting on how DBT (Dialectical Behavioral Therapy) has been a game changer in a life largely structured around living with treatment resistant bipolar disorder.

Before I can offer up a delightful before and after like some kind of mental and behavioral makeover I have to say that I feel lucky just for getting into a DBT program here in Seattle. I am on Medicaid and the waitlist for people receiving public mental health services here in Seattle means it takes typically months and in some cases years to get into a group. In the time it took me to get in I tried all sorts of treatments and even went to two consultations for ECT (electro-convulsive therapy). Obviously it seemed like DBT was a popular option, but after having a hard time with other types of therapy (like CBT, cognitive behavioral therapy, as an example) I couldn’t be more pleased with discovering why DBT has gained so much popularity and why I had to wait in the first place.

Me

Just so you know where I’m coming from on this I think it might be helpful to tell you a little bit about what I experience.

I have treatment resistant bipolar disorder which means there haven’t been any medications that have been able to help stabilize my ongoing mood swings or prevent new ones from happening. My mood swings range from several intense swings in a day (which can range all the way from euphoria to suicidal depression and back again in a matter of minutes) to long intense episodes that can last months at a time. I experience mania, depression, agitated and sometimes hostile mixed episodes, suicidality, homicidality, and psychosis.

Needless to say… that has been a bit of a handful both for me and for other people to deal with. I can be unpredictable around other people which means they don’t typically know if I will be excited or devastated or aggressive from one moment to the next and I’ve had too many issues with homicidality, suicidality, and psychosis at work to keep a job for the last several years to boot.

The things I have felt needed the most immediate addressing have been things like:

  • feeling strong urges of violence toward myself or others
  • feeling unable to communicate with my boyfriend or others during intense episodes
  • losing relationships and jobs because of my emotional reactivity
  • constantly relinquishing my own self-respect in attempts to make others happy and avoid confrontation or the potential triggering of more episodes
  • isolating myself due to constant fear and paranoia that someone might hurt me or I might hurt someone else
  • negative thoughts I could not seem to stop or make quieter

In addition I have experienced very intense anxiety since I was old enough to remember. This has typically caused problems like:

  • worrying to the point of causing physical illness
  • believing horrible, sometimes life-ending events are about to unfold at any minute
  • fear and panic overwhelming enough to keep me from having a driver’s license (at age 30)
  • attempts to control other people’s actions to keep their unpredictability from making me more anxious (I wouldn’t recommend it…)
  • constant obsessive thoughts that I felt powerless to stop that also often keep me from sleeping
  • Ongoing panic attacks

Sometimes I can pass as a typical stable adult to others because I am intelligent (might as well toot my own horn there but people often point that out as a reason I can be high-functioning at times) and periods of hypomania tend to dissolve the anxiety I feel when they are occurring. Unfortunately as I have gotten older my episodes have gotten progressively worse and those periods of “normalcy” have been few and far between.

Before DBT

The ways in which I have coped with these issues have definitely evolved over the last 15 years. I’ve gone through my fair share of harmful coping strategies (self-harm, alcohol, binge eating) but I have also gone through a long line of coping methods that may not have been directly harmful but weren’t exactly effective either.

Ineffective coping strategies are usually those I’ve come up with and then discarded after a period of trial and error. Without much direction (both from my doctors and therapists previous to DBT – with exception to CBT) I kind of just came up with ideas I thought would work and tried them… I’d like to chalk this up to the scientific method but it may have been equally spurred by a constant feeling of desperation. Sometimes the methods would work for a while and then I would begin to get exhausted because they took all of my focus and effort to maintain. Things like:

  • seeking approval from other people when I was depressed
  • reaching out to every person I knew in times of crisis instead of just people I could trust (resulting in sometimes landing myself in dangerous situations)
  • constantly fighting the obsessive or negative thoughts by arguing with them
  • keeping myself in a state of constant distraction so it wouldn’t get quiet enough for me to hear negative or obsessive thoughts
  • never being alone because then I would be alone with the obsessive or negative thoughts
  • changing jobs frequently in an attempt to find one that “made me happy”.

Obviously I found a few things that worked, even if I didn’t know it at the time. Writing, art, playing music, playing video games… all seemed to make things feel easier, just not enough for me to base all of my activity on them. After all, how was playing the piano going to help me maintain friendships? How could I work retail and be drawing at the same time?

When it came to CBT I could get behind the idea of doing activities like journaling but the idea there was that there was a thought that was ultimately prompting my emotion and behavior. I found many of the activities soothing for a time, but even after I managed to figure out what negative thoughts were prompting my emotions or behaviors I couldn’t find anyone who could tell me how to change those negative thoughts (or stop from obsessing) in a way I could understand and it frustrated me.

I was disheartened when therapists would simply say, “you just stop obsessing.” or “you just accept the situation,” and when I asked how one does those things (as I couldn’t seem to make them happen voluntarily) nobody could answer with anything more than a statement a golf caddy could have given me. It seemed to go against the whole idea of working toward having better mental health, after all… if I could stop obsessing or just suddenly accept a situation I wouldn’t need to ask how to do it.

Beyond that I often felt like I had mood swings that seemed to happen totally independently of what I was thinking or doing. I could be at Disneyland on a roller coaster and suddenly find myself depressed, but none of my therapists or any of my hospital workers were willing to consider or explain why that might be happening. Most of them told me I didn’t know what I was talking about which I could watch transform my curiosity into livid rage.

Needless to say, I started DBT feeling skeptical after my time with CBT but what I found was a language I could understand.

Dialectical Behavioral Therapy

I think it is import to point out that in my situation (one where every previous treatment option has failed) I have been desperate for any kind of help with my mental health for some time which means I found myself in the DBT group both ready and eager to learn as much as possible and practice the techniques. I needed relief from my symptoms and without anything that could provide that previously I was ready to throw my whole self into the class and take it very seriously. Being willing to dive in to the class helped me push through the frustrating or difficult parts I faced in the beginning.

I encountered the material in a structured weekly class with homework each week and I think in my case that structure really helped hold me accountable to practice the skills and do the reading. The previous week’s homework was reviewed each week so I needed to finish it. Being in a group also allowed us to compare ideas on what different ideas meant and discuss which coping strategies worked best for each of us.

The sections discussed were:

  • Mindfulness
    • basically how to live in the moment instead of being distracted by internal thoughts as well as how to enjoy each moment fully
  • Emotion Regulation
    • how emotions work, what goes in to working to keep them balanced, and how to change an emotion
  • Interpersonal Effectiveness
    • maintaining relationships and how to have positive social interactions
  • Distress Tolerance
    • tools for crisis situations

The thing I found most effective about the material is that it suggests that the best strategy for living a balanced life is to operate using both emotion and reason. Each section goes on to describe strategies that work to help you create that balance by bringing in whatever is missing (usually for me it is the reason element) into the situation.

While there were some aspects of the workbook I had already figured out on my own through the trial and error I mentioned earlier this style of workbook offers many different kinds of strategies and basically you keep what you like and leave what’s left. I really respected that idea because I was able to tailor my own set of skills based on my needs and everyone else in the group was able to do the same. In that regard I can see where DBT’s popularity comes from because it is accessible to a wide audience.

After DBT

The important thing to understand about DBT is that I still have mood swings. I still feel suicidal urges, I still feel most of the things I felt before. The group wasn’t a magic cure for those feelings and urges, but it helped me understand how to negate or change them in healthy and manageable ways. More than that, I’ve been equipped with an arsenal of coping skills that work for me, and that is HUGE.

The mood swings may not be gone but being able to bring reason and logic to the table when they happen tends to mean less reactivity on my part. Less reactivity means it is easier to maintain relationships. Being friendlier to people means I feel less paranoid about potential reactions to my reactions. It all starts to trickle down through all these channels because everything is connected.

The only hard part here is that it only works as long as I use these skills. That might seem like a no-brainer, but mood swings can sweep me up sometimes and I find myself swirling around with no idea of how long I’ve been there. Anxiety can leave me worrying so much that I forget to let myself rest or use the skills that might provide some relief. Yes, it takes a lot of effort, but I’m doing my best to be as diligent as I can because even though this may require more energy than if I’d found a medication that worked straight away DBT has led me to the first glimpse of relative functioning in years.

Even though I only started this class six months ago I can see changes. Three or four situations happened just over this last weekend where I found myself thinking, “wow, this really would have ruined the whole weekend before, but I seem to be able to accept and to move past these situations much more quickly now.”

I had a neighbor who kept parking in our building’s guest parking spot in an attempt to dodge paying for a spot. It went on for months, and even though I had to remind myself every time I saw it that it would be better to accept the situation (and not leave rude or threatening letters on his windshield) and to be effective than to make enemies with my neighbors I did it. They moved away and I did a celebratory dance because I was able to keep myself from being a total A-hole.

I’ve also found it very useful to distance myself from my own thoughts and remind myself that just because I’ve thought it doesn’t make it true, it doesn’t mean I will act on them, or that they will happen. I’ve got several ways of weeding out bad ideas now before I find myself doing them, which means creating a sense of self-trust and self-respect where I didn’t have one before.

While DBT has made things easier (less effort for better results) the more stress I am experiencing the less reliable the system is for me. If I am too distracted or upset to complete the skills things simply operate… well, as normal. In some respect that means I’m working to weed out stress before it’ll swamp me now, trying to be proactive about avoiding avoiding things. There are some situations though, like Corey’s broken arm, that came with an intense whirlwind of stress I couldn’t dodge and as a result I quickly slipped right back into a state of crisis. I’m still working on climbing my way out of it but each day gets a little easier.

Finally, apart from being immediately useful to me, I really respect the DBT program because it provided content that wasn’t given to me in a condescending way but made sure to fully explain why each part was important. DBT fits my personal values, and makes room for those with values that are different from my own.

The obvious take away here is that there is some serious potential for more DBT groups in the Seattle area, and I wouldn’t be surprised if that was a trend across the country.

As for me, when seeking treatment for mental illness has often meant taking one step forward and two steps back I am really glad to have had a chance to work through this program because in many ways it is changing my life for the better. Having the opportunity to change my negative behaviors while learning how to take the reigns back from mental illness has given me the footing to be able to respond with, shove off, I’m queen of the mountain now!”

 

Antidepressant Turnover

You may have read (here: Back in the (Rx) Saddle Again) that I have been experiencing a significant enough decline into depression to warrant attempting an antidepressant again. Being home with my boyfriend who has a broken shoulder on a daily basis has been quite exhausting, and despite my typically treatment-resistant symptoms (and negative reactions to new medications in the past) I have a new psychiatrist who seems hell-bent on un-wedging me from my latest foray in desperation.

Her latest idea was to start me on 12.5 mg of Zoloft (sertraline). Previously I tried 100 mg of Zoloft and started to vibrate out of my own skin with manic energy so we were hopeful that a tiny dosage might be enough to nudge me out of the black abys without launching me sky-high like some kind of slingshot of euphoric destiny.

As much as I find myself feeling like an emotionally unstable lab rat I admit, I’ve always been interested in science and how the body works. I’ve spent the last six years documenting my symptoms several times a day to try to help me understand where they are coming from and what helps me negate them. This has led to a complicated system of notes I sometimes see my boyfriend trying to read but tends only to result in a lot of head-scratching on his part. That said, even though my doctor has recommendations for my health and what might help, I have worked hard to pay close attention to the process for every medication we’ve tried, even those that were meant to help curb side effects and several that haven’t been related to psychiatry at all.

I guess it helps that I am interested, but much of my documentation has come out of necessity. Living with a mental illness has been super hard to get a grasp on and for many years I didn’t know exactly what was coming from bipolar disorder or anxiety and what was me. My rigorous note taking was what allowed me to show something like physical evidence that my doctors could contemplate to diagnose me in the first place, and beyond that it has been necessary because having treatment resistant symptoms (and often unusual side effects) has made it hard to know if something is helping or potentially hurting me overall. I have enough experience with physicians at this point to know that they are much more likely to believe what I tell them when I can present it in a formal and organized way. Rationality doesn’t hurt either, but sometimes that is hard to come by.

On a personal level, these notes have been totally invaluable when it comes to situations like trying Zoloft again a couple weeks ago, not just because they are something I can show my doctor but because living with a mind that can have trouble judging reality from fiction can make it difficult to believe in myself and the conclusions I am drawing at any given time. Having something tangible I can go back to so I know that I’m making important decisions (like whether to start or stop a medication) based on my experience and understanding of my situation and not a psychotic delusion has made me more confident about understanding my own health than I feel about any other aspect of my life.

As helpful as that can be, it can undermine me as well. Being confident about how I have assessed the results about any medication I’ve tried tends to leave me on the defensive with some doctors and I can come off as hostile or difficult to work with. When faced with the wrong doctor, one who tries to push their own agenda rather than listen to my point of view, I know I can become volatile. That’s why having the right doctor has been equally as important to me as the note taking.

So everything I’ve said about note taking was to get to this: the last two times I tried a new medication each one was a repeat of something I tried many years earlier. 5-15 years earlier. It is the oddest thing because I would almost swear that I’ve become even more sensitive to medications and develop more side effects than I did a few years ago. I don’t know if that is possible, but that’s the way the data seems to lean.

Ultimately this time around 12.5 mg of Zoloft had more adverse effects for me than the original 100 mg did. Yes, last time I was manic, but this time I waded through several days of intense dizziness, nausea, and GI upset only to be blindsided by 8 straight days of severe headaches in a row.

By the time I reached the seventh and eighth day my irritability was rising exponentially, to the point of being more reactive and depressed from the pain than I was before I started the Zoloft in the first place. I didn’t want to gamble the pain continuing(or even worsening) over the weekend since both my boyfriend and dog are relying solely on me for their care and I was already irritable to the point of arguing with every commercial that was coming on tv.

I called my psychiatrist’s office and the nurse suggested the headaches were a product of allergies (due to the intense tree pollen bloom this year) but if I really felt sure I should stop the medication over the weekend and call on Monday to report any changes.

I went with my own gut and stopped the Zoloft and within 24 hours I felt totally fine physically. The 8 day headache was gone, as were the other issues -all except the irritability that took more time to reduce itself. I admit, I did a little jig -both because the headache was gone and because I was happy I had made the right decision.

All too often it seems that doctors are more than willing to force me into a position of feeling much worse before I can begin to feel better, and while I understand the concept of waiting out side effects long enough for them to dissipate, in my particular situation of treatment-resistance it has never once paid off. Either the side effects become debilitating to the point of requiring a trip to the ER or hospitalization or I manage to get through the side effects after several weeks or months of struggle (like with lithium) and find I receive no beneficial effect from the medication.

Thursday I will be meeting with my psychiatrist to go over the notes I took from the trial and I’ll see what advice she has for me next, if any. Writing about the situation in this forum allows me the space to really think about the situation and try to understand it without feeling overwhelmed or sad or angry. I guess I am just ready and willing to accept that this is how things are for me, and even though I would say that is some serious progress I still hope to find whatever it is that will allow me to move toward wellness -or at least the best approximation I can afford.