The Importance of Reassurances in Psychotherapy – C: Week 22
I had what I felt was a really good session with C on Thursday. That, to me, seems like an odd thing to say, as the best I’ve had to say upon departure in the past is that it ‘wasn’t bad’ or some such, but I actually left the other day feeling very positive about the whole thing.
I’m not entirely sure why; I felt reassured and taken seriously, and felt the dynamic between the two of us was good. Not that it isn’t normally, but it seemed to ‘flow’ particularly well and naturally on Thursday morning.
Apart from the very start, that is; he always wants me to start the session, and I almost never know where to begin unless something has been very definitely playing on my mind. Plus I hadn’t slept all night and had missed a dose of the dreaded Venlafaxine, so I was kind of two seconds behind him intellectually.
Eventually, with my inability to articulate myself, C decided he would draw attention to my starting arguments with A over nothing (see here, and latter part of here), as we had discussed to some extent last week. I didn’t really have much to add to that, to be honest, mainly as I don’t remember the circumstances on many of the occasions.
So began a discussion regarding disassociation. He thinks that I have amnesia as regards the stupid arguments because then I completely freak out that I am going to be abandoned, so in order to cope with the enormity of that in my mind, I have to disassociate from myself and the world. He went on to lead a dconversation on what can be done to “ground myself in the moment” when I first start to notice negative feelings that could cause me to lose it and ultimately disassociate.
He asked me what I thought I could do in such a situation.
I laughed and said, “you don’t honestly want me to answer that with sincerity, do you?”
C pretended to be perplexed by this apparently cryptic comment but he knew as well as I did that it was a reference to self-harm. I said, “what I think I can do in such a situation is carry a knife about with me.”
He muddled his face, but laughed when I admitted this was probably not the best idea in light of the police crackdown on knives thanks to so much knife crime doing the rounds in the UK and Ireland of late.
But I continued, asking him what the problem with self-harm was – he made some comment to the effect that it was potentially dangerous, but I waved my hands dismissively at him and pointed out that any cuts I made were superficial.
“Look at me,” I challenged. “Apart from where I’ve picked the spots on my face, can you see any scars?”
He looked me up and down, and eventually concluded that he couldn’t.
Excellent. “In that case, what’s the problem?” I asked.
He thought about it for a minute or two, then said something like, “don’t you think it can have negative consequences?”
I complained that because my entire abdomen is covered in stuff like ‘hate’, ‘death’, ‘vile’ etc, that it would certainly make it difficult to get a cut-price* full-body massage from A’s sister, a beautician, but beyond that minor disability, I didn’t really see any negative consequences. As stated a million times here, cutting is quick, and it works.
(* Perhaps a poor choice of term given the subject matter?!).
“Other people vilify self-harm,” I whinged. “I don’t get it. What’s the big deal? It’s effective, and if it’s superficial – ie. not life threatening, and none of these scars would have been – then I really fail to see the problem. What is it?”
“If I define a problem, you’ll see me as someone who wants to defy or contradict you,” he replied. “If I don’t, then you’ll take that as carte blanche to inflict self-harm on yourself, as the perceived need arises.”
I don’t consciously think that would have been the case, personally. I was asking him to explain what, objectively, the problem with self-inflicted injury is, given that it’s a speedy and effective antidote to severe agitation. But to be fair to him, I can’t tell you what my unconscious might have thought if he’d answered the question directly, and knowing this, I let it pass.
I noticed that he was trying to avoid making me aware of any judgement he may have had on self-harm, but predictably he did reiterate that there are other methods I can use to “ground myself” rather than merely grabbing the nearest sharp object and slashing myself. We discussed briefly the DBT methods such as breathing techniques, using rubber bands and/or ice cubes to hurt myself.
He said that he thinks I can appreciate that there are times when they can be effective distractions, but that maybe I do not garner the same satisfaction from them.
I affirmed this. I told him that even the simple cuts I’d inflicted to my arm this night didn’t have anything like the satisfaction of a big, angry ‘HATE‘, which I kept going back to and looking at in awe. If that is the case, how can breathing or whatever possibly offer an appropriate level of satisfaction?
However, I continued by telling him that whilst I certainly didn’t necessarily dismiss these techniques completely, I saw this whole coping method as being on a “sliding scale”. I can’t remember how I expressed it, but I think I was suggesting to C that if I try these DBT methods and they don’t work to calm me, I can then give myself permission to cut myself, if it is the only thing remaining that will ease my distress. I mean, it’s better than taking myself out, right? …Right?!
I was astonished when C didn’t argue with this. He didn’t agree with it, but he didn’t argue. It reminds me a little of a recent documentary I saw on self-harm, hosted by author and comedian Meera Syal. It told of a controversial treatment employed in some psychiatric hospitals (the featured one was Bethlam – still Bedlam to me – in London) in which the staff allow the patients to self-harm, as long as they document the incident in detail afterwards. The young woman interviewed said that when she had been stopped from cutting, she simply found more inventive ways to harm – eating lightbulbs, throwing herself at the wall etc. Obviously my example is considerably less extreme, but rightly or wrongly I felt that C was meeting me half way; if I was willing to try his methods, and they failed, he would reluctantly tolerate my methods, as long as they were implemented in a controlled and non-dangerous fashion. Perhaps I read too much into this though – perhaps his decision not to argue was based around the aforementioned notion of my feeling (in his mind) that he was judging me, whatever way he responded.
He went on to state that he was “concerned that there’s two sides of you in conflict with each other – during a previous self-harm incident, you spoke of being in a trance-like state, saying, ‘it’s beautiful, it’s beautiful’ [this incident is discussed here] and finding that your mood dramatically improved after inflicting the cuts. One side ‘hates’ the other and whenever she feels that side is getting out – for example, when she’s feeling depressed or lonely or anything that she perceives as weak, she has to be punished. This then affirms her position as strong, and makes her feel better. In suppressing the other her, though, she is ultimately repressing stuff and in the long-term is going to feel worse because of it.”
Two things strike me about this. The first was that he spoke in the third rather than second person for so much of this particular part of the session. I didn’t think about it at the time, but now I wonder if he thinks I have Disassociative Identity Disorder? For what it’s worth, I don’t really actually think he thinks that, as it’s certainly not uncommon for a myriad of mental health issues to feature disassociative symptoms in some way. But his choice of phraseology was interesting.
Secondly, I became completely fixated with the fact that he’d said he was “concerned”. The word ‘concerned’!!! He actually used it! Any reference to him giving anything that vaguely resembles a shit about me in the past has been along the lines of, “…but if I do x, you’ll think I don’t care about you,” or whatever. In this session, unsolicited, he actually outright stated that he was concerned for me. I literally had to bite my bottom lip for some time to prevent a delighted smile. This is a pathetic over-reaction and I think I need to die. (Sorry, not allowed to say that. Bad Side is suppressing Nice Side again. Bad Girl. I am not empathising with nor showing compassion to myself. More on this later).
C said that I need to start recognising triggers for negative experiences. He didn’t phrase it like that, but that’s what he meant I think. He then went into a monologue about how humans do so many things on autopilot – cycling (“you’d probably fall off the bike if you started thinking about how you do it, actually”), opening doors, driving, breathing, whatever. Such revelations nearly floored me, of course, who would ever have thought it, eh? [/sarcasm] But his point was, if we do that for these innocuous processes, sometimes we can let an autopilot take over for more important matters. In my case, he is of the view that I ‘automatically’ respond in an inappropriate (not that he used that word) fashion to (relatively) minor things.
He said, “imagine someone or something pisses you off, whether or not it was intended. Stop a second. Try breathing before you respond. I know your reaction is an impulse but try and control it by remembering this discussion. Then think about what’s going through your mind – identify the thoughts, emotions you experience, how you want to respond in light of that.”
Although that sounded way too easy to be true, the latter part of the instruction was interesting, as I had read very recently somewhere that it was important for individuals diagnosed with BPD to try and recognise the exact nature of their emotion; for example, rather than feeling ‘miserable’ or ‘low’, you’re ‘sad’, or you’re ‘depressed’, or you’re ‘scared’ or whatever. I have to say that by and large I think I can identify these different experiences, though not necessarily when I’m in the middle of them, which is the issue I think C was driving at.
Back-referencing a little, he said the side that inflicts harm on herself experiences triumphalism in its wake, because she has won. He said that in learning what’s going through my head and what I am actually experiencing, I could begin to develop some sort of sense of empathy for myself (or Bad Side could do so for Nice Side, whatever).
You can imagine my reaction to that, of course. “We’ve been here before, C – I can’t imagine ever wanting to or being able to experience this empathy thing.”
“What’s the worst that can happen if you empathise with yourself?” he queried.
That took me aback somewhat, and I had to think about it. Eventually, I said, “OK, I’m in the middle of an abject depression, feeling sorry for myself, so I stuff my face with chocolate and red wine (or maybe red wine isn’t the best idea when you’re already depressed, but you know what I mean). How does that look? ‘Oh, look at that lazy bitch, lounging around in her self-indulgence whilst nothing is wrong with her’.”
I paused then, my words reminding me of an earlier discussion with C in which he concluded that I was pathologically terrified of being scrutinised (negatively, at least) by others. “What I’ve just said relates back to that, doesn’t it?” I mused, as an aside, and mostly rhetorically.
“Whatever the case,” he said, “what is clear is that you aren’t allowing any room for middle ground. You can only be intensely self-critical or self-indulgent. Is there any potential to reach a half-way point?”
I babbled on a bit incoherently about this for a minute. C summed my position up better than I had by saying that whilst I could objectively appreciate there may be more of a grey area than my previous comments suggested, I didn’t really feel it. Indeed.
“But what’s the point of empathy anyway?” I asked cynically. “How is it going to make me feel less shit?”
I don’t remember exactly how he put it, but his response was something along the lines of if you fail to empathise with yourself, you fail to empathise with others, that can alienate others, thus making the self feel worse, etc etc. (I knew altruism was about selfishness, really).
I said to C, “are you saying I’m a sociopath?”
“No!” he exclaimed instantaneously. “No, no, no!” He shook his head vigourosly and sort of put his hands out as if to stop me saying stuff like that.
“I’m sorry,” I said, “I was joking – I just did so much about psychopathy at university that I found it funny how closely what you just said matched the description of that condition.”
He sort of laughed, and yet again he insisted emphatically that no, he does not think I am a sociopath. Well, that’s one less thing to worry about, then.
As if to prove his point, he went on to say that in fact I am more than capable of expressing empathy; the thing is I tend to express it towards inanimate objects, such as Disraeli, my car. (Case in point: on Thursday night I ended up in tears thinking that I had ‘offended’ a lamp. Yes, folks; a lamp. Repeat after me: SI is not a loon, SI is not a loon – keep repeating it and we might CBT ourselves into believing it, right?).
Having read over parts of this blog for something to do during the particularly painful bout of insomnia the night before this meeting with C, I remembered another set of ‘objects’ (in the psychological and philosophical, not physical, sense) for whom I do feel empathy: my online friends.
C’s assertion on that occasion was that, perhaps, online relationships are, for me, ‘safe’, just like inanimate objects. I had dismissed it at the time as even though I’ve not met any of my current online friends in person, I still do see them as very real. However, I thought about it on Wednesday night / Thursday morning and concluded that he might have a point, as long as he accepted that the personnel concerned were still ‘real’ to me.
I raised it with him. Did he still think that?
He sort of shrugged without shrugging, if that makes any sense; whatever the gesture was, the implication was that it was something to which he was open, without necessarily feeling that it is fact. Indeed, he said, “it’s an idea.”
I told him that I now thought he had a point, and he went on to voluntarily tell me that if we accepted that this was possibly indeed the case, that I was definitely not to think that it diminished the importance of my internet friends in my life, nor was the implication that I – nor he, for that matter – saw them as ‘unreal’ figures. (Though what is real anyway? Sometimes I wonder about the validity of solipsism. An aside – in Googling ‘solipsism’ to double check the spelling, I came across Solipsism Syndrome – what a cool psychiatric diagnosis to have! I wonder if I can try and get it. I would probably have to fulfill my childhood dream of becoming a professional space-based cosmologist, however, and that’s not fucking likely).
Anyway. What was I saying? Right, so C said t’folks on t’internet are still very real and important friends. “But,” he continued, “online relationships are…” – he searched for appropriate words – “…less complex than ‘real life’ ones.”
I accepted this, but did want to make it clear to C that I wasn’t engaging in the “less complex” relationships to avoid dealing with the “more complex” ones. “My real life friendships are stable,” I said, “even if there are fairly few of them. I haven’t sought out new ones for a very long time, but I’m not sure that’s related. I’m socially inept, I’m a misanthrope, I just can’t deal with people.” Certainly, I admitted, I don’t trust people and fear being hurt, but there are other factors. They’re probably related via some electron cunt thing in my brain somewhere, but they aren’t consciously so.
“But then,” I continued, “it’s funny being me. If I’m in some sort of hyper or manic mood then I tend to be exceptionally good with people, if over-talkative and arrogant at times.” As a relevant example, I related having met A’s parents the other weekend, when I was pretty manic and apparently good craic (for those uninitiated to Northern Ireland Speak, ‘craic’ is pronounced ‘crack’, though does not denote drugs ((well, beyond dopamine and/or serotonin, I suppose)). It means ‘fun’, ‘entertaining’, ‘a laugh’, etc). And about how A’s mother had cross-examined him on the phone afterwards wondering (in not so many words, to be fair to her) how I could possibly be mentally ill in any way when that was the behaviour I exhibited in front of her. I can see her point.
“This annoys me,” I continued. “I cannot stand ambiguity or unpredictability. I used to work with a woman who was terribly moody. One day you’d go in and she’d call you all the names of the day. The next she’d throw her arms round you and practically declare undying love. It infuriated me. Either always be nice, or always be a bitch; don’t fuck about. I don’t know how to deal with you if you fuck about. Point being, I don’t know how to deal with me if I fuck about. I want certainty.”
I paused, and asked C if I was rambling.
“If I say that you are, you will perceive me as being critical, but if I say that you aren’t, you’ll feel I didn’t really take an interest in what you said.”
I tilted my head and stared at him enigmatically.
“What?” he asked. “What do you think?”
“I think if you answered the question you’d be someone who answered a question.”
He smiled in an odd sort of way, almost as if he was embarrassed. I’m not sure what his exact response but he was basically asking if he thought I thought he avoided answering questions a lot.
Well, dear readers, you will know that this is indeed the case. His ability to bullshit around a question is akin, at times, to that of a politician. I know that there are probably fair reasons for this – “NHS Guideline 1,090,073.233.642 – Thou must patronise the stupid mental to avoid said stupid mental having a clear or definitive idea of the service thou hast provided or that thou willst provide, thus ensuring the NHS is not taken under the ludicrous claim culture of the 21st Century” – but it still winds me the fuck up. I actually feel bad even writing something remotely critical, because me likes C today. And thus was the case at the time too; in fact, it was almost a reversal of previous situations, as I became the one who avoided the question. I can’t remember exactly what I told him but it was something like my conscious mind at least would not pass judgement on him answering the question honestly. I deliberately refrained from referring to whether or not there was a reflection of him anywhere in there.
“OK,” he said, “I think we maybe need to trackback a bit.”
Which means he did think I was rambling, and I wondered that when I was evidently going to realise that, why he didn’t just answer my original question, but I forgave him and let him continue. To be honest, my memory is not 100% clear on what it was to which he actually did backtrack, but it was something to do with the whole empathy crap. Presumably I am meant to allow myself to be hyper or whatever and not berate myself for it.
He asked me if I had heard of a bloke called Paul Gilbert. I had. I read his Overcoming Depression when I was about 16. It wasn’t the most patronising self-help book I’ve ever read, even if it employed a bit of CBTish nonsense, but nonetheless, here I am about 10 years later and I’m completely off-my-head mental, so it didn’t exactly fucking cure me, did it?
C said, “there are two books of his that could be useful; they both have ‘compassion’ in the title…” He trailed off, I am convinced in order to gauge my reaction to this.
I actually laughed out loud. Naturally, he wasn’t surprised by this and in fact laughed a little himself.
“Self-help,” I said, finishing his sentence with evident disdain.
“Quite. I know you’d prefer the more intellectual style of the first one, but…”
“Let me stop you there,” I interrupted. “If you’re asking me to read one of these, it’s going to have to be the first one. There are a few things I can’t tolerate in life, and being patronised is one of them. That’s what self-help books do, sorry.”
“Isn’t that like saying that all works of fiction are shit?” he asked.
“Well…OK, it’s a gross generalisation, but I can only speak from my own experience, and my own experience of self-help books is that they’re universally shit.”
To be fair to him, C admitted that a lot of them are rubbish. He described the ones like that as having a “new-agey American* love-in tone”, which he appreciated I would hate, and for which he didn’t have much time either. But he was keen to make clear that in his view they’re not all like that.
(* Sorry American readers – his words, not mine. I did laugh though, I admit, and he did acknowledge that there are plenty of British knobs writing the same wank. I’m sure cynical readers will appreciate what was meant; the whole “you can change your life by thinking happy thoughts about your inner rainbow flying out of your arse [ass, if it’s Transatlantic, presumably]. Remember, I – who do not even know who you are because I am merely writing this bollocks and not spying on everyone who buys it [hopefully] – love you, and so does everyone else despite the fact that in your life you’re likely to meet maybe 0.0000000000000014% of the world’s population, some of whom will actually hate you, except that they don’t because everyone loves you, because that’s the way it works in my world which is as black and fucking white as yours, except I pretend it is white whereas you think it is black. Remember, the only person that doesn’t love you is you, except for all the world’s population that are indifferent to you because they don’t know you exist, not to mention the ones that do know you exist and think you’re a prick! Smile, it can change your day and help you love yourself, not to mention the added bonus of a punch in the face because people think you are a smug, condescending piece of shit! You are worth loving, for now at least because if you feel worthwhile you will feel inspired to recommend me to your wrist-slashing friends and I will earn even more undeserved money! Etc etc, blah blah, yadda yadda, now fuck off cos I’ve got my royalties from your purchase you despicable, self-indulgent, psycho piece of shit that I’m exploiting by writing this jism” thing).
Ahem…*clears throat*. Again, where was I? Yes, C was keen to reinforce his point to me that not all self-help books are of the ilk of the preceding paragraph. He went over to his desk and looked both books up on Amazon. I joined him, and he showed me that – slightly unusually for Amazon UK – they had the ‘Read Inside’ feature. He turned to me and asked if I would look up the self-help one, read inside it, read the reviews of it and at least consider getting it (or, “if I must”, the academic one).
We sat down again, and I agreed to at least look into it. “If I buy it, though, and it’s rubbish,” I wryly told him, “I’m sending you the invoice.”
To wind C up, I told him that I was reading a very analytical and academic book at present called Social Factors in the Personality Disorders: A Biopsychosocial Approach to Etiology and Treatment. The effect of this attempt to tease him was rather lost because I couldn’t remember the name in its entireity. FAIL! He said, “that sounds interesting.” It wasn’t meant to sound interesting; it was meant to underline the point that I need something ‘proper’ to read. But the fault is mine for not remembering the name properly. (For some reason, I never can. I have to go back and search through my previous posts here if I don’t have it to hand, as the book in question was very kindly recommended to me by one of my commentators, beautifulstones).
To compensate for not having the intended effect, I decided to be critical of Lost in the Mirror, which I recently finished, reviewing it as having “interesting psychological points, and being empathetic towards this hateful borderline condition, but not being helpful because of its extraordinarily childish and ergo patronising prose.”
I was interested to note that the above was the first time since I related my diagnoses to C that I have used the term ‘borderline’ in front of him. Hitherto the very thought of doing so has made me cringe. I still avoided looking at him when I said it, but say it I did. This is progress. As anyone who read the end of this post will know, I was convinced C would no longer wish to treat me, given the intense dislike of BPD that still permeates many mental health professionals. Thankfully, it does not at all seem to be the case. (Incidentally, regarding the diganosis of BPD, there has been an interesting discussion on the comments of my last post regarding its validity. I had hitherto had little doubt that it was correct, but some interesting points against it were raised).
To get back to the books C had recommended, I asked if ‘compassion’ referred to extending same to the self, or to others. He contended that they go in tandem; one feeds off the other. I wondered to what extent I agree with that, as whilst feeling I am a complete piece of crap I don’t necessarily that think others are (not that the concept of compassion is as simple as that, but you know what I mean). On reflection, though, I do think it makes some sort of sense. I am incapable, or at the very least unwilling, to demonstrably extend compassion to others in my life who clearly deserve it at times. When my Mum’s partner died when I was 11, my way of comforting her was to say something like, “um…right…sorry?” When her brother died when we were on holiday in 1996, I couldn’t deal with her grief and started an argument with her! (For the record I am citing these examples only here; I didn’t relate them to C at the time because I didn’t think of them).
After he’d stated his position on compassion, I must’ve looked contemplative because he asked me to articulate my thoughts. I said, “I’m not for one second going to sit here and tell you I don’t need practical help for being mad; clearly I do. However, I am keen that we also establish the causal roots of my mental health problems – I don’t want to just have the symptoms treated, you know?”
He jumped in quickly to that, emphatically denying that providing practical treatment alone was what he intended.
“I think, intellectually, you’d much prefer something like psychoanalysis…”
I interjected stating that I didn’t want to still be sitting in his office every Thursday morning in ten years’ time, but let’s face it – as of now that is a lie. I would be quite happy for that to be the case. Or at least I would at the minute – there are times when I don’t want to see C ever again for as long as I live, but now isn’t one of them.
“…but,” he went on, acknowledging my comment only with a subtle grin, “you present a number of symptoms that are proven to be treatable by practical methods, so I think it’s important we do some work in that regard. Having said that, it’s only one dimension to what we should be doing here – I do agree that we need to delve deeper and explore causes.”
“A dual approach,” I murmured.
He nodded, then looked directly at me, smiling reassuringly. “Don’t worry,” he said. “We’ll get there.”
I am not sure I will ever forget the profound feeling of reassurance I took from those five words. Anyone can say something like that, of course, but I felt that he really believes we can get ‘there’, wherever ‘there’ is. Not only that, but he wants to get me ‘there’, not (just, anyway) because he has to meet some stupid Health Service quota or because he’s scared of getting in trouble because I have topped myself or ended up in the bin, but because he actually gives something of a fuck.
This was the end of the session. As I was walking out the door, he said, “all the best,” which is not something he’s said to me in ages – perhaps not since our initial assessment meetings back in February or March. It’s a stupid thing to feel pleased about, of course, but it just adds to my general feeling about the session. The whole thing, however temporarily, set my perpetually troubled mind at ease, at least as regards psychotherapy, which can be a difficult and murky process. I felt there was a clear rapport in the dynamic, perhaps even a sense of camaraderie insofar as that’s permissible in the circumstances and the relationship, and moreover, C seemed to me to make a real effort to try and alleviate a number of concerns I expressed. ‘Reassure’ is a word I’ve used a lot on this post, and whilst it’s still the most appropriate one I can find, it doesn’t even seem to grasp the safety I felt.
In terms of my current thinking, almost two days later, I hesitate to use the word ‘hope’, because I’m way too cynical to even believe in that concept anymore, in its most abstract sense anyway. But let me put it this way; for now, for this week at least, and even if it never happens again, I feel a very slight tingle of cautious optimism that there may be some light somewhere down the tunnel, that is for once not a train hurtling towards me.
This entry was posted on Saturday, 29 August, 2009 at 1:29 am and is filed under C, Moods, Psychotherapy with tags anxiety, bipolar 2, bipolar 2 disorder, bipolar disorder, bipolar II, bipolar II disorder, borderline personality disorder, bpd, clinical depression, cutting, dbt, depersonalisation, depersonalization, depression, Dialectical Behavior Therapy, Dialectical Behaviour Therapy, hypomania, insanity, insomnia, madness, major depressive disorder, mania, manic depression, mental health, mentalhealth, panic, panic attack, psychiatry, psychology, Psychotherapy, self harm, social anxiety, therapeutic relationship, therapy, transference. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.