The Three Goals

Every three months Sadie and I have to update my treatment plan.  The first page reviews progress made since the previous treatment plan was created, and addresses strengths, needs, abilities, and preferences (SNAP).  It lists the members of my treatment team and any “natural supports” – people in my life who are helpful to my recovery.  The rest of the plan consists of overall goals and any smaller objectives within those goals.  Each goal is tied to a problem identified on the Adult Needs and Strengths Assessment (ANSA) which is updated every 6 months.  Each objective within a goal contains criteria for identifying when it is completed, a target date, and any interventions that will be provided by the therapist or other staff.

My treatment plans have varied widely.  They used to be crammed full of objectives that we sometimes never worked on, but they were there in case I wanted to work on them.  The benefit to this is that Sadie’s paperwork for each appointment (a Service Activity Record or SAR) requires that she choose a goal or goals from my treatment plan that we addressed during that appointment.  I’ve experienced firsthand the struggle to choose something relevant to the actual work, so I like to ensure that she has several choices and/or sufficiently vague goals that can apply to anything we do.

My last treatment plan had only one goal, pertaining to interpersonal problems.  It was about setting healthy boundaries.  We kept that as an objective, and incorporated another objective, with the goal of “have more realistic interpretations of other people’s comments”.  One of my major struggles in relationships is that I get disproportionately upset by things people say (particularly with my mother), so I am aiming to tone down my reactions.  The completion criterion here is to complete at least one thought diary per week.  We made it a small goal because sometimes I struggle with the longer thought diaries, but there are also forms that do a quick mini version where you can log several different thoughts on the same form.  I plan to keep one of those handy and fill it in as often as possible.

The next goal, pertaining to depression, is to “work on accepting imperfection”.  The material from which the thought diary form comes also contains a series of modules on Perfectionism in Perspective, so Sadie and I plan to work through these modules together.  The final goal, pertaining to self-care, is to “explore Buddhism”.  I have committed to reading at least one book per month on the subject, although knowing me it will be a lot more.  I’m starting with Buddhism for Dummieswhich is probably not the most enlightening book option, but gives a thorough overview and suggestions for additional reading, which I can use to help me figure out where I want to look next.

I feel better about this treatment plan than the last one, as the things I’m trying to accomplish are more concretely measurable.  I like to be able to check things off a list, and these are all things I can check off if I work hard.

Self-Harm and Buddhism

At work there is a program called Illness Management and Recovery (IMR).  It was developed for the Substance Abuse and Mental Health Services Administration (SAMHSA) and consists of 10 modules on managing mental illness.  I am not trained to teach it, but have been working through the modules myself to learn more.  Most recently, the assignment was to explain a symptom to others.  I wasn’t sure which symptom to cover, until I spent 5 nights back in the inpatient unit last week.  I’ve struggled a lot with suicidal ideation and urges to self-harm over the past three months, and reached a point where it was beyond time to take a breather from life and go somewhere safe where I could focus strictly on taking care of me.

While there, I began reading The Buddha and the Borderline by Kiera Van Gelder.  It is a memoir of her experience of Borderline Personality Disorder and her path to recovery via Dialectical Behavior Therapy (DBT) and later delving into its roots in Buddhism.  Early in the book there were some fairly graphic descriptions of self-harm, which I only felt okay with reading because I was in a safe place.  It turns out, it wasn’t entirely safe.  They do the best they can with keeping dangerous objects out, but those of us who self-harm can get pretty creative.  At one point I found something dangerous that was built into the architecture.  I showed it to a nurse and she said she would report it to the director of the unit and that I should come tell a staff member if I was feeling tempted.  One night I did.  I’d been feeling anxious during visiting hours and when my mom left I called the same nurse over and told her I felt tempted toward the thing I had shown her previously.  I also handed over my statistics folder mom had just brought for me and asked her to please remove the staples from the packets of notes.

The nurse told me to stay put, but it didn’t totally register and after a different staff member handed back my folder without even speaking to me I started to get overwhelmed by the noise in the main commons and moved to a smaller area near my room.  The nurse came rushing in and happened to see some recent scratches on my arm from before my admission, which led her to exclaim, “Did you hurt yourself?  I told you to stay put!”  I explained that the scratches were older, and she told me that they would like me to sleep in the quiet room that night so they could keep an eye on me.  The quiet room?  That’s the nice term for seclusion room, which is the nice term for restraint room.  The only furniture was a bed in the center of the room, with restraints built in.  The lights were controlled from the outside, there were cameras monitoring the room, and there was no handle on the inside of the door.  Now on the bright side, they really just were putting me there for the cameras, and the door was not fully shut.  I was allowed to get up and leave to use the bathroom or go to the water fountain or ask for sleeping medication.  It was still rather intense.

It was also completely warranted.  The dangerous item I had found wouldn’t do serious damage, but it was in a place where no one would see and stop me, and I could have hidden the marks had I acted on my urge.  So why self-harm?  It can be many things.  It can be a punishment.  It can be a release of psychological pain in physical form.  Those are the main two things for me.  If I’m hurting intensely, it’s less painful to transfer that into something physical.  I’m also usually tempted toward it when I feel shame, which unfortunately I feel frequently and for sometimes inexplicable reasons.  The important part to note is that, while many people both self-harm and feel suicidal, the act of self-harm is not a suicide attempt.  Severe acts of self-harm could result in death, but it’s different if death is not the intent.  Self-harm is a coping skill, just not a very healthy one.  Some people come home from a hard day and have a glass of wine or eat a comforting meal or go exercise intensely for an hour, and all those things reduce the pain somewhat.  Self-harm does the same thing for some of us, and therapy (such as DBT) is about replacing that with a healthier way to reach the same end result.

I finished reading The Buddha and the Borderline last night, a couple of days after my release from inpatient, and toward the end the author asked one of her Buddhist teachers if suicide was the same as killing another person.  Likewise, is self-harm the same as attacking another person?  The conclusion was that it is impossible to fully practice loving-kindness toward others if you cannot love yourself.  I can’t say that I will never slip and act on those urges again, as that’s much too simplistic to think a line from a book is going to undo decades of experience, but the book did inspire me to look more into Buddhism.  I am not a spiritual person.  I am even less a religious person.  I have, however, found myself drawn toward Buddhism over and over throughout my adult life, and have benefited immensely from DBT and the elements of Buddhism Marsha Linehan incorporated into it.  So I am steering my upcoming focus on reading toward books on the topic, to discover if it is something I want to explore further.