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.

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A Coming Out E-mail

At the first meeting I attended of the Crisis Intervention Team we discussed a difficulty with CMHC’s inpatient unit.  That is, that they were experiencing a nursing shortage and had to limit their census to 4 clients (down from the maximum of 16).  They usually have no more than 5 or 6 at a time, so that’s not a huge reduction, but it did mean that the emergency department was having to hold people longer while trying to find another facility to send them to.  This is difficult as we are near the state border and the nearest hospitals are all in other states.

I was asked not to spread this around to other clients and alarm them, since there is a solution,  even if it’s not a great once.  So I haven’t discussed this much.  However, there was recently an e-mail sent to the entire nursing staff of the hospital asking for RNs to work 2 shifts per week at CMHC for a 60-day period.  This e-mail stated that inpatient was closed, and unfortunately that seems to be the case.  I’m no longer seeing their meal and laundry carts in the hall, and when I wait for the elevator I can’t hear the TV that they have blaring during all waking hours.

I’ve never been very quiet about my mental illness…it comes up in conversation and I don’t have much of a filter as far as who to share with.  It was still a huge leap when I hit reply to all on that e-mail and asked for the nurses to please consider helping out.  I said that inpatient is a vital part of mental health care in our community.  I said that they had saved my life and I hate to see that resource be unavailable for others in crisis.  I probably haven’t even met half the people who received my e-mail, but I felt something had to be said.  Maybe hearing from someone who has actually been there will persuade some people to volunteer.

Super Picky Directions

In inpatient they are really good about accommodating client preferences in regards to medication.  My BuSpar prescription was originally written with the directions “TAKE ONE TABLET BY MOUTH THREE TIMES A DAY AS NEEDED”.  The next time I entered inpatient, they were expecting me to come ask for the BuSpar if I needed it, but at that point I’d been consistently taking it on a schedule and when I told the psychiatrist that it got put on a schedule.  A very strange schedule, that I’m sure made sense to them, but I was used to taking it with meals and that lining up pretty well with when I started to get anxious.  So I mentioned that and next thing I knew I was getting it with meals.

Latuda is designed to be taken with a meal – it requires 350 calories to be metabolized properly.  Unfortunately, if I take it with a meal I am going to be antsy and irritable within 60-90 minutes and have to resolve that by going to sleep.  So I’ve traditionally taken the Latuda at bedtime, with Brent’s approval, despite the fact that I rarely eat that large of a snack before bed.

On my latest inpatient visit they were quite agreeable to moving it from breakfast (their preferred time) to supper, but reluctant when I asked to wait until bedtime.  The first night the nurse came to check the calories in my snack and made me take a second carton of milk because there weren’t 350 calories.  The next night, I had some Fritos given to me by another client and that nurse suggested I take peanut butter and graham crackers to fill up the rest of the required calories.  I did not want peanut butter and graham crackers, but I ate them and was halfway through the Fritos when she came back with the Latuda and didn’t want to give it to me because I hadn’t finished my snack!  I promised to eat the rest of it but felt an overwhelming temptation to throw it away out of spite.

I picked up my Latuda prescription today and happened to notice the directions.  It now says “TAKE ONE TABLET BY MOUTH AT BEDTIME AS DIRECTED WITH 350 CALORIES SNACK”.

The Joy of Lamictal

I’m writing this on my phone so it will be shorter than usual, but I wanted to share that I’m really glad I went to inpatient last week.  I wish I had done it 6 months ago, although that would have been bad timing with my then-new job.

I started asking Brent for Lamictal over a year ago.  He consistently put it off, trying to fiddle with dosages on my existing meds instead of trying anything new.  When I threw the idea out there in inpatient, I expected to get a similar response from Dr. Bhatia.  Imagine my surprise when he said, “Okay.”  Well, what he actually said was, “Four medications is a lot, but that’s a class you aren’t already on.”

A week and a half later, I feel stable.  I’ve had days here and there in the past that felt okay, even sometimes several days in a row, but this sense that I am calm and can handle stress and everything is going to be okay?  That’s totally new.

For the past few days I’ve been on vacation, staying with my best friend, her husband, and their 5-year-old daughter.  Their daughter is intense, to put it mildly.  She has not calmed down any since my last visit in summer 2014, and has actually been wilder since she’s getting over chicken pox and has been cooped up in the house.  On my last visit I had a very difficult time handling her and had to practice my newly-learned mindfulness skills to survive the week.  This visit is going much smoother for me.  The mindfulness skills are much easier to put into practice now, partially because I’ve been using them longer, but mostly because I’m just not feeling the stress. 

There have been some studies that indicate Lamictal is also helpful for the day-to-day mood swings associated with Borderline Personality Disorder, and it feels like that might be true.  There have been the occasional thoughts of suicide or self-harm popping into my head, but instead of temptation to do it I just think, “Gee, why would I want to do that?”  The real test will come when I am back home and have my first conflict with mom since my release from inpatient. 

Group Activities

 

Life in inpatient is centered around food and groups.  I’ve talked at length about the food before, but only mentioned groups in passing.  The first group each day takes place at 9:15 and is called Goals Group.  You are supposed to think about the circumstances that led you to be in inpatient, and set a goal for something you can do that day to help yourself.  My goals usually centered on reading or doing exercises in therapy workbooks.

The second group, at 10:30, and the third group, at 1:00, are both activities.  Sometimes we fill out paperwork, such as the lengthy set of questions to reflect on 2015 and make plans for 2016.  Sometimes we answer questions from Life Stories (a board game about sharing random experiences) or Homeward Bound (cards about reflecting on your experience in inpatient and what you need to do to move forward).  Sometimes we do art activities, like the coping skills tree or the collage below.

2016-collage

The theme of this collage was things to do to improve our lives in 2016.  We had plenty of magazines to hunt through, and the activity therapist, Nikki, also had pictures and phrases she had cut out during some downtime.  She kept handing them to me and saying, “Here, this one’s for you.”  She apologized to another client, Bryan, for not knowing him well enough to give him any and I said, “It’s really depressing that you know me well enough.”

So, somewhat top-left to bottom-right, we have “Center Stage” for continuing my involvement in theatre projects, “Let yourself believe.” for believing in myself (like a coworker encouraged me to do with the Believe coffee mug she gave me), “Literature” for all the books I plan to read this year.  A birthday cake for doing something special to celebrate my birthday, maybe by traveling like the travel guides suggest.  Office supplies for trying to get more organized, abstract art for getting back into my creative hobbies, a cat for spending time with my four cats.  Sunshine for time spent outdoors, Prilosec for taking care of my physical health, a snack bee for cooking and doing cute projects from Pinterest, a little kid for spending more time with my cousins’ children.

We also had a 3:00 group with the social worker that was designed to be a therapy group, in which she liked to load us down with paperwork.  After I was the only one to complete it, she opted for an activity in which we were each given two emotions and asked to describe a time when we felt that emotion and how we coped with it.  The first one I was given was “depression”, and I commented that there were too many times to choose from.  “Scared” was easier, with me telling about my latest car accident and everyone chiming in about their own car accident stories.

The final group, at 8:45, was my least favorite.  It was usually some sort of worksheet led by a program assistant, and at that point we’d just gotten through 2 hours of visitors and I was ready to go pass out.  They wouldn’t hand out nighttime meds until after that group, however, so there was no point skipping it in favor of bed only to be awakened an hour later.

When I got out of inpatient, I missed the groups.  At least the three in the middle.  I lamented to Sadie that I wished I could go in during the day just for groups and not have to spend the night.  The options for groups in this area are not so helpful.  There’s the DBT group that I just graduated from, and despite Jan’s suggestion that I go back I will not be doing that.  There’s AA and NA and eating disorder and grief support groups, none of which are relevant to me.

Sadie suggested that there are groups for the residents of the dual-diagnosis facility, and they may allow me to come  in for those.  She also said that CMHC used to offer groups and had trouble getting people to attend regularly, but they might start new groups in the future.  She said she’d look into some possibilities for me.  I would be relieved to have a bit more structure and a bit more social time, since right now all I get is my one day per week at work.

Inpatient Summary

Just over a month ago, in Oops, I Did It Again, I talked about an appointment with Brent in which I expressed some suicidal ideation and he did not think I needed to be in inpatient.  Fast-forward a week to A Narrow Miss and I had developed a plan (a combination of pills on January 1st) and Sadie reluctantly let me leave after signing a safety contract.

The plan was only to be enacted if life didn’t improve before the 1st, and life did improve.  I bought a car only 2 weeks after totalling the previous one.  It’s the same model and same year, just a different color (and in slightly better condition).  I also adopted another cat, a very sweet-tempered Russian Blue.  I no longer wanted to die.

Even so, I felt there was about a 10% chance of me acting on the plan anyway.  I felt like I was going to fail by not following through.  I was also feeling physical heartache over every little thing that happened.  Despite my goal to get through all of 2015 without going to inpatient, I packed a bag and told Sadie that I thought it was time to go.  I had to go to work doing yearly inventory, but on the 31st I had appointments with both Sadie and Brent scheduled and I fully expected to go to inpatient after seeing them.

Sadie was in favor of inpatient.  She seemed to think that I would be okay if I didn’t go, but was concerned about that 10% chance of suicide.  I was feeling a little better when I saw her, but the thoughts still wouldn’t leave my mind and she felt that inpatient would be willing to admit me if I told them the same things I had told her.  I decided I would go to my appointment with Brent before making my final decision, but I really expected to be admitted.

It didn’t happen.  I wasn’t feeling suicidal right that second and Brent said there was no reason for me to be in inpatient.  So I went home, crying, and the next day I went to work with a bottle of Wellbutrin in my purse.  I spent all day obsessing over taking it.  Work was slow, so there was plenty of time to obsess.  I managed to get through the day without taking the pills, but after texting with a friend I was pretty convinced I should go to the ER.  I didn’t want my mom to be mad at me though, so I went home after work.

I was staring off into space when mom asked what I was thinking.  I said, “I don’t want you to be mad at me…”  She said, “But you want to go to the hospital and be admitted.”  She said she would take me, but then she put her nightgown on.  She said I could have her get dressed again, but I couldn’t work up the courage to ask.

The next day we went out shopping, primarily to go to an antique mall she wanted to visit.  I was feeling a lot better that day, but kept worrying.  I’m due to go to Chicago on the 9th to visit my best friend, and what if things got worse again and I did have to go to inpatient?  If I didn’t go right away, I probably wouldn’t get out in time.  So when we got home from shopping, I picked up the bag I’d had packed for several days and we headed to the ER.

Bear in mind that I work at the local hospital and pass through the ER on almost a daily basis.  The nurse practitioner they sent to see me was a stranger, as was the nurse who took my vitals, but when I pressed the call button to ask for water it was a unit clerk I know who came in.  He brought me two bottles of water and didn’t act weird at all about the fact that I was there, despite knowing that I was waiting for the on-call therapist to show up.  In fact, he had to call over to CMHC after I’d been waiting over an hour, as the on-call therapist was late.

When the on-call therapist, a man I hadn’t met before, did show up, I explained why I was there and he agreed that inpatient seemed like a good idea, so he called the psychiatrist to get approval.  I signed the paperwork to be transferred into inpatient, and he walked me downstairs and through the cafeteria, and when I set foot in the cafeteria I started panicking and whispering to mom, “I can’t do this.  Don’t make me do this.”  I expected her to stop the on-call therapist and ask if there was a way for me to back out, but instead she just said, “Too late, sweetie.”

I did calm down once I actually got inside and started the admissions process.  Stories from my stay will be forthcoming, but at this point I’ll just summarize that I was there for 4 nights and got one med adjustment.  They kept all my existing meds, but at my prompting added Lamictal.  At this point I’m taking 25 mg twice a day, and the next dose increase probably won’t happen until I see Brent on the 27th.

The other important point is that, when I was released yesterday, I was expecting to go to an appointment with Sadie that afternoon.  I called over from the inpatient unit to verify I still had the appointment and found out it had been cancelled.  I was panicking all over the place, shaking and pacing around the room.  Jean passed through and asked how I was, and I said, “Not good.  Anxious.”  She asked why and when I explained she told me to go to the nurse’s desk and ask the people there to call and try to get me another appointment.

It turns out, one of those people was the one who cancelled my appointment.  I was pissed, but remained civilized.  She did try to get me an appointment but they didn’t have anything available except for a day in the middle of my trip.  I was still a bit panicked when mom arrived to pick me up, but it resolved later in the day.  I e-mailed Sadie to tell her I was sorry I wouldn’t see her until after the trip and she ended up having a time available on Friday morning.  I’ll have to cut it a little short in order to get to work on time, but I’m so relieved I’ll get to see her.

A Narrow Miss

Tuesday in DBT group, someone commented that she likes the word ones (mindfulness exercises) “except when Donna’s here”.  I told her she could look forward to doing them in 2016 when I wouldn’t be back.  Sierra said, “So things are going well then?  We should talk later.”  There wasn’t an opportunity to talk to her after the group ended, so I sent her a rambly e-mail that I instantly regretted.

I said that in terms of avoiding acting on negative urges, everything was great, but in terms of having those urges, things were possibly worse.  I said that I wished my car accident had been fatal and had a plan to do something about that if things weren’t improving by the beginning of next year.  I said that I’d either be fine or I wouldn’t, and it didn’t much matter either way.

Surprise, surprise, instead of replying to me she forwarded it to Sadie.  I was not in the mood for therapy yesterday and strongly considered calling to cancel, but if I canceled at the last minute she’d probably send the cops after me, so I went.  I walked in and said, “I don’t want to be here.”  Sadie asked, “This office or this planet?”  “Both,” I replied, although at that moment I didn’t really want to be dead, just very strongly did not want to spend 50 minutes talking to her.

Sadie asked about a plan, and I said that I was scheduled to work alone on New Year’s Day, and although I was giving life a few weeks to start working out in my favor, if it didn’t I intended on overdosing that day, because I would have “lots of pills” at that point.  Sadie asked when I see Brent again.  “December 31st.  That’s why I’ll have lots of pills.”  She said, “You do realize that he’ll know about this plan and probably won’t give you the pills?”  Shit.  Although I didn’t quite mention to her that the plan involved a combination of pills, two kinds of which I have access to right now whether he gives me anything or not.

By the end of the appointment, she was very concerned about the idea of letting me leave.  She said that although I have goals such as staying out of inpatient the whole year, she doesn’t care whether I accomplish those, she just wants to make sure I’m safe.  I told her inpatient doesn’t help, and she said, “But it provides supervision until these feelings change, and they will change.”  Yes, and then they will change back, over and over and over again.

She was also hesitant about the fact that I could not promise I’d call for help if I felt like moving up the timeline on my plan.  At first I said that I didn’t know how to tell when I needed to call.  “When you started forming this plan would have been a good time.”  She was concerned that I hadn’t e-mailed her like I usually do when I’m having a rough time.  I finally acknowledged that I probably would know when it’s necessary, but…I hesitated.  “Never mind.”  She was even more concerned that I was holding something back from her.  I eventually did say, “I might not want to call for help.”

I swore to her that nothing would happen before the 1st.  There are far too many plans – concerts and comedy shows and Christmas celebrations with family – and if she sent me to inpatient and I missed out on those moments it would just make everything worse.  She said that I absolutely had to sign a safety contract if I wanted to go home, and I signed.  It’s been a long time since she made me do that, and Brent and Jan have given up on getting me to sign.

There was a lot said in those 50 minutes, about finding purpose and figuring out why I have such a depressing view of human existence (“we’re all a big accident”).  About keeping things in perspective and having realistic expectations for what life will be like.  Then I mumbled, “The holidays suck.”  That’s not entirely true.  I have a love-hate relationship with the holidays.  There are things to enjoy (sending cards, giving gifts, ordering a snack tray from Figi’s, letting my cats come to the basement on Christmas morning as we sit around the tree and open gifts).  There is also a lot of pain, as described in O Christmas Tree.

I told Sadie about ruining grandma’s last Christmas.  She tried to persuade me that I didn’t ruin it, that I did what I could to make the day special despite some tough obstacles.  I was starting to get a little choked up.  I mentioned not being there when grandma died, and she said that she wasn’t sure we’d ever talked about the circumstances of grandma’s death.  Oh, jeez, not the topic I wanted to get into at that point.

I struggled through explaining why I wasn’t there, and why I was so ashamed of that fact.  I did not break down into total sobbing, but there were tears on my cheeks.  This was the first time I cried in front of Sadie in the whole 19 months I’ve been seeing her.  I got done, unable to look at her, and said, “Can I go now?”  She said, “But we have 2 minutes left!”  Seriously?  I mean, I couldn’t actually go, because she still had to force me to sign a safety contract, but had I not been tortured enough for one day?

When I got home I had an e-mail from Sadie, offering me a half hour opening she had on Monday, in case I wanted to come in a little extra until I feel better.  It was a sweet offer, but I will be at work, and I don’t really see what good it will do to see her more.  She can’t wave a magic wand and make my stress go away and make my memories not hurt.