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.

Things I Like About Me

Sadie frequently encourages me to do thought diaries, which I am very resistant to doing.  We can’t figure out why, since I always go above and beyond on other tasks she assigns.  Ironically, a Bing search for “thought diary” has the first image result as one from my blog.

This week Sadie and I were discussing my overall lack of self-liking.  She wanted me to identify positive traits that I have, and since the daily gratitude journal has been helpful I suggested that I also write down one thing I like about myself.  She tweaked this a bit so that I’m supposed to identify a situation in my day and what positive trait I showed in that situation.

On the first day, I said that crying in front of Sadie (yes, again) showed that I’m able to show vulnerability.  On the second day, I showed cleverness by tying someone’s derailment in DBT group back to the topic at hand.  On the third day, I was insightful in knowing that I couldn’t deal with productivity at that moment and needed to veg out by binge watching TV on Netflix.  On the fourth day, I showed that I care about my health by scheduling a follow-up for a leg injury.  On the fifth day, I showed that I can keep things in perspective by realizing that losing my Fitbit was not a huge tragedy.

I’ve been writing these in my regular journal instead of a separate book, but may have to get another book and copy them over since it seems to be really helping.  I was actually lying in bed last night feeling at peace with my life for the first time in forever.

Too Good to Be Bad

Last week I had nothing but good news to share with my therapist. I had just submitted 3 job applications, and later that evening I was headed to the first readthrough of the play I’m stage managing. We discussed the week’s diary card in record time, and she asked if I wanted to end early. I thought for a moment, and came up with one concern that I wanted to discuss first: the fact that I’m still having negative urges even when I feel what I think they mean by “euthymic”. It was suggested that these urges have been comfortable for me in the past and that I can learn to be comfortable with better coping methods.

We still weren’t out of time after that discussion, so we did end a few minutes early. My therapist asked how I would feel about meeting less often. I said I wasn’t quite ready for that, and she agreed but started planning for that future reduction in appointments. She proposed that we soon reduce appointment length to 30 minutes, and after a while we’d then switch to every other week. I left feeling both thrilled at the progress I’ve made, and saddened at the thought of seeing her less often.

I know my therapist is not there to be my friend, but as I thought further on this I felt abandoned. It’s a simple case of transference – I have had a number of experiences of people being there for me in a crisis only to disappear as soon as my life started to improve. It makes it very tempting to stay in crisis mode indefinitely. This is not what I want for my life, so I was determined to keep my cool and let this transition happen without falling into old habits. The last thing I want is to look like I’m being manipulative.

Then I read Loud in the House of Myself by Stacy Pershall.  I’ve been holding onto this book for months, waiting to enjoy it.  I didn’t.  I mean, there was nothing wrong with the book, but instead of being inspiring it made me feel inferior.  Boring.  Books about mental illness typically do that, because I end up feeling that my life has been horribly damaged and yet I haven’t done any of the exciting things that normally come along with manic impulsivity.  No spontaneous travel, no tattoos, no tumultuous romantic relationships.  I’m too bad to be good and too good to be bad, and I fear that telling my story will just lead the “real” mentally ill people to laugh in my face.

Upon reading this book, I felt convinced that I cannot write a book of my own, that my life is not even remotely worth writing about.  Given that the idea of writing this book was a major source of joy in recent weeks, this turn of events left me feeling very depressed.  I felt as though my life had to get worse in order to be interesting enough to warrant a book, and I ended up cutting myself.  No major injury, but a large number of minor cuts with minor bleeding.  The kind of thing that gets described as “cuts” (with the quotation marks) in my medical records, which furthers my sense that I’m too pathetic to even do mental illness correctly.

The next day, still feeling this disappointment that my book could not be written, I started feeling increasing destructive impulses.  Toward cutting, toward alcohol and nicotine gum, toward binge eating.  I fought with myself all day, trying to force my way into alternatives.  A walk on the walking trail.  A drastic haircut.  Just buying some more coffee and going home.  Instead I ended up at the grocery store with nicotine gum and half a dozen Krispy Kremes in my cart.  I told myself to leave the cart and walk out.  I told myself to put the gum back and just buy the donuts.  I checked out anyway.

I made another stop to buy more coffee and headed home, where I started eating the donuts.  And finished them.  I started chewing the nicotine gum, and the combination of way too many donuts and the gum made me very sick to my stomach.  I was already inclined to try purging, and the way my stomach felt made it an inevitability.  It was completely unsuccessful.  I spent the rest of the day miserable, and unable to admit that being sick was my own fault.

I was disgusted with my behavior and felt that if I couldn’t control my negative urges and I couldn’t do anything productive like write a book then there was no sense in living.  I knew deep down that I had things to live for, like the play, but part of me questioned whether that even mattered.  If I were gone, I wouldn’t know what I’m missing.  I was a bit scared of what I’d do, and handed over all my pills, prescription and OTC, to my mother.  Naturally this just left her alarmed and nagging at me to explain what could possibly be wrong when I was in such a great mood just days ago.

It wasn’t until the next day that mom noticed the cuts.  She asked if all this was a reaction to my therapist wanting to reduce our appointments, which was very upsetting as that’s exactly how I feared it would look.  I tried to hold out until Thursday and go into my regularly scheduled appointment cheerful and ready to put this incident behind me.  However, I felt like I was going to be dishonest if I did this, and I sent an e-mail to my therapist to explain that I was not doing so well and that mom was guarding the pills.  She offered me an appointment the next day, and I took it, while saying to her that I know I should decline to prove that I don’t depend on her.  Her response was to say it’s okay to ask for help and to thank me for my willingness to come in.  I wondered whether the unwritten end to the sentence was “so I don’t have to call the cops on you”.

I must admit the appointment turned out to be very helpful.  We did a thought diary together regarding the book, and established that I can’t know whether people will find it interesting until I actually write it, and that writing the book will be beneficial to me even if no one else ever reads it.  I acknowledged that my story may need to be told for all the other people out there who are feeling that their pain isn’t legitimate just because they don’t measure up to the stories that normally get published.  I started to feel interested in writing again.  However, I’m still really disappointed in myself that I needed to go in for extra help right when things had been looking up.

Thought Diaries About Thought Diaries

I’m telling my stories all out of order again, so to preface this I must say that I quit my job 10 days ago.  In those 10 days, I’ve struggled with many things, including the feeling that I must be busy 24/7 to make up for the fact that I’m not working.  Yesterday I had a huge list of things I could be doing.  I even did some of them.  However, one particular thing I didn’t do made me feel like a failure, and as I journaled about it I kept pulling out more and more failures from my day.  I failed to make a dentist appointment.  I failed to apply for a new job.  I failed to do any exercises in any of my three self-help workbooks.  I failed to comment on any blogs, upload any photos, or add any information to my family tree.

Today, my therapist questioned why I did not do a thought diary (an exercise from CBT) regarding these thoughts of being a failure.  Oh, look, I failed again!  In fact, I have failed repeatedly, as I quit doing thought diaries within a few weeks of her teaching them to me.  I felt guilty as I explained that they are difficult.  I let her think it was strictly about the amount of work, but they are emotionally difficult as well.

My therapist is smart, and clearly knew that telling me to go home and do a thought diary was not going to be very effective, so we worked on it together.  One small event, or rather a lack of event – not making a dentist appointment – led to four negative beliefs driven by four different types of unhelpful thinking styles:

thought-diary

“I am a failure.” (labelling)
“Nothing I do is good enough.” (all or nothing thinking)
“I’m wasting my time.” (should & must)
“Anyone else could do this.” (magnification & minimisation)

As we moved on to disputing my “hot thought” of “I am a failure.”, I listed all the things I didn’t do yesterday as evidence of this “fact”.  When providing evidence against the hot thought, my therapist asked me to think more broadly about my past accomplishments.  So while I included “I did write a blog post.” and “I made other phone calls that day.” as accomplishments from yesterday, I also came up with a few from the past.  I wrote a play.  I designed a style for a website.  I’ve been in a few plays.

Then she asked me to think about ways in which others have complimented me.  She mentioned that some people from my ex-job had probably told me I did well at things.  She was right.  I used to work with people from a department outside my own, and they frequently lamented the days when I was working on other tasks or was unable to attend work.  They told me how well I did at the job.

I’ve left a couple of our pieces of evidence out of the previous two paragraphs, because the act of doing the thought diary actually brought up two additional negative beliefs.  The first was that scores on standardized tests are not an accomplishment because they are just numbers that no one cares about (disqualifying the positive).  The second was that any positive comments made by my mother don’t count, because she feels obligated to compliment me (jumping to conclusions).  This proved my therapist’s point that I need to be doing these thought diaries regularly or I will never stop having negative thoughts that stir up negative emotions.

After the evidence for and against the hot thought, the next step is to answer one or more disputation questions designed to bring up positive alternatives to the negative thought.  I chose to answer “How might someone else view the situation?”  My therapist said, “What would Wendy* say?”  *(former therapist, not her real name)  I really hate it when she uses Wendy against me.  It just stirs up the pain of her having finished her internship and left, and even worse I feel like my therapist’s subtext in these moments is that the two of us still haven’t built a rapport.

I’m doing the best I can.  I wish she knew how much I like her and want to feel comfortable with her.  How much I beat myself up internally every time I sit in her office and deflect pain with humor.  I would give anything to show sadness or anger in front of her, to prove that I’m more than a really bad comedy act.  So now I feel like I need to do a thought diary about doing this thought diary.  Therapy is becoming entirely too meta.