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.

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Piles of Paperwork

Last week Sadie and I had to update my ANSA and treatment plan yet again.  She expected that we could do all this in one session and still have a little time left over to talk.  She was mistaken.  We got the ANSA done with 5 minutes to spare and she asked if I wanted to do the treatment plan “really fast” or come in another time.  There is no way we could have gotten done in 5 minutes, so I agreed to come back the next day to complete it.

The next day I came in and it took us at least 30 minutes to get the treatment plan done.  She said that I’m more goal-oriented than most of her clients, who usually say their goal is “to be happy” and don’t care what else she writes.  That seems utterly unproductive to me.  Happy is not quantifiable.

My overall ANSA score, which tells her what level of services I need, has gone down from a 4 to a 3.  This is great news.  Less great was when we did the Suicide module and she said, “If I didn’t know you, I’d send you to inpatient based on this score, but I don’t think you need inpatient.  Do you?”  No I definitely didn’t.  Part of the score is based on history of attempts.  My Benadryl overdose counts as an attempt, so that part of the score will never decrease.  At the time we talked I had a concrete plan (but I will always have some form of plan) and had thought about it in the past 24 hours (because someone else was discussing a loved one’s suicide attempt), so that looked rather alarming.  However, I had no intent to act on it.

I am displeased with the new format for treatment plans.  The previous one was very open to filling it in however we saw fit.  This one pulls in the highest needs from the ANSA and forces you to choose from a list of options for things that need addressed in that area.  There is the option of adding in your own ideas, but I feel like what I actually want to work on is not addressed in the treatment plan.

However, this will be the last treatment plan.  Sadie has seemed to be pushing me away for the past few months and most recently responded to a request for help by indicating that I don’t need it.  Of course my instinctive impulses were self-destructive: overdose, self-injury, going off my meds, cancelling my appointments and not ever speaking to her again.  I refuse to let her be the reason I self-destruct.  However, after a couple of days of thought, I’ve decided that when this treatment plan expires in 3 months then I’m done.  It doesn’t feel that productive anymore.

As Evidenced By…

Thursday was my first time seeing Sadie since I dropped in on the on-call therapist.  There were new developments in that situation, as well as me being in the midst of a stressful day.  Mom was having surgery that wouldn’t be over until after my therapy appointment, so I had to leave her there and drive home from the city, then drive back, and then back home again with her in the car.

Working on my anxiety about driving is an element in my latest treatment plan, which ended up being the topic that dominated my appointment.  The plan was due that day, so although we’d discussed some aspects of it over the past couple of weeks, we had to drop everything and get it done.

I think the treatment plan is a terribly frustrating aspect of therapy.  I understand the necessity of outlining my goals and how we will measure them and what steps the CMHC staff will take to help me.  However, it has to be updated every 3 months, and there is nothing I’m trying to accomplish that can be completed in only 3 months.  We carry goals over from plan to plan all the time.  It’s a pain to have to give up a whole appointment to complete paperwork.

The treatment plan form has space for three goals, and under each goal there is space for three objectives with details about how they will be measured, deadlines for completion, and therapeutic interventions.  At the time of my last treatment plan, the three goals were “to improve social and recreational life”, “to improve daily living situation”, and “to improve self-esteem”.

I wanted to add “to graduate from DBT group”.  It’s easily measurable, and I expect to actually complete that within the timeframe of this treatment plan.  So I had to drop one of the other goals, and opted to defer working on “to improve daily living situation”.  We weren’t actually doing anything in that area anyway and nothing is going to change in that regard given my current situation, so it seemed futile to keep setting that as a goal.

So my objective under that goal was “will attend DBT group and use skills daily” as evidenced by “no harmful actions for 2+ months”.  Today marks 3 weeks down.  If I don’t screw up, I will graduate by the end of the year and not have to attend group at all in 2016.  When we had everything all filled in, Sadie said, “I forgot to include Brent anywhere.”  I said, “We’re not very happy with Brent right now, so you can leave him out.”  She couldn’t.  Somewhere under one of the objectives we have to have a note that he will prescribe and monitor medication and how often I will see  him (1x per 1-3 months).  She shoved that under the DBT group goal, with another objective stating that I “will attend psychiatric services as scheduled”.

We didn’t make changes to the “to improve self-esteem” goal, other than the target date.  The only objective under that goal is “will be able to identify reasons she is valuable” as evidenced by “Rosenberg Self-Esteem Scale”.  The two times Sadie has administered this I have ended up scoring a measly 6, with scores between 15 and 25 being a normal range.  I just took it again on the internet and scored a 12, so even though all of my answers were negative, they weren’t strongly negative anymore.  Yay for progress?

The goal that was massively reworked was “to improve social and recreational life”.  The old objectives had to do with joining activities and making plans with friends, which are fine but sort of put the cart before the horse.  My anxiety is a major obstacle to achieving those objectives.  I find things I want to do all the time, but some combination of social anxiety and anxiety about driving usually prevents me from actually doing them.  A couple of treatment plans ago, Sadie encouraged me to sign up for Match.com and Meetup.com.  I did.  I made a dating profile and I joined a bunch of Meetup groups in the tri-state area.  I proceeded to insta-delete all e-mails from those sites without reading them.

When I mentioned that anxiety was an obstacle, Sadie pulled an anxiety workbook off her bookshelf and showed me some hierarchies for desensitizing oneself to various anxiety triggers.  We decided two of the objectives in my treatment plan would be to create and work through hierarchies for social anxiety and driving anxiety.  This had already been entered in the treatment plan form before Thursday’s session, but I pointed out one more obstacle.

Although it was deeply embarrassing, and something I’ve struggled to bring up in the year and a half that I’ve been seeing Sadie, I mentioned that I will never be able to go on a date until I resolve my fear of sex.  It’s sort of the inevitable conclusion to the dating process, and I can’t even fathom starting that process feeling this sense of dread about where it will lead.  After some thought, Sadie entered this objective as “will work to resolve fears of intimacy”.  Then she opened up my last ANSA, an update to which is not due for another 3 months, and updated it to include the “Sexuality” need.  I knew that list of needs wasn’t done growing.

The “as evidenced by” section on all three objectives is very concrete.  To prove I’ve accomplished these things, I have to join a club or group, go on a date, and – my suggestion for the driving anxiety – go to the NAMI Peer-to-Peer classes that are being held January-March in a town 45 minutes away from home.  The local NAMI group only offers Family-to-Family and the Family Support Group, neither of which I’m eligible for since I’m the actual mental illness sufferer in my family.

#6 is Not an Option

I went into today’s appointment with Brent bearing a letter instead of my usual bullet-point notes.  It detailed the past month of alternating compliance and non- with my prescribed medication, and ended with six possible changes we could make:

  1. Reduce the dose of Latuda.

  2. Change to a different antipsychotic.

  3. Drop Latuda and add an anticonvulsant.

  4. Keep existing meds and add an SSRI.

  5. Keep existing meds and add a stimulant.

  6. Drop all meds and suffer the consequences.

Brent immediately said that #6 was not an option.  He didn’t specifically discount options #4 and #5, but I knew when I wrote it that they would not be options in his mind.  He went with option #1, reducing my dose from 60 to 40 mg, and said that if I still had complaints about the Latuda when I see him in a month, then we can discuss option #3.  He remembered that I had suggested Lamictal at one point in the past, and cross-tapering the Latuda and Lamictal would be the next step.

Brent said that he wants me to have energy and motivation; that he doesn’t want me to be overmedicated.  I was so grateful he said that, because I feared he might be one of the many professionals who are content to keep the bipolar in a mildly depressed state so long as there’s no risk of slipping into mania.  I’d be much happier with the opposite: staying mildly manic so long as I never, ever have to suffer depression again.

I had been receiving the 60 mg Latuda free from the pharmaceutical company, so that’s what he had available to give me.  I told him that I believe my new(ish) insurance will cover it with prior authorization so he sent the prescription to my local pharmacy.  When I checked with them it was awaiting authorization.  So for now, I’m still going to be taking the 60 mg without sufficient calories at bedtime, until I have access to the new dose.

After meeting with Brent, I went back to the waiting room until my appointment with Sadie.  It was time once again to update my ANSA and treatment plan.  We went through the ANSA much more quickly than last time, tweaking some ratings here and there.  Several needs went down in severity; none went up.  I still ranked a 4 for level of need though.

For my treatment plan, we dropped the goal of reducing risk of suicide and self-harm.  I’ve been doing much better at using coping skills to deal with those urges, and I’m much more aware of when I’m at risk enough that I need to seek emergency help.  We made some minor edits to the details of the other two goals (improving interpersonal relations and daily living situation), and added a new one regarding increasing my self-esteem.

We also came to an agreement that scares the crap out of me.  In discussing my previous blog post, which I had sent her to read, I summarized the situation with “You are my social life.”  Sadie thought that seeing her less often might encourage me to seek other social situations, and though I didn’t like what she was saying I agreed that in September we could try meeting every other week.  Given what I expect from my work schedule, that may be necessary due to scheduling conflicts anyway.

Sadie reassured me that I could try to schedule an appointment in-between if a crisis came up, and if it were very serious she’d be willing to stay late if she couldn’t fit me in otherwise.  I was reminded that, though I don’t like these options, I can always contact the on-call therapist or go to the emergency room if necessary, and that I have learned numerous coping skills and have supportive friends to reach out to.

Positive, Unconditional Regard

A few days ago my therapist warned me that next week we will have to update my treatment plan and ANSA yet again. I groaned. In my post ANSAs to My Questions, I discussed the first update that was done, and commented “All those needs exploded everywhere”, as compared to the original.  My therapist indicated there might be some improvement this time, but I honestly can’t see where there would be.  I suppose there’s a slight chance that my depression could be considered less severe, given that at the time of the last update I had two back-to-back inpatient stays.  Other than that, I almost expect there to be new needs added, regarding topics that had not previously come up in our sessions.

The treatment plan should be easy to update, and look essentially the same as the last one.  I recalled that the goals from last time were rather long-term, and we set deadlines 6 months away, despite the treatment plan needing to be updated every 3 months.  I suggested that we would just be copy/pasting the information from last time, including the deadlines.

When I got home, I pulled out my records to read through these documents once again.  I was reminded of something on my treatment plan that has nagged at me these past three months.  One of the listed therapeutic interventions was “Therapist will provide positive, unconditional regard for Donna*.”  *Not my real name.

This made me laugh when I first read it, but as time has passed, it has become increasingly less funny.  I get frustrated talking to someone who I know is obligated to be nice to me whether I deserve it or not.  I don’t trust that she actually means any of the positive things she says, because I know she’s not free to tell me that she thinks I’m being an idiot.  In fact, I pretty much assume that it’s all lies, which makes me wonder why I try so hard to be completely honest with her.  In all the times that I’ve confessed to skipping pills I should take, taking pills I shouldn’t take, or otherwise being self-destructive, the closest she has come to expressing disapproval is to say “I support the idea of you taking your medication this week.”

With my previous therapist, it was clear when she thought I’d said something ridiculous.  She could say, “Really, Donna?  Really?!” in this tone that instantly smacked sense into me.  Now I’m seeing someone with whom my weekly struggle is to figure out what the hell she thinks of me.  We have issues come up where I have no idea what her opinion is, and I can’t figure out my own opinion because there’s nothing there to agree or disagree with.

I can’t decide how much of my annoyance here is from not knowing which statements to trust, and how much is from feeling that there’s no possible way any of it could be genuine, because I don’t believe anyone who really knew me would have anything positive to say.  I want to say that I’d feel better if she wasn’t always positive, so that the times when she is would hold meaning.  However, it’s equally possible that I just want her to criticize me because it’s more comfortable to deal with.