Coming To The End Of Therapy

It can take a little while to find the right therapist. But once you do, you begin to build a relationship like no other. You tell this person your deepest, darkest secrets, and you trust them to an infinite degree to keep those things private and safe, and not to reject you.

For me, it turned out to be particularly important to have a male therapist. The approach he took with me was a compassionate one and it felt amazing to have a male “in my life” who wasn’t going to harm me physically or mentally, or reject me, or abandon me, shame me, or betray me, or any of those things that the men I had in my life had been doing.

As the relationship develops you may begin to experience some transference (the redirection of feelings for a significant person to your therapist). For example, at one brief point I began to wonder whether I had romantic feelings for my therapist (since a normal, stable relationship was so lacking in my life) and then I began to wish that he was my dad. This stuff can be really confusing but the best bet to understand it is always to talk to your therapist about your feelings. Because it’s totally normal, and they will know how to respond.

Then, after working through the transference, before I knew it, I’d been sobbing my way through Saturday mornings for nearly FIVE years. Much of that time I have no recollection of, because of the heavy medication I’ve been on and also because of the PTSD. And that’s kind of scary. What did I say? What did he say? What did I learn? How did I cope? Was I a wreck? But somehow he’s worked his magic and now I’m through almost everything life has thrown at me.

So now, it’s time to spend my Saturday mornings doing something a little more light-hearted and enjoyable. Time to start living life!

I was ecstatic when I made the decision with my psychiatrist and therapist to stop doing therapy. I felt like I’d made so much progress, was well on my way to being “better” and I generally had a lot of hope for the future – for the first time in a long time.

But the day after I last saw my doctor and my therapist and made that decision, I crashed. Sobbing at the kitchen table, sobbing in the bathroom, sobbing in bed. It seems as though when I’m doing well there’s always some weird karma that has to follow it up with a low. But I don’t think that was it. The truth was: I was afraid. How will I cope on my own? What will I do with my thoughts and symptoms? Who on earth in my life can rival or replace the relationship I have with my therapist? And that last one is a very personal thought – but it feels like an important one to share for many reasons.

Your relationship with your therapist can be like a practice run for “real life”. You can play out your best dreams and your worst fears with them, and never feel rejected or laughed at or belittled or ashamed, never get any negative feedback. And that is unusual in “real life”.  Usually we go through life trying to please others – but you don’t have to please your therapist (unless you’re me, and that is a whole different issue). Usually, too, we go through life only partly being true to ourselves, concealing the negative aspects of ourselves or our lives. But with a therapist, the whole point is to examine those parts of ourselves, again within a no-shame environment. I could go on, but the point is that our therapists become figures to us of important people in our lives and they also provide us with loads of validation, so it feel good talking with them.

Once the day was over and I’d finished all my crying, I began to think differently about everything, Every time I go in and sit on that chair, it reinforces the idea that I’m not well. It undermines my strength. I’m an incredible, strong woman. I don’t need a man in a chair to tell me everything’s going to be okay. I can tell that to myself now, and believe it (most of the time). I’m not ashamed to reveal my difficulties, and I can have difficult conversations with friends and family. I’m a more confident me, I maintain healthy boundaries, and I have learned how to soothe myself. Cured? Occasionally I think so. Better? Yes, definitely.

And so it felt like a good time to “terminate”. I have two sessions left, spaced out over two months. And I think I’m ready. It’s time to spread my wings and engage with the world out there.

 

 

Advertisements

Maina and Me

tumblr_m75wc8KG6D1qgkoejo1_1280

During the onset of a mania it feels like having in your hand a mixture of liquid gold, love and luck. It feels like it could take you anywhere, to the infinite possibilities of your wildest dreams. Everything is beauuutiful, even the every day things; they are imbued with cataclysmic significance; every light is green for me; every song written for me; everything that occurs is the perfect coincidence – all lined up especially for me, the most insightful, intelligent, powerful being on earth. Rainbows appear, stars shine brighter. The world speaks to me.

The euphoria is the most intense feeling I could ever imagine; it is unmistakably “bipolar” in nature, because no “normal” state could ever rival the deep, extraordinary, almost painful level of joy and excitement I feel. I have limitless energy springing from nowhere, and am a million times more productive and I’m at my most creative. I can clean the whole flat, complete study or work at lightning speed, paint a modern masterpiece and run a marathon all in one day (almost). I feel invincible, like I could tackle anything and win a thousand times over. I have an endless amount of confidence, and strike up conversations with complete strangers. It’s magical.

But then I start spending money. Lots of money. On anything and everything. Things or clothes or shoes or furniture for myself, and unnecessary random and incredibly generous gifts for others. I do things like buy three lots of identical £100 shoes in three different colours, just because I “need” them all, or buying £50 cushions here there and everywhere just because I like the feel of them. I get a thrill from it. It’s exhilarating and it fuels the fire of mania. I can’t stop. I am out of control. I spend more money than I have and create financial havoc. I lose friends and damage relationships through reckless, unreasonable and unthinking behaviour. My libido goes through the roof (hyper sexuality in mania is very common and often very destructive). I party and drink excessively and dangerously. And when I say excessively I mean to the point where I wake up in a strange bed in a strange house choking on my own vomit, or to where I’m falling in and out of consciousness lying on my mother’s kitchen floor with her screaming down the phone to 999 that I’m not breathing.

Despite what I said, the beginning of the end really starts at the very beginning. One of the first things I notice – even before the mania begins – is that sleep goes out of the window – I can stay awake for days, weeks at a time. I’m not exaggerating. I start talking very very fast, my thoughts are racing. I’m smooth, I’m eloquent, I’m clever, I’m witty and cool, or so I feel. But destruction is a hidden thread that weaves it’s way through the entire mania.

And then the mania reaches its peak. When I’m so high there’s no reasoning with me. I get delusions of grandeur. Sometimes I tip into psychosis, where I am out of touch with reality, for example believing that I am chosen to understand complex systems of government or mind control. Either way, when I start to come down, it’s impossibly disappointing. I develop a great sense of dysphoria. Then come the real blues. Crying for weeks. Unable to get out of bed. Total exhaustion sets in. All those sleepless nights catch up with me and my body feels like lead. This usually leads to a full on depressive episode, which can last for months.

But what causes mania? For me personally, major stress and lack of decent sleep play a big role. If I am experiencing a particularly stressful time, or a particularly stressful life event occurs, it’s likely I’ll head for mania. But nobody exactly knows what causes mania. We know it can be treated by drugs that work on certain neurotransmitters, so maybe faulty neurotransmitters are to blame. We also know that certain chemical imbalances in the brain, particularly dopamine and serotonin imbalances, can cause problems with mood too. Bipolar generally is thought to stem from a combination of childhood trauma, stressful life events, brain chemistry, and genetic inheritance. And that seems to fit for me.

So how is a mania treated? Well, if left untreated, a mania can last for several months. But I take the mood stabiliser Lithium every day to keep my mood level. If I am experiencing a mania the dose of that will probably be increased for a short period of time. Increasing the dose of any antipsychotic drugs I take is also helpful in normalising my thought processes and my beliefs or paranoia, and if applicable any voices I’m currently hearing. Usually I feel some resistance to these medication increases because I enjoy the feeling of mania too much, even once it has become destructive. However,
I am generally an advocate for medication when I’m not manic (and always with hindsight when I have been manic).

 

Avatar Therapy: Confronting the Face of Evil

tumblr_mxlwnypuDT1qdr8pro1_1280

In 2016 I was lucky enough to take part in the trials for a brand new type of therapy: Avatar Therapy.

It was invented by Professor Julian Left “to improve the lives of schizophrenic patients suffering from persecutory voice hallucinations despite the best available drug treatment.” (http://www.avatartherapy.co.uk)

150 people took part in the trial, and I was one of the lucky 75 who were given the treatment instead of simply receiving psychotherapy (a control group).

During the first session, your therapist will speak to you about your voices and other issues you have, and assess you. They’ll make a note of the things your voice says to you.

Then you get to grips with some specific software to create an avatar (face and head). The aim is to make the avatar look and sound as much like the impression you have of your persecutory voice; you can adjust the features, skin colour, eye colour, hair, even the sound of the voice to match the voice you hear. This was a terrifying process because as the avatar developed I was literally coming face to face with a man who I was very afraid of.

Once you’ve created your avatar, you can begin a conversation with it. You’re set up with a microphone, speakers and webcam so that when the therapist leaves the room they can sit at their computer and hear and see you. The therapist goes into another room leaving you alone to look at the avatar. The therapist will ask if you’re ready to proceed, then will  ‘speak through’ the avatar to you, so that it looks like the avatar’s lips are moving in sync. For me it was “You’re a terrible person. You’ve killed 150 people and if you don’t do what I say, I will tell everyone what you’ve done!” Several times during each session, before it becomes overwhelming, the therapist switches back to using their own voice, telling you how well you’re doing. Over several sessions, you can begin to confront and challenge what the avatar voice is saying to you. For me it was getting the courage to say things like “You’re wrong, I haven’t killed anyone, you don’t know what you’re talking about.” After the conversation with the avatar the therapist returns and you have a short therapy session to discuss the days progress. Each session lasted a couple of hours overall.

It was an incredibly gruelling and exhausting process. I would be in floods of tears after each session. Facing a voice that I considered to be evil each week was both the highlight of my week and the worst part of my week, because I was eager to make progress, but it was just desperately emotionally taxing.

It sounds simple but one of the breakthrough moments for me was when my incredible therapist said “You’re not a terrible person, you’ve just had terrible things done to you.” This was enlightening for me because I had previously been carrying stuff that wasn’t mine to own. For somebody to examine my psyche so closely and still say “You’re not a terrible person” was unbelievable to me. We also identified where and who the voice was coming from, which was especially helpful in being able to say good-bye to the voice.

I had an overwhelmingly positive experience and was one of the nine people whose voice totally disappeared after the therapy was over. Although I still suffer from other auditory hallucinations, that particular character – the most evil – seems to be gone forever.  I am incredibly grateful that I was able to take part in these trials, and the results are very promising, so I hope that with a bit of tweaking, this therapy can be rolled out nationally.

What’s in a label?

tumblr_n19h6gveA11rmqafyo1_500

I wasn’t even surprised when I heard the words come out of the professor’s mouth. “We think you have Schizoaffective Disorder.” I was calm, I was compliant. I listened to all his acronyms – ECT, DBT, SZD. I knew what they all meant, but they meant nothing to me. It was only later that I realised the gravity of this new ‘label’, and that I realised I hadn’t asked a single question. Why DBT? How severe is my disorder? What’s the prognosis? How likely is it that it’s something “organic” that the brain scans will pick up? I didn’t even ask questions about the heavy medication he wanted to start me on.

But what is Schizoaffective Disorder? The Professor told me that it’s ‘the gap between Bipolar and Schizophrenia’. It comes with the manias and the depressions of Bipolar, but also with psychosis, with the ‘positive’ symptoms of Schizophrenia.

For reference, the symptoms of Schizophrenia are organised into ‘positive’ and ‘negative’ symptoms. ‘Positive’ symptoms include delusions, disordered thoughts and speech, and tactile, auditory, visual, olfactory and gustatory hallucinations, typically regarded as manifestations of psychosis. I tend to experience auditory hallucinations, as well as delusions, typically paranoid.

Positive symptoms tend to respond well to medication, which is good news, and I have finally struck upon the one drug that does work to stop me hearing voices.

But the day after I was diagnosed with Schizoaffective Disorder, I went back to my regular psychiatrist and cried. Why? Because I still didn’t understand the disorder, and because of that, it felt like a terrible burden to carry.

However, I had also seen the nation’s expert psychiatrist on Schizophrenia and he believed the correct diagnosis was Bipolar Disorder, and my psychiatrist agreed with him and felt that he trumps all. So the Professor’s Schizoaffective diagnosis was obsolete, but, given my revulsion at being diagnosed as Schizoaffective, it made me ask myself a few uncomfortable questions about my feelings on various more severe mental illnesses.

The thing is, and there’s no getting away from it, people hear “Schizo” and run. In the media, the spotlight is on Bipolar Disorder as acceptable to a far greater extent. Celebrities have it, it’s ‘cool’, it has a certain cache to it. But nobody’s talking about Schizoaffective or Schizophrenia, unless they’re talking about criminals. We need to change this. 51 million people worldwide suffer from Schizophrenia. That’s 1.1% of the population. That’s your friend, your mother, your uncle, your niece…

When you’re given a diagnosis, like my diagnosis of Bipolar Disorder when I was 23, that is so entwined with your personality, you can’t help but come to identify as that disorder. It becomes part of your personal identity and you find yourself saying “I’m Bipolar” rather than “I have Bipolar Disorder”.

But whether it’s Schizoaffective or Bipolar, it’s still a big loss. It’s just that the label makes it an even greater loss, because attached to it is the heavy burden of ignorance from others.

So how do I come to terms with this? Do I need to “come to terms” with this? What is this? It’s a word, a string of letters next to one another. It’s not me. It’s just something that I live with, whatever it’s called.

Post-Traumatic Growth

e440f0_37df5830ec9349729d5882aadf6039e2

I grieve for the young adult I could have been, but what about the young adult I have become?

Everybody has at least heard about Post Traumatic Stress Disorder (PTSD). But in the mid 1990s, the Positive Psychology movement began to research something they termed Posttraumatic Growth (PTG), although research has only really taken off post millenium. It’s also referred to as “benefit finding” and “stress-related growth”. PTG refers to positive change occuring in ones life after facing an adversity or experiencing a trauma. Literature is relatively conclusive, and it is thought that around 30 – 70% of victims experience PTG. That’s a fairly wide margin, but at it’s lowest it’s not an unconsiderable amount, and at its highest it’s bloody fantastic. Nietzsche stated that “what doesn’t kill you makes you stronger” and perhaps he was on to something.

The three main areas that victims experience positive change are:

(1) feeling stronger and finding hidden abilities and strengths; this changes the persons self concept and gives them confidence to face new challenges, e.g. If I can survive this I can survive anything;

(2) good relationships are strengthened, which is reflected in how people often speak of “finding out who their true friends are” after they have experienced a trauma; and,

(3) priorities and philosophies concerning the present day and other people are altered, e.g. living for the moment and prioritising your loved ones or changing career for more meaningful work.

(Haidt, 2006 and Joseph & Linley, 2005).

Before the rise of Positive Psychology, literature had previously concentrated mainly on the negative effects of trauma: PTSD, depression, anxiety, heart disease… And also concentrated on “resilience” —  an individual returning to life as it was before. Now with PTG, the term “triumph” is used: the individual getting to an even better place than they were before the adversity or trauma.

Benefit finding after a trauma was previously considered to be more strongly related to less depression and more positive affect when the trauma occurred more than two years before. However, it has more recently been found that the overall time since trauma is not related to an increase in benefit finding.

The literature surrounding PTG is unclear about the interactions that occur between PTG and physical wellbeing outcomes. It is possible that PTG is actually a coping strategy used to manage distress and it is the extent of the success of that coping strategy that mediates the relationship between PTG and health outcomes. The literature and research evidence is mixed when it comes to explaining the link between PTG and wellbeing. Three main hypotheses have been put forward, which are (1) PTG leads to positive life changes and this improves wellbeing, (2) PTG does lead to life changes but this is stressful and so leads to lowered wellbeing, and (3) PTG is a coping strategy and its effectiveness as a coping strategy mediates the relationship between PTG and wellbeing. Research is inconclusive as to which hypothesis is accurate and so further work is required.

Either way, I can say that I am on the verge of, or have, fulfilled all three areas of positive change. Since my spinal surgery, I have always thought of physical pain I can easily deal with – in a sort of  “I coped with that so I can cope with this pain” kind of way. Since my more recent traumas I have definitely re-evaulated my friendships and crave more “real” friendships or relationships than I previously experienced… I do cherish my loved ones more. I also ditched law to chase something more fulfilling. I have become a lot more spiritual since my traumas and meditate daily.

 Just hearing about PTG has given me more hope that perhaps this PTSD will evolve into something more positive. So it even has the placebo effect going for it. Great research.

Treatment-Resistant Depression

e440f0_879a7c2cbb2d4cd39e28387ba54744dc

Citalopram, Sertraline, Mirtazapine, Venlafaxine, Nortriptyline, Amitriptyline, Lofepramine, Valdoxan, Duloxetine, Fluoxetine, Ecitalopram, Bupropion, Trazadone, Paroxetine, Mianserin…. The list of antidepressants I have tried without success goes on. But when is enough enough? When is it time to face facts and conclude that your depression is treatment resistant?

Seven years ago my psychiatrist did conclude that I have treatment-resistant depression. I felt suddenly claustrophobic. Like walls were closing in on me and there was nowhere to go; I was trapped with this illness forever.

To be diagnosed as treatment resistant, you only have to respond inadequately to TWO antidepressants (Wijeratne, Chanaka; Sachdev, Perminder (2008)). In reality, many patients try a far greater number of medications than this before being considered treatment-resistant.

Causes of treatment-resistant depression include early discontinuation of treatment, insufficient dosage of medication, patient noncompliance, misdiagnosis, and concurrent psychiatric disorders, particularly anxiety, which often goes hand in hand with depression. The symptoms of anxiety and depression can be relatively similar, and this can interfere with treatment. But what about when you’re doing your best but it’s just not working?

Trying different types of medication can often solve the problem. Lithium has proved successful and psychiatrists are increasingly using low doses of atypical antipsychotics alongside antidepressants. Olanzapine and Fluoxetine is an often used combination. For me, Lithium was the life-saver that dragged me out of my deep, deep year and a half long depression,  and now keeps my bipolar stable. It’s often considered to be a ‘dirty’ old drug because it requires regular monitoring by blood tests; but for me it comes with few side effects and totally curbs my suicidal thoughts when it is at a therapeutic dose.

Interestingly, Ketamine has been tested as a rapid-acting antidepressant for treatment-resistant depression in bipolar disorder. I have just started taking Modafinil, a narcolepsy treatment, and although its an uncommon line of treatment, so far so good!

Of course there are other treatments for treatment-resistant depression such as Electroconvulsive Therapy (ECT), Vagus nerve stimulation, rTMS, and of course, psychotherapy.

Treatments such as ECT and Vagus nerve stimulation should be undertaken as a ‘last resort’ because of the side effects and particularly the invasive nature of Vagus nerve stimulation. It is generally not advisable to give ECT to patients with Bipolar Disorder as it can cause ‘switching’ into a manic state. rTMS, which uses magnetic stimulation (more on that in another post)  is a relatively new treatment, and is considered to be a more accurate, less invasive version of ECT, with minimal side effects and promising success.

Whether or not your depression is treatment-resistant or not, there are always options and there is always hope. Suspend your disbelief.