Life after mirtazapine – and moving on

I will do the important part first so that nobody misses it. I have a new blog! It can be found here: [edit: I have now removed details of my current blog, but if you’d like the link, please leave a comment here or get in touch].

I’m not planning to post on Seeking Myself for much longer (although I will keep the site open), so please take a moment to update your bookmarks / RSS readers / WordPress follower or whatever you use to keep track of new content. I will continue to discuss mental health on the new blog, but it will also include my poems and more posts about Christianity, politics and other issues.

I’ve now been completely off all meds for just over a month, and am starting fertility treatment. 🙂 And my mental health is at least as good as it was before I began to reduce the mirtazapine. I’ve had some issues with anxiety and insomnia, but I’ve been able to manage these myself. It’s been quite a revelation, to be honest. I think my GP is still half expecting me to relapse, but it’s become clear to me that although I desperately needed the drugs when I was first prescribed them, at some point they had stopped keeping me well, and the side effects (sedation and increased appetite > weight gain > body image issues) were outweighing any benefits. I’m not in therapy either, and although I have seen a couple of awesome counsellors who really helped, I’ve also been treated by some complete duds and I think now it’s time to find my own path through my residual craziness.

The result of all this is that my view of my mental health difficulties has changed. I see them less as a medical illness requiring treatment (whether that be meds or psychotherapy), although it’s hard to put into words what I do see them as. I don’t think I could have recovered without medication when I was severely depressed, and the better therapy I’ve had has definitely changed my life. I also think it can be very useful to view depression as a medical condition in terms of understanding how disabling it can be and how, well, ill it can make people. I suppose I feel, though, that the medical model is too rigid and doesn’t take into account all the complex factors influencing my mental health.

The issues I’m working on now have to do with both the after-effects of childhood trauma and what I think is my inherent makeup, but while they might make me more prone to depression, none could be diagnosed as mental illnesses or treated with medication. And while you might think therapy is more appropriate for these kinds of issues, my experience has been that most of my therapists adhered to overly restrictive models too. It seems to be so rare to find someone who is actually willing to truly listen and help me find my own way forwards, rather than trying to squeeze me into a theory that doesn’t quite fit. I still haven’t ruled out the possibility of further therapy, but right now my faith and church community are doing at least a good a job as any counsellor I’ve seen.

Hence the new blog – somewhere I can take a more holistic view of mental health and write about the many other facets of my life. I hope you’ll follow me there.

Reducing the mirtazapine

It’s going well!

In March, I dropped from 60 to 45 mg with no ill effects whatsoever. In April, I went down to 30 mg, and that’s where things got a little hairy. First I had withdrawal symptoms, and stepping up to 37.5 mg temporarily made no difference, but just dragged out the whole process. Then I began to notice that my mood felt ‘wobblier’. I was getting upset more easily and having more intrusive thoughts, or perhaps it was just that the intrusive thoughts were ‘louder’ and harder to brush off. So it was with some trepidation (but my GP’s support) that I reduced the dose again to 15 mg last week.

The effect has been immediate. Despite some withdrawal symptoms in the first couple of days, from the start I’ve had more energy and drive. The concept of working full time and doing a little housework in the evening is no longer alien to me! It’s much easier to wake up in the mornings and I no longer need to mainline tea. Of course it makes sense that this has happened, as mirtazapine is a very sedating antidepressant, but this has been the first dose reduction where I’ve noticed a change in side effects, and these are adverse effects I’ve been living with for years. The last time I was on 15 mg was in 2006.

Even more excitingly, my mood has stabilised and the intrusive thoughts have stopped bothering me. This is harder to explain, as when I started taking mirtazapine, stabilising my mood and quietening down the ‘noise’ in my head were two of the ways in which it really helped. However, I think I’m more vulnerable to these symptoms when I’m tired, so it kind of makes sense that being on a less sedating dose has made a difference. 30 mg felt like an unpleasant no man’s land where the drug had stopped doing much for my mental health, but I was still getting all the side effects.

Of course, it remains to be seen what will happen when I come off mirtazapine altogether, currently scheduled for some time in June. Watch this space!

Protected: Sad

Alternatives to medication

I have been taking antidepressants more or less continuously for the past decade. During that period, I’ve had five episodes of moderate to severe depression, ranging from two months to three years in duration. But now I’m coming off medication completely in order to start fertility treatment. It’s a daunting prospect, and with my mood becoming a little more labile, my GP has suggested I think about non-medication strategies I can use to keep myself well and manage any mental health symptoms that occur.

What follows is a list of pretty much everything other than medication that has helped me in the past and that I think could be useful now. I haven’t limited myself to depression, firstly because mirtazapine has done more than just lift my mood (it’s also reduced my anxiety and helped me sleep), and secondly because I think everything has a knock-on effect when it comes to my mental health. It’s not unusual for prolonged stress and high anxiety levels to trigger an episode of depression, for example.

I hope this post will be useful to others who, for whatever reason, need or want to manage similar mental health problems without meds. It comes with some caveats, though: 1) What works for me may not work for you. 2) Always seek appropriate medical advice. And feel free to make suggestions or share what’s helped you in the comments. 🙂

Baths: A hot bath (preferably with Lush products) is great for calming me down and reducing the generalised aches I sometimes get when depressed or fatigued.

Books: This could be a whole post in its own right! My favourite fiction and cartoon books are real comfort reads when I’m feeling a bit rubbish, but some mental-health-related ones I think will be especially useful are ADD-Friendly Ways to Organize Your Life (concentration), When Things Fall Apart (mindfulness), Radical Acceptance (ditto) and the psalms in the Bible.

Blogging: When there are too many distressing thoughts swirling around in my head, blogging or journalling gets them out onto the screen and helps me make sense of them so I can figure out a way forwards.

Breaks: It’s important to take regular breaks when I’m working, especially if I’m finding it hard to focus.

Choral music: Listening to choral music is one of the best and fastest ways to calm me down. Singing is also very cathartic and making it to choir rehearsals is usually one of my top priorities!

Church: Going to church regularly helps me feel closer to God and makes it easier to separate what’s really important in life from what’s not. I need to make more of an effort to get to church on weeks when I’m not required to sing. Attending a different church from usual can also be helpful (great to get a different perspective on things).

Compassion: Beating myself up for not being perfect and pushing myself too hard are surefire routes to stress and depression. Being compassionate doesn’t mean that I can’t acknowledge when I’ve genuinely done something wrong and make amends.

Counselling / psychotherapy: In the near future I’ll be able to afford to see someone privately. I think this would be a good idea, though I don’t want to get into anything too deep and heavy while I’m adjusting to life without meds. Someone who could help me with more practical coping strategies and provide ongoing support would be good.

Fun relaxation: Activities that are both restful and enjoyable (like reading Harry Potter) seem to be much better for my energy levels than doing something fun and energetic followed by a boring rest.

Humour: My sense of humour has been my lifeline at times, and laughter helps whether I’m depressed or just struggling a little. This can include funny books and cartoons, comedy programmes, being silly with my partner and of course The Real Energizer Bunny.

Mindfulness: I try to practise mindfulness by regularly taking a moment to connect with what I’m really feeling and what my needs are in this moment. Mindfulness helps ground me – counterintuitively, really focusing on how anxious I feel actually makes me feel less anxious! It also has an important role to play in preventing depression. I have a tendency to stick rigidly to goals, rules and plans that made perfect sense when I created them, but might no longer be the best way forwards, and I think this is often a key factor in relapses of depression.

Never put things off: Nothing drains me more than putting off doing something that’s very important but scary or challenging. I need to get these things out of the way if I want to maintain good mental health.

Reaching out: Letting other people know what I’m feeling and how they can help me is something I really struggle with. This ties into my longer-term work on learning to trust people more – which I still plan to write about in depth, but which has somewhat taken a back seat as I figure out how to cope without meds. It’s something I will keep chipping away at, though, because having good support really does help.

Reducing responsibilities: When I’m depressed or really struggling with my mental health, I try to reduce my responsibilities to a level that feels manageable.

Relaxation CDs: I particularly like Experience Yoga Nidra.

Rest: It’s important that I get enough of this.

Pacing: When I’m depressed or fatigued, I try to start with a level of activity that feels comfortable to me (which often means doing very little!) Then I gradually start to stretch myself by adding activities, but always remaining mindful to how that makes me feel.

Prayer: For me this ties in closely with mindfulness. Asking God to calm my mind and help me focus on what’s important really helps.

Prioritising: I resisted this for years. I’ve finally come to accept it’s essential for avoiding stress, exhaustion and overwhelmed-ness! For work stuff, I use the ABCDE method.

Professional help: Although I’ve been asked to try coping without mirtazapine, it’s important that I stay in touch with my healthcare professionals and let them know how I’m doing. Medication in pregnancy is always a balancing act between the risks to the mother and baby from the drugs, and the risks from the mental health problems themselves. If I become too depressed, my GP or psychiatrist might recommend I start taking antidepressants again, or they might be able to offer other treatment. I’ve also bookmarked some local charities on Delicious.

RET for freak-outs: I find this exercise helpful when something has happened that’s really triggered me. It’s supposed to be for anger, but I find it helpful for any intense, overwhelming negative emotion. That said, sometimes when I’m very upset I don’t want to do anything constructive about it, because it feels somehow invalidating. The best thing to do when I feel like this is just get into bed and let myself grieve – I might be grieving something “trivial” but allowing myself to feel whatever I feel is important.

Step away from the smartphone: The second most draining thing I know, after putting off important tasks, is circling around Twitter, Facebook and my RSS reader mindlessly checking for updates. Of course, these two things often go hand in hand. 😉

Showers: I find taking a shower calms me down, helps me think more clearly and can “reset” me.

Small goals: When I’m depressed or otherwise struggling, I find it helpful to set a few small and achievable goals, breaking larger tasks into lots of baby steps. This helps give me a sense of achievement and by combining it with prioritising, I can stop an episode from derailing my life completely.

Small treats: Likewise, when I’m depressed lots of small treats are better than one big treat – because there’s less pressure and disappointment if I can’t enjoy something. I try to focus on what I really feel like doing in the moment, as long as it’s not totally self-destructive. Even if I’m not capable of enjoying anything, there are usually things I can draw some comfort or relief from.

Staying hydrated: This doesn’t apply to full-blown depression, but it’s amazing how often problems concentrating or focusing go away when I have a drink of water.

Sunshine (or light therapy): Getting out in the sunshine helps lift my mood whether I’m depressed or not. Unfortunately, it’s been pissing it down solidly for about a month, so I might have to reclaim my lightbox from the friend I lent it to and see whether that helps.

Supplements: I’m currently taking evening primrose oil (which stops me from aching) and omega-3 fatty acids (which are supposed to help with mood and concentration). I need to double-check whether these are safe in pregnancy. Update: I’ve just been advised that EPO is best avoided in pregnancy as it hasn’t been proven to be safe. However, most omega 3 supplements are fine (not cod liver oil; check with a pharmacist, or get one that’s specifically formulated for pregnancy).

Thought records: Irrational thoughts aren’t as big a feature of my depression as they used to be, and I’ve become a little wary of (NHS style) CBT-based self-help, because I got sick of being given a sticking plaster and told it would cure me. Nonetheless, when I am being tortured by thoughts I suspect aren’t accurate, listing the evidence for and against them does help me cope in the moment.

Walking: Walking helps ground me. It’s been part of my daily routine since January and I intend to keep it that way. (I’ve never found exercise effective as a treatment for depression, however.)

More will probably be added as I think of them…

Edited to add: Compassion (11/05/12).

Where I’m at

Things feel a little scary at the moment. I’m coming off my mirtazapine in preparation for getting pregnant, and I’ve left my therapy group. Intellectually I have no qualms about these decisions – after all, I can always go back on ‘safer’ antidepressants or find alternative therapy if I need to – and emotionally it feels good to be saying, “I am normal enough. I am well enough. I have my issues, but I have the strength to deal with them within me.” But emotionally there’s also the fear that comes with any venture into the unknown.

Meds-wise, things are easy enough to explain. My GP has agreed it would be better to start reducing the dose sooner and take longer coming off the drugs, than do it all in a month as my psychiatrist had suggested. So I’ve spent three weeks at 45 mg with no ill effects on my mental health, and I’m now enjoying some lovely withdrawal symptoms, having dropped to 30 mg two days ago. Dr Right has also emphasised that no one will expect me to go without antidepressants if it turns out I need them, but it would probably be a different drug. Unfortunately, the main ones used in pregnancy – sertraline and Prozac – are SSRIs, but we’ll cross that bridge if and when we come to it. She thinks SSRIs are more likely to work for me than they did ten years ago, because I’m in such a different place now, and I think that at least if they do Bad Things to my brain I will recognise the early warning signs and know what to do about it.

Therapy-wise… I’ve previously written a lot about what I learned from therapy, and why I don’t think Group Therapist’s approach was right for me, even if I haven’t been able to sum it all up neatly. I am very grateful for the things GT taught me. I definitely don’t agree with all his opinions and beliefs about my issues and about mental health in general, but even where he ‘got it wrong’, it’s been helpful to bump up against a different perspective and that’s been a chance for me to clarify and reconsider what I do believe.

At the same time I’m 100% certain that walking away was the right thing to do. It’s funny, but I don’t think the ‘official’ reason I gave for leaving the group – that therapy in a group setting didn’t work for me – had much to do with it in the end. Once I’d committed to my decision, a lot of that fear seemed to melt away and I was able to participate fully and connect with people in my last few weeks. I left with the sense that actually, this was a group of people with whom I could have worked on learning to trust – but that my problem was with Group Therapist and perhaps psychoanalysis in general. It’s a shame I didn’t feel able to articulate this in the group to him, but I need an approach where practical stuff can be incorporated and where the good as well as the bad in me is understood as important.

I’ve spent most of the past decade struggling to get mental health professionals to take me seriously, and having to fight to get any help. GT was the total opposite, which lured me in at first. But having someone ignore your achievements, dismiss the things that have helped you, and assume you must be feeling really depressed and worthless when actually you’re fine – my issues are cyclical – is no better. And that last sentence sounds very critical, but in fact one of the best things GT did for me was get me to recognise that and push me to a place where it’s no longer about communicating how much I’ve suffered, but refocusing on what I need to do to continue my recovery. I think I’ve finally come to terms with how badly the NHS let me down in the past and I feel ready to move on from this. Was that GT’s intention? If so, he played his cards very close to his chest.

What am I focusing on now? Two main things, really – one is depression relapse prevention, which ties in a lot of threads from other issues I’ve been writing about (perfectionism, mindfulness), and the other is learning to trust people and reach out to them more. I will write more about both of these things at a later date.

Looking back over group therapy part II: the unfinished symphony

I was in group therapy from June last year to this March. That’s nine months. Long enough to have a baby – which, I hope, will be my next nine-month project. 😀

When I joined the group, it was in quite a state of upheaval. Three members had left (one abruptly), two newbies had replaced them, and things had only just resumed after GT being on sick leave. I felt that because of this, it took a long time for the group to ‘gel’ and for me to see any benefit. So today I’ve been surprised to find this gem in my description of the very first session:

One thing that really struck me was the various comments made about the importance of looking at things from an emotional perspective as well as a rational one. That emotions aren’t and shouldn’t have to be rational. That it can be dangerous to have too rigid a view of yourself, of your issues or of what caused them. This all seemed to tie in with something I feel is very important at the moment – that any framework I hold for recovery needs to be flexible. Figuring what helps and what doesn’t, how my problems developed and how I can move on from them, is very important but it’s even more important that I stay mindful and pay attention to how I am now, to what is helping now. Fixed ideas about my illness and about recovery are very comforting because they help me feel in control but what happens when that framework doesn’t, in fact, quite fit? At best it chafes and at worst it shatters.

What a very timely reminder! I don’t agree with GT’s view that “rationalising” is an unhealthy defence mechanism, I think it has its place, but mindfulness and listening to my emotions whether or not they make sense is going to be very important in the way forwards.

In my write-up of week three, I discussed how issues I thought were buried and gone were in fact preventing me from participating:

I knew the group was unstructured, but I’d envisaged it as something established, pre-existing, alive that I could slot into. Instead, it feels like something we all have to forge from scratch. I hadn’t realised how much I was counting on this. I hadn’t realised how much I still feel the need, in new social situations, to observe for a while to make sure I don’t do or say anything ‘wrong’. By and large, this doesn’t cause me too many problems but it’s making the group feel impossible. I ended up zoned out for a lot of yesterday’s session and couldn’t believe it when GT said the 90 minutes were up already.

This is interesting on several counts. Firstly, it illustrates the way the group environment can magnify mental health or relationship issues – which is supposed to help you work on them, but was one of the reasons I decided to leave. Secondly, it highlights how difficult it was for me to engage with the group, and thirdly, for all I’m not sure I agree with the approach, I learned something useful about myself here. In many ways, the past year (including the assessment sessions) has been a process of me learning to what extent I still find it difficult to trust people and feel I need to protect myself from them, and that’s one of the main things I want to work on now.

Learning to trust is a theme I expanded on in my post about St Philip and Harry Potter. There’s too much good stuff in there to pick out any one quote, but if you haven’t read it already, I recommend the whole post. Read it. It’s got Harry Potter in. You won’t regret it. 😉

In August, I described how much better I’d become at coping with conflicting needs, which I attributed to the therapy and/or my recent mindfulness practice:

In the past, these kinds of conflicts have involved denial. For example, suppose I found myself needing to take on more work and earn more money, but also feeling really exhausted. In the past, I would pretend one of those needs didn’t exist. I would either push through my exhaustion, possibly making myself ill in the process, or I would bury my head in the sand about the money issues and overspend on top of not earning enough. Likewise, if there were multiple things I needed to do and I didn’t have time and energy for all of them, I would convince myself it was possible, I could do all of them, and ignore my need for time off and rest. This doesn’t lead to an episode of depression every time but it does set up a bit of a vicious circle where I yo-yo between neglecting one need and neglecting another.

Over the past week or so the conflict I’ve been facing is that I need/want to earn more money so I can better support my partner financially when she loses her job, but at the same time, the whole situation is actually making it harder for me to work. I’ve prayed about this and I can see that money is not the most important thing right now. My partner needs emotional support more than she needs cash in the bank, and I need to take care of myself so that I don’t make everything worse with another five weeks of sick leave.

Meanwhile, the last session before the summer break gave me an interesting perspective on my ‘inner critic’:

Group Therapist referred to the authority voice that’s within us all, the harsh, controlling voice that, in my case, tells me I’m not good enough and pushes me to achieve more and more. He said we think that voice is coming from a place of strength, but actually it’s weak. I immediately found myself thinking about bullies being cowards. When that voice is at its worst, when it makes me feel really bad about myself or pushes me to the point of illness, what is it if not a bully? And if it’s a bully, doesn’t that make it a coward? CBT taught me to ignore the voice and look at things more rationally, but now I feel as though I finally have some proper ammunition (“You’re just a coward!” is a pretty good comeback). And the idea that strength might have more to do with accepting myself, warts and all, than with the pursuit of perfection is also a helpful one. Trees can be felled and uprooted in a hurricane, but reeds only bend.

The idea that I ‘bully myself’ turned out to be one of those bees in GT’s bonnet that he repeated so often, I stopped paying attention to it. Indeed, for the past couple of months I’ve felt that GT was completely wrong, and that my inner critic’s intentions are good – it’s misguided, but something I developed to protect me from getting hurt as a result of doing something ‘wrong’. So it’s refreshing to look back and see a different perspective. Whether I like the bully metaphor or not, I have to agree that the voice is coming from a place of cowardice, of fear, and that strength has far more to do with being able to live with my flaws.

During the summer break, I realised that while I’d got so much better at coping with episodes of depression (there’s an earthquake metaphor there which I love), my experience of “not being depressed” hadn’t changed much in a decade:

It still feels like one endless, exhausting struggle to stay on top of things. I am ruled by to-do lists and never seem to have enough time for the things I’d really enjoy – and this is persisting despite all my best intentions and all my mindfulness practice during my last episode. There’s a part of me that doesn’t believe working too hard makes me ill, that thinks my depression is purely a brain chemistry issue and the relapses will always come, but even if this is the case, my perfectionism is still stopping me from having the life I really want.

That’s something I’ve been working on a lot over the past few months. 🙂

* * *

This post is an unfinished symphony because I’ve realised that trying to summarise a year’s worth of therapy, and everything I learned from it directly or indirectly, is not how I want to spend my blogging time. It’s a mammoth undertaking (much more so than I thought it would be!) and it’s draining me. I already know what I did and didn’t get out of therapy and where I want to go from here, even if I find that hard to articulate. I’ve decided to publish what I’ve written anyway, in case it’s of interest to me later or to others, but now I’m going to refocus my blog on moving forwards.

Looking back over group therapy part I: the assessment

Already it’s been almost a week since I left my therapy group. It’s sad to go, because I’d come to really care about that group of people, and to connect with one or two in particular. But at the same time I don’t regret my decision. I learned a lot during my time in the group, but it was keeping me stuck, and I have no doubts that saying goodbye was the right way to move forwards.

I want to write some sort of summary of my experiences in group, to look at what I’ve learned directly and indirectly and come up with a road map for the future. I’m not really sure of the best way to do that, so these posts are something of an experiment as I look back over my blog.

First, to set the scene, this is what I wrote about my individual assessment sessions with Group Therapist in February 2011:

The NHS psychotherapy service, [compared to my previous person-centred therapy with F], really is traditional. The guy who’s assessing me has a couch in his office (mercifully, he hasn’t asked me to lie down on it). He doesn’t say much, as apparently my silences and the things I say to fill them are important. When he does interject, though, it’s to say things that probably have a lot of truth in them but that make me squirm. He asks about my dreams and draws parallels between apparently unconnected areas of my life. I have gained some potentially helpful insights from sessions with him already, but those insights were stated by him and I thought, “OK, yeah, that’s true actually,” rather than me discovering them for myself as I did with F. I find things much harder to take in this way. Maybe there are things I’m not yet ready to learn about myself.

On the plus side, I think he has a really good understanding of my issues. It’s obvious he’s carefully read the reams of questionnaires I had to fill in and remembered what was in them (not exactly rocket science, but it’s surprising how many people fail to do this…) He seems to ‘get’ me and squirmy things I’ve pushed out of my mind notwithstanding, the things he says about my problems are perceptive and accurate. He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.

On the negative side, I feel he doesn’t really acknowledge how far I’ve come and the progress I’ve made in my recovery. I don’t think he disputes it; it’s more as though he feels it isn’t relevant. He makes references to my self-harm and my bulimia when those things are 6+ years in the past. He isn’t interested in whether or not I know my thoughts and feelings aren’t rational, and there’s an interesting spectrum here. The CBT I had was all about learning to challenge my thoughts and look at things rationally – a skill I find quite useful but sometimes invalidating. My approach since therapy with F has been to try to find a balance between validating the way I feel and not losing sight of rational fact. C, however, is at the other end of the spectrum where rationalising masks the true issues and should be avoided, at least in the therapy room. I feel that in a way, therapy with him is a bit like the CBT in that one model is rigorously adhered to and everything else is discarded, much like the similarities between the far left and the far right (oops – humour is a defence mechanism and also best avoided in the therapy room). He says I’ve been pulling myself together all my life and I suspect – though really must ask whether – he thinks a lot of the help I’ve had before has only changed things on the surface. He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.

It’s really interesting to read that back now. A couple of sessions into my assessment, I already had a handle on what would turn out to be the advantages and disadvantages of the whole experience. I loved how seriously GT took my issues, that he’d obviously read my questionnaires closely and remembered what was in them, and that he seemed to understand what I struggled with. He was the first NHS professional who, I felt, recognised the extent of my problems and was willing to help me for as long as it took. At the same time, he didn’t seem to acknowledge my strengths or show much interest in the things that had helped in the past. His ‘style’ of therapy was uncomfortable, and so very different from what had worked for me before – I was open to trying something new, but I still worried that perhaps he was adhering to a model just as rigidly and inflexibly as my CBT therapists had refused to budge from theirs. You’ll notice that the final disadvantage I gave was also one of my advantages: “He takes my issues far, far more seriously than any mental health professional I’ve ever seen before.” This turned out to be a real double-edged sword.

Probably one of the first things I learned from GT was that I have a cycle of pulling myself together and falling apart again, which he compared to bingeing and purging:

I’ve been thinking about what my therapist said about my lifetime of ‘pulling myself together’, and he’s right. As I look back over the years I can see a pattern of falling apart then picking myself up and putting the pieces back together again. Sometimes this is in very big ways (breakdown during finals, took years to rebuild my life), sometimes very small ways (oops, I took on too much last week, I’ll take it easy this week), and everything in between. I suppose the question is how much of this is normal. I’ve observed before that trying to find a balance in life isn’t something you can do once and stick with it; things constantly need reassessing and adjusting. That has to be normal, because a tightrope walker can’t just find his balance at the start then plough across the rope regardless. I guess what concerns me is how difficult and counter-instinctive it is for me to find balance and how much I’m still wobbling around all over the place. Does this mean I need more therapy, or is it just a question of practice? I feel I’ve been practising for years and not improving.

I love the feeling of getting back on track and starting to pick up the pieces (which is where I am with my debts right now), but then I get carried away and take on too many things, and the cycle repeats itself. Perhaps what worries me most is when I first realise it’s all too much, I force myself to keep going and it’s very difficult to acknowledge I can’t cope.

Knowledge of this cycle has been very useful to me. It’s allowed me to take a step back and look at the big picture of my struggles rather than constantly hone in on the details of coping in the moment. In particular, I’m much more aware of the “bingeing” and “must keep going” phases of the cycle and this has helped me to make more sensible choices. I’m very grateful to GT for this piece of information.

My comments on tightrope walking and how to maintain a balance, though, came entirely from me – and were very perceptive. Whereas GT seemed to view my cycle as purely pathological, I think some falling apart and picking up the pieces is going to be inevitable in life. What I’ve come to realise is how my difficulties in ‘set shifting‘ (thank you, Katie, for teaching me that term!) cause me to wobble more than most people. At some point, I’d like to find out more about the cognitive remediation therapy that Katie mentions.

In my next assessment session, GT stated that I use the cycle to avoid feeling. I’m still not sure to what extent this is the case, but I had to acknowledge that one emotion – shame – is problematic for me:

I could write pages about all the different ways I take care of myself when I’m depressed, but with shame there are really only two options: block it out or make changes in my life to make myself acceptable NOW.

There are some other conclusions in that post which I now think may have been erroneous, or at least overstated. I’ll look at those later, when I write about the period where I started to suspect the therapy group wasn’t right for me. For now, I’ll skip ahead to the goals I set for treatment:

I want to be able to let myself experience what I’m really feeling, and know that I can cope with it.

I want to break the cycle of taking on too much, falling apart and putting myself back together again.

I want to get close to people and let them support me without being frightened that my desperation and neediness will scare them away, or that they’ll take advantage of my vulnerability. (People can’t always be trusted, so I guess this also comes down to trusting that I will cope if someone does screw me over, and still being able to reach out to others afterwards.)

It wasn’t long after this that I decided on group therapy. I didn’t see GT again for some time, but I’d like to mention a post I made in the interim. In The one about coping skills, I recognised how being betrayed by people I thought I could trust had rekindled my difficulties in reaching out to people, and acknowledged the impact this was having on my ability to cope:

Yesterday, I said I had not forgotten my healthy ways of coping. I saw pain/stress/dodgy mental health as outweighing those coping skills not because I’d lost skills, but because my circumstances had changed – either life is just more stressful now, or my mental health is inherently worse. I suspect now that this may have been a little white lie.

In 2007 [I was] daring to develop my career after years when simply making it into any kind of job was an achievement. I was winding things up with my private therapist and felt pretty damn well recovered. But perhaps the biggest difference of all is that I had and used a support network. I was an active member of a depression forum, a fantastic group – I thought – of people. I was also working on talking to the people in my life about how I was feeling. The usual pattern was I would sound things out online first, then venture on to the scarier task of face-to-face conversations. I was aware of a need to lean on the internet less and develop my real-life relationships more, but I saw this very much as something within my grasp, as a continuation of a journey that had already been set in motion.

In early 2008, I was very badly betrayed by the owners of that forum. To be strictly accurate, the betrayal had occurred about nine months earlier but I was only just discovering the web of vicious lies they had spread about me while being warm and supportive to my face. On the surface of things, I coped with it very well. I recognised that this was about them and not me; I had not done anything to deserve it. In therapy I had come to realise that I wasn’t a bad person after all, I wasn’t fundamentally unlikeable and I hadn’t done anything to cause the bullying and abuse of my childhood, and when it was put to the test, this view of myself held up. I was also able, for the first time, to confront the bullies and feel proud about it.

It has taken some time to spot the damage that was done, the extent to which I have stopped trusting people and stopped reaching out. I planned to join some sort of more private forum, but there was never really anywhere that seemed right. There was always a tangible reason why a place wasn’t right and it has taken a long time to recognise that perhaps those were only surface reasons. It has taken even longer to realise that my plans to develop my relationships with real-life people, to be more open with friends and relatives and lean on them more, got shelved somewhere along the way.

This realisation has also been very important in helping me figure out what I want to work on and where to go from here.

A few weeks before joining the group, I met up with GT again and we discussed my current episode of depression, leading to some unexpected (but, I feel, accurate) conclusions on self-care and validation:

I suggested that actually, I take care of myself far better when I’m depressed than I do most of the time. I can make sense of depression and I know, through past experience, what helps when I’m feeling this way and what doesn’t. Although my self-critical thoughts increase, I recognise them as part of the illness and in a way I’m forced to stop, or at least slow down, and look after myself. My therapist commented that perhaps becoming depressed after a period of pushing myself too hard could be a healthy thing.

My suggestion then led us in two interesting directions. One was to do with validation. He observed that almost as soon as I realised I was depressed, I began to think about what could have caused it. He agreed with me that this can be useful in terms of understanding how to get out of the dark place and how not to end up there again, but I also agreed with him that my need for self-understanding runs deeper than this. If I can make sense of the way I feel, I can cope with it. It’s when I can’t find an explanation for a strong or negative feeling that I really struggle. I feel that I have no “good reason”, I “shouldn’t” be feeling that way, and then I start to question whether I really am feeling like that at all.

Finally, following my last individual session, I pondered what needs my perfectionism might be serving:

I have a very firm idea in my head of how I ‘should’ be. When I’m depressed and non-functioning it’s a million miles away, which is oddly easier, because when I’m well it’s tantalisingly close. If I just push myself a little bit harder, if I just stretch myself a little bit more, I’ll be there. I’ll be ‘good enough’. Well done! The problem is that deep down I know I’ll never be there because the goalposts move. It’s always ever so slightly out of reach.

Why do I operate this way? I think a large part of me believes this is what’s needed to motivate myself. That if I didn’t set myself so many goals, if I didn’t always push myself, if I didn’t hold myself up against an image of a Moon Tree who’s just slightly better than I am now, nothing in my life would ever improve. And then what? I’ve been trying to think about a different way, a way where I trust myself, where I am mindful and allow myself to be motivated by what I truly want. I’m not talking about hedonism here – there needs to be a way of taking future needs/wants into account as well as present ones, and of resolving any conflicts. I have an idea that this could work, and that maybe it’s how ‘healthy’ people operate, but I’m not sure of the specifics yet.

The first paragraph sprang from a discussion with GT, but the ideas in the second paragraph – about why I still operate in this way, and what the alternative might look like – are all my own. I don’t think I ever brought them up in group therapy, possibly because I sensed he would disapprove. But that’s a topic for another post, because I’ve reached the end of writing about our assessment sessions and it’s most definitely time for a break.

Catch-up

It’s been a few weeks since I’ve blogged, so here’s a short catch-up post. (It’s got bullet points and everything to stop it from turning into an essay…)

1. I am definitely saying goodbye to my therapy group, and my leaving date will be 28 March – just two sessions to go! In contrast to how he reacted when I first raised the issue, I’ve been pleased with Group Therapist’s response. Although he hopes I’ll change my mind and thinks staying in the group will help me, he’s been very respectful of my right to make my own decisions about what I need.

2. I started feeling a bit low a couple of weeks ago, following a very busy week at work. I decided to take this seriously rather than plough on regardless, and I took steps to reduce my workload. I am now 100% back to normal and enjoying a week’s annual leave – my first since September. When you’re self-employed and don’t get paid holidays it can be difficult to make yourself take time off without a ‘good reason’, but I’ve realised that simply needing a break is a good reason. Go me!

3. I’ve been reflecting a lot on ways I can reach out to other people more, which I feel is my main issue at the moment. My Christian faith is going to be very important here. More on that in its own blog post soon. 🙂

4. I’ve found a book with an excellent-looking chapter on core beliefs that I also intend to work through. However, I definitely haven’t ruled out the option of getting individual therapy if I need it.

5. OH and I have an appointment at our local fertility clinic on Maundy Thursday, and it’s looking likely we’ll be starting treatment in a few months, although I need to taper off my mirtazapine first. I’m going to discuss a back-up plan with my GP in case coming off the meds makes me depressed again, and if I get pregnant I will be referred to the perinatal mental health service. I’ve told my parents about our plans to start a family using donor sperm and they were fully supportive. Hurrah!

That’s all for now, folks…

A decision

I’m pretty sure I’ve made the decision to leave my therapy group. I’ve talked about it, written about it and reflected on it a lot over the past couple of weeks and it’s come to seem like a no-brainer. It just isn’t working for me, and I’m not at all happy about how Group Therapist has handled my concerns and desire to leave.

I’ve experienced therapy that has helped me before and I know what it’s like. A good therapist to me, or perhaps a therapist who’s a good match for me, is someone who helps me to feel at ease and to open up. Someone who doesn’t tell me how to make sense of my problems, but helps me to come to my own understanding. Someone who balances self-awareness with practical ways of changing. Someone who (dare I say it?) demonstrates normal social skills instead of that clichéd analytical silence which is supposed to help with transference but so often comes across as rude and uncaring.

I do understand how psychoanalytical therapy is supposed to work. I know it’s meant to be a difficult process, that it’s normal not to see any benefit for a long time, but that the theory is when change does come it will be all the more profound for it. I also know it’s likely that some of the things I feel about Group Therapist are transference and more a reflection of my own issues than his ability or otherwise, but I just don’t want to work in this way. It seems unnecessarily painful and risky to me.

My financial circumstances will soon be changing for the better 🙂 which means that, should I need therapy in future, I can go private and see someone of my own choosing. The option of group work also still remains open to me through A’s charity.

You’ll notice that I said “should I need therapy”. I’m not planning to jump straight back into something, because my mental health is really good at the moment and I want to allow the dust to settle. Given the recurrent nature of my depression and other issues, though, I doubt I am done with therapy for life. 😛

Baptism by fire

My therapy group on Wednesday was very, very difficult.

Not surprisingly, we returned to the topic of my difficulties engaging with the group, and the fact that I’m questioning whether group therapy is the right approach for me. We talked about gender a little first, and whether the fact that it’s a mixed-sex group is a problem, but then Group Therapist said something that really upset and angered me.

He said that me wanting to leave the group is basically just avoidance. I explained that I feel as though to get much out of the group, I’d need to have already overcome the issues I’m there for in the first place – and he said I should let the group help me overcome them, and that he thinks group therapy is the only thing that will help me with said issues.

Ouch.

The thing about letting the group help me is interesting. I hadn’t really thought of it like that, but I think he has a point there – although another member of the group did then immediately say that they didn’t know what to do to help, and that they felt quite powerless in the situation. Not the most encouraging response.

But the reason I’m so angry is that when I was assessed, I was offered a choice between group or individual psychotherapy, and I was told either would help me. When I found that a difficult decision to make, Group Therapist reassured me that it wasn’t irrevocable, and that if one approach didn’t work for me I could go back on the waiting list for the other. (I also feel as though he nudged me towards group therapy a bit by offering me a place in this group before I’d made my mind up, though I appreciated the information at the time.) Now that I feel group therapy isn’t working, I’m a little shocked that he would go back on his word, dismiss my reasons for wanting to leave as not valid, and imply individual psychotherapy wouldn’t actually help.

I’m also upset by his assertion that I’m just being avoidant. I understand that giving up on a particular type of therapy, when you’re finding it difficult and think another approach might work better, could be about avoidance but it could also be a healthy and appropriate treatment decision. It may even be a little bit of both. From my point of view, to understand all the different factors at play you have to tease them out and examine them closely (and isn’t that what therapy is supposed to be all about?) We haven’t really done much of this, and I appreciate I’m not making it easy by finding it so hard to open up in group, but that GT thinks he knows best anyway I find arrogant and unhelpful. Maybe he’s calling my bluff, trying to draw me out that way – but if so, I wish he’d f*** off.

It was early on in the 90 minutes that he said it, and the rest of the session involved a lot of silence. I’m normally OK with silence in the group. That is, I find long silences difficult to break, but they don’t make me particularly uncomfortable or uneasy. This time was different. The silence seemed oppressive, thick and heavy, suffocating. I was literally finding it difficult to breathe. Then GT suggested we all share how we were feeling in order to ‘move things on’. Nobody did. I couldn’t find the courage to speak up about how hurt and angry I was with GT, and whatever anyone else was thinking, they didn’t want to share it either.

One of the things that concerns me most about group is that I’m not usually like this – or not to this extent. Yes, I find it hard to open up to people, and I’m cowardly about confrontation, and that undoubtedly makes life difficult for me, but I’m not normally this dysfunctional in my relationships. The psychoanalytical group environment brings all my issues to the surface and magnifies everything. It’s meant to do this, I know that, so that we can really understand my issues and tackle them at a deep level – but not all therapy works this way, and I’m questioning whether it’s necessary.

I’ve written before about some of the things I’ve preferred about person-centred therapy, which has helped me in the past. But one aspect I didn’t really touch on is the environment. By being flexible to my needs, and though unconditional positive regard, my person-centred Ts created an environment that felt safe and nurturing, and where it was as easy as possible (not that it’s ever easy) for me to engage with them and to change. It was all about bringing out the best in me and often about getting as much as we could out of the time available. Psychoanalytical group therapy could not be more different.

I think one disadvantage of the person-centred approach, at least as I’ve experienced it, is that sometimes issues can get missed. Certainly the biggest problem I had with F was I sometimes felt her view of me was too positive – that she didn’t always ‘get’ how much I was still struggling during relapses. So it’s not that I think person-centred is good and psychoanalytical is bad. I think they can both be valid approaches to treatment, with their own strengths and weaknesses (and I think the same of well-conducted CBT too). What it comes down to is which is going to be best for me, and there’s no easy answer to that question.

I had a bit of an epiphany today, though. One thing I’ve learned through therapy with GT is how much the environment makes a difference – and to what extent I use changing my environment as a way of tackling problems. For example, when I was really struggling with B/Ping after dinner, I started spending my evenings in places where I wouldn’t binge – I would go for a walk or to the library or visit friends. When a bitchy or stressful work environment caused a relapse of depression, I changed jobs (I’ve done this twice). When I’m pulling from my eyebrows a lot, I cover them with a scarf or hat so I can’t access them. Leaving the group for (possibly person-centred) individual therapy would also be an example of this. I don’t think there’s necessarily anything wrong with this, and I don’t regret any of the decisions I’ve just described, but I do think I’m probably over-reliant on tweaking my environment and I’d like to be able to cope better in difficult situations rather than having to leave. Maybe that’s what GT meant about avoidance. Harumph. Two epiphanies for the price of one. Anyway, the original one was:

One of the things I don’t like about GT is I feel he sees the way I am in group, in a difficult environment that brings all my issues to the surface, as somehow ‘truer’ than how I am in situations where I’m able to cope just fine. I think he sees my functioning normally in the right setting, or when my mental health is good, as a front and not as the real me. I realised today that I cannot agree with this. For an environment to bring out the best in me, that ‘best’ has to be there in the first place. It’s all within me, the good and the bad. I need this to be understood and while it sounds ridiculous to suggest that a therapist wouldn’t understand that, I do feel the things I’ve achieved and the progress I’ve made with my mental health over the past ten years, before I started working with GT, get discounted. I could be wrong. This could well be transference. And the only way to know for sure is to discuss it with him… which brings me back to my original problem.

I think the person-centred counselling was about a series of increments. Baby steps, tackling the easier issues first, starting from an encouraging environment. The one danger with that approach is that as things get harder and scarier you may step off the ladder. By contrast, my psychoanalytical group is baptism by fire. If you can address your problems in that environment you’ll probably be sorted everywhere. The question is, can I take the heat?