Tumbling

Last Sunday night, I fall. I fall into a mire of suicide ideation and self-loathing. I have just been to visit my mother. Things appeared normal. If family life was normal, then I am bad, bad, bad, for seeking, let alone being in, therapy. I am a terrible daughter. My mother recounts each time I see her, episodes of my childhood epitomising the fact that I was a difficult, horrid child to parent. Nothing like she imagined motherhood.

Alone that night, I self-harm. The first time in eight, nine weeks. It is release, and it helps me feel calmer. But I have broken my therapeutic community contract not to self-harm. So I have to review the reasons why with the community. And I do.

 

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And it might have felt justified to say that it was because I was left on eggshells one day because I was organising a seminar on the most triggering topic ever, and I kept dissociating. Or, that at an event at the Royal College of Psychiatry, I was constantly intellectualising, and found it quasi-impossible, surrounded by psychologists, to hold my position as a TC member. Or even, that my parents’ decree absolute came through, and I felt numb to it. Or that my housemate is away and my cat is remonstrating in no uncertain terms, her primary attachment to him, and I am feeling rejected and unwanted. But I didn’t self-harm in response to any of those things. These things happened after last Sunday. The self-harm did not feel justified. Post-calm, it feels rubbish as rubbish.

Again, I repeat my prayer, God, keep me from self-harm. My junior church made glitter jars this morning. Jars to help them find courage to face difficult situations, to breathe when feeling difficult emotions. One child asks if I have one. I have not -I didn’t have time for the Blue Peter moment this week. Yet I struggle, probably more than these children do. I need to make a glitter jar. I need faith that it is worth picking myself up, in spite of the stuff that’s happened this week, and that it is worth continuing with the TC, worth dealing with it. As I do, God, keep me from self-harm.

 

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Piled Under

Between TC and work, I feel I am living almost two separate lives, one where I am learning to be vulnerable and real; one where I maintain decorum, and meet deadlines, visit schools, and support ailing students. The veil between the lives is thin as paper; I pray that no one at work sees through, sees the struggle. I take on more work to compensate, just in case. In any case, work is helpful, distracting, I can work more when I’m in this state.

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But work is uncertain. Another round of recruitment has opened. TC is two days a week. I could do the job. But, if I apply, I could be rejected.  I still haven’t heard from my landlord about whether I can stay in the house; and my housemate’s solicitor doesn’t think I can get the address redacted from court, even though its publication would put me at risk (we back on to a primary school, FFS). And housemate will leave in May, but where I will live, with whom I will live, whether I will stay or move, is all unknown. I can’t face moving. And I will have a cat to care for. And no job. And the TC work is hard, and I think I’m doing it wrong anyway, and I’m scared that people don’t like me there.

I fold and sink in an overwhelming sense of stress. And I want to harm, and I want to harm, and I want to harm. How rubbish I must be to have gotten into this mess. I cocoon.

I cocoon to try to drown out the situation I am in, the voices telling me I am rubbish. But I want to harm. I go to stay with my mother for the weekend. And she loves the surprise of the visit, and she is upbeat and happy, and life seems normal, and I feel worse because of all the bad things I am saying about my past family life in TC. Maybe life was normal. I want to harm. Please God, help me to stick with my contract not to harm.

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Personality Disorder and ICD-11: A Patient’s Reflection

This post is something of a departure from my normal, experience-based posts. Here, I want to review the new diagnostic criteria for personality disorder, as proposed by Tyrer, Reed and Crawford (2015) . The categories trouble me, for several reasons, so here is to (attempt to) explain why.

For those who haven’t heard, the current plan for the International Classification of Diseases – 11 [ICD-11] (see current revision here) is to collapse descriptive labels, (e.g., Emotionally Unstable Personality Disorder, Avoidant Personality Disorder, Narcissistic Personality Disorder) into one diagnosis, personality disorder, where, after general personality disorder criteria are met (surrounding the usual suspects; e.g., empathy, intimacy, dissociation issues)  categorisation happens on a continuum, from ‘no disorder’ to ‘severe disorder’.

The first reason I am uneasy about this is its utility. Accepting that I am not the best judge, I cannot definitively put myself into any one of those categories. To have ‘mild disorder’, one has “some problems” in  functioning occupationally, with relationship difficulties, but no mention in the criteria of harm to self or others. At the other extreme, to have severe personality disorder, one’s ability or willingness to hold down a job is severely compromised,  one has profound social dysfunction, and self-harms to endanger life. And then there is me. Full-time work over two jobs. Plus voluntary work. Plus relationships, that I have to put huge emotional effort into maintaining. Plus self-harm that has put my life in danger (and arguably continues to do so). I feel pretty constantly, inches away from tearing myself to ribbons. A TC contract hangs me a thread’s-width from doing just that. My living arrangements are precarious. But that is my housemate’s responsibility, not mine.  No really; he’s in seriously big trouble with the law. My jobs are also due to end. But that is not unusual for someone at my stage in academia. In sum, I do not fit into any one of those categories, neatly or otherwise.

The other reasons I have for disliking the categorisation are more psychological and societal. I take issue with a diagnosis of mental distress that is defined in terms of occupational or relational functioning. I do so, not only because I go to great lengths, and utter exhaustion, to maintain functioning (and these categories invalidate that effort entirely — maybe I’m not ill after all…) but because of the problem of self-fulfilling prophecy and low-expectation — Oh, s/he has a personality disorder, s/he’ll not be able to hold down a job– that those who are younger than me, and who have not yet entered the job market, may face. Not to mention that this criterion for categorisation is blasted out of  the water by research showing that there are more folks with significant traits of antisocial PD in a corporate executive boardroom, than there are in prisons, proportionally-speaking (see Babiak, Neumann & Hare, 2006).

When it comes to relationships, I already believe I am all bad, and all to blame for what goes wrong in them. This criterion affirms this perspective. And let’s not forget that lecture I had in second year Psychology, taken from text in Davison et al.’s (2008) Abnormal Psychology textbook, stating that those with BPD are impossible to live with. Many folk have lived with me and survived to tell the tale. I found the conflicts tough. But I kept myself to myself: it was others’ conflicts, into which I did not want to be embroiled, that frightened me.

There should,  as noted by Pearce and Haigh (2017)  be a number of benefits to receiving a diagnosis of PD.  For example, it allows for a meaningful treatment plan, and gives an often relieving explanation of symptoms – as well, I would add – a sense of not being “the only one”. But, all of these benefits are overridden by stigma. Practitioners state reluctance to give this diagnosis, precisely because it is stigmatising. And because it could be that patients will “misuse” the diagnosis to negate responsibility for their actions. So, from the ground, the diagnosis remains hidden. As a case in point, note that my recent reflection mentioned my depression – but not my PD diagnosis.

I am not alone in worrying about this. The most excellent Dr. Jay Watts reviews the psychological research on the prejudice shown by mental health staff to those with PD versus other diagnoses, in particular the finding that PD patients are seen as acting up out of choice, and as more to blame for their problems than other patients. There is, it seems to me, a bitter paradox in receiving this diagnosis.  On the one hand, you know what you’re dealing with. On the other hand, the world knows what you’re dealing with. In the media, in films, characters with personality disorder are oftentimes portrayed as dangerous, even criminal. People who are disliked intensely (Donald Trump) are viewed from afar by psychiatrists as having possible personality disorder. PD is stigmatised. And this new severity continuum could well add to that stigma, pulling in multiple innocent parties along the way; those who have never acted aggressively, or selfishly in their lives.

Meanwhile, in academia, the debate rages concerning whether PD may even be considered as a mental illness; in today’s terms, as something for which a person is not to blame (any more than they would be for a broken leg or diabetes) thanks to the work of organizations like Mind and Time to Change. But the rubbish of deciding what counts as mental illness has fallen squarely on the shoulders of PD.( see Kendell, 2002).   Rather than being a mental illness, personality disorder is more often cited as a mental health problem. A disorder. And not a disorder of biological functioning (in spite of a plethora of brain imaging evidence pointing to deficits in that regard) but of personality. With varying degrees of success in their essays, my undergraduates define personality for what it is – the essence of who you are – the pattern of thoughts, actions, and feelings, that make you – you. The value judgement placed on our personality, on receiving a PD diagnosis is harrowing. It is confirmation of low (or absent) self-esteem – of a personality not worth having. What will the severity continuum do to the self-worth of those receiving the diagnosis? Nothing good, I suspect.

The ICD-11 severity continuum, now in beta-version, looks set to happen. Mindful of the fear and stigma surrounding personality disorder and its diagnosis even now, among the public, and those who really should know better, I am scared of what that stigma may become. By the time I end TC, I hope to have fewer symptoms of PD with less intensity than I do now. Since, to lose these labels, I have to be symptom-free for five years, I am struggling with the knowledge that the symptom goalposts will change, that I will carry the stigma-by-association of personality traits I never had in the first place. Whatever happens, I think it is time for Psychiatry  and Psychology to address with the same honesty and vigour that was seen towards mental illnesses, the stigma of personality disorder.

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Struggle

I’ve said it again. Again, I have noted that I am struggling. I hear my voice saying it, over and over in TC meetings. Struggling to understand protocol, struggling emotionally, struggling to stay in the room; ironically, struggling to speak.

There is no script for this, no defined role, or part to play. I must not be the academic, even though my mind is thinking more quickly than it does in classes or conferences. At the same time, I am fighting to maintain  focus on what others are saying, whilst reeling with all that I combed through at the case conference last week. I am drowning in a sea of self-loathing, and panic, because I am not sure I can do this. At the weekend, I slept, but now I can’t. I am exhausted.

I want to speak, but I can’t find the space to speak. I don’t want to speak out of turn. I am terrified of doing the wrong thing, getting on the wrong side of someone. Ruining things before they have even begun. I’m frightened I will be asked to leave.

But also scared of what I will say when I do speak. Right from before the start, from my parents meeting at church, in their teens and twenties, all that I know, and really don’t want to know, about that relationship. The endless fights between them over my (lack of) church attendance, and my own, adult, journey of faith that began with a desperate attempt aged 14 to arbitrate the rowing: There – you have one child who does, and one who doesn’t go to church, now. That’s before even considering the last few years. My feelings around church are messy and horrid – and unattractive. I feel bad, bad, bad that I will likely have to share that.

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I am struggling to see how this will work. How I will contain this much emotion and agitation,  between and around, and even in, T.C. I cannot contain it. I want to cry and cry and cry, but I can’t. I sit and rock. But I don’t cry. Bonum est confidere in Jesus Christ.  The Taize chant for our church services during Lent. I am reminded of two years ago, when I talked with a brother, at a loss to fathom how God views mental health.

God sees the struggle,  he said. God sees the struggle. God knows I am in TC and knows the work I will do, and those to whom it has been entrusted. I must trust them, too, in locus Christi; let them work with me. Brave making mistakes, in order to learn. Hold faith that God wants my healing. That it will be worth the struggle.

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Brittle

On Tuesday morning, I arrive promptly. Not arriving on time is not tolerated here; whatever state you are in, you have to be on time. I sit – calmly – zoned out. I have not slept last night, nor have I slept properly for weeks. I sit calmly, too, through the opening agenda items, almost forgetting what is to come, as I focus instead on what is being said.

But then I am invited to speak. And the  terror rushes back at me. And I start to  shake, and my right side goes into spasm again, and I can’t speak. I stutter. And then there is noise outside, so I am stopped and then invited to start again. My voice doesn’t sound like mine, barely audible, stammering through what is written in front of me. And quick – because I don’t want to take up more time than I am allowed to, and I think what I have written might be too long. I am not the academic anymore – and without that identity, I am barely there.

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Then comes questions. About  my working hours. I try to explain that my work are supportive, and that I don’t have “working hours” as such, but it feels like it isn’t enough, and I break down and cry in front of them. I am not sure whether I have said or done enough, because I have to then honestly say that I cannot withstand conflict, either. And that I don’t expect that being in the TC will be easy on me, that it will be painful. I hear “there is brittleness, there” – that I won’t cope easily with being challenged. I am brittle. I despair.

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But I am voted in. Unanimously. And there is still concern about my workload, but I am in. It feels like I have been relieved of a ten-tonne weight. For a few days after that, I still do not sleep well – waking two or three hours before my alarm,  falling asleep five hours before it. But since then, I have rested. I have swum, and had two nights of eight hours’ sleep. I feel ready to face the TC in the morning.

Ready – but apprehensive. I will have to return to the past, to the emotional unavailability of both my parents; to life at school, at home. On some days, I am very brittle indeed. And my old coping mechanisms aren’t a valid option anymore. I don’t know how I will cope with this. Whether I will cope.  After service this morning, after my reflection, someone I’d never met before – but a lay preacher – told me, ‘I can tell; God’s got His hand on you’.  If I am brittle, then God is resilient. If God is resilient, I can get better. If I trust the TC, in locus Christi, to help me heal. I place myself in God’s hands.

 

 

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Parallel lines

Eleven years ago, round about now, I found out that all my PGCE applications had been rejected. Until then, people were bored of hearing my anxiety around them. Those who had seen me work with children, seen my CV, could, they said, not imagine that my application would be unsuccessful. But it was. Already in the grips of depression at the time, I was left devastated, in a suicidal heap.

So – as people now offer assurance that I will get into TC, I am not comforted – but terrified. I’ve heard those words before. And it’s not a certainty. I have no idea whether staff will vote me in or out tomorrow. They’ve been silent – neither encouraging nor prohibiting my case conference.

I am terrified because nothing else has ‘worked’. Not counselling, nor CBT and its cousins, nor medication, which solely functions to stop me acting on the suicide ideation that incessantly interrupts my thoughts.

I am exhausted with fear of what is ahead. Reading week has meant zero visits to London last week, yet I haven’t slept properly. My emotions are running riot again. I want to tear myself to ribbons – to cut and cut and cut with the self-hatred coursing through me, but if I do cut, I won’t be accepted, de facto.

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A few months after not getting onto a PGCE course, I was offered a PhD studentship – without applying for it. And that has turned into the best. thing. ever. Most of all because I *teach* students – and different groups of children, too – and see the understanding in their eyes time and again and again.

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Me, giving a school assembly

 

But I can’t see a better option than getting into the TC. As far as I know there isn’t one. But that makes my TC application the same as the PGCE one. I couldn’t see a better option then, either.

No amount of worrying is going to change this. But it’s so hard not to worry over it. I wish I could let go, trust more. One more day to go.

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