My Life in Outpatient Treatment: Week 1

As I posted here, I was recently admitted into a psychiatric outpatient treatment center for my depression. I kept what could loosely be termed as a diary while in the program and I would like to share with you some of the daily ups and downs that I experienced. What follows are the day to day thoughts of one depressive person while in Intensive Outpatient Therapy.

The first few days were tough.

Week 1, Day 1:
I’m afraid that group therapy isn’t going to help. There’s such a large gap in ages. I’m worried that some of the programs won’t be helpful. I know quite a bit about depression, medication and treatment all ready, so I’m not sure what else there is to learn.
I also learned about Avoidant and Passive-Aggressive Personality Disorders. I have homework from my psychiatrist. I am to research these personality disorders as well as a couple of the medications that he intends to ‘inflict’ on me.

Day 2:
I still feel like I don’t fit in with the group. I can’t relate to what they’re talking about it. My therapist for the day says that I should talk about it in the next group session and that I need to have more awareness. I’m starting a chart to see when I fit in and when I don’t. Maybe keeping track will make me be more aware.
We also talked about change today. I’m not very big on change.

Day 3:
Today we learned a little about self-soothe kits. I’m going to have to make one. I also figured out that I have to take my medication AFTER I eat, unless I want to toss up everything in my stomach again.
My homework for the weekend is to write down examples of avoidant symptoms.

Day 4:
The weekend was not fun. Every time I took my medication, even taking it after I had eaten, I experienced nearly every side effect I could possibly experience. Nausea, drowsiness, weakness, dizziness, etc. We decided to switch the medication immediately.
I also learned that ‘what you resist, persists’ and I have to have awareness of my viewpoint. Mindfulness is being in the moment, and that’s something I’m going to need to work on. I’m not so good at it right now.

Day 5:
Today was fun. We had music therapy group. I played Someone Who Cares by Three Days Grace and I learned about a couple of other really good songs as well.
I learned that relationships can’t be 2 almost fully overlapping circles, or one circle inside another. A healthy relationship is like a venn diagram. I’m beginning to wonder about my relationships/friendships. Am I giving too much of myself to others?

Day 6:
I learned about NAMI and Art Therapy classes in the area today.
I also experienced a quick change of mood from happy to depressed about 15 minutes into therapy today. I don’t know what triggered this quick mood change. I feel like I’m withdrawing. I don’t want to be here today. I don’t know why. I just want to cry.

Day 7:
Today I learned about the Itty Bitty Shitty Committee, or as I’m going to call it from now on, the IBSC (which sounds a lot more official).
My therapist told me I need to focus on me. He told me to ask my best friend what he liked about me, so that I could have “I am” statements to repeat to myself. I’m also supposed to describe my personality and then have a close friend or family member do the same. That could be interesting.
After program today I began to wonder, how are these coping skills that I’m learning, going to help when it’s just me & the IBSC after I discharge from the program?

Day 8:
I feel like crap. I feel worthless, like I’m not worth people’s time and attention. I don’t like myself. I don’t even know how to like myself.
Today’s journaling became it’s own post and can be seen here.

Please stay tuned for parts 2, 3, 4, and 5.

Self-Soothing

One of the biggest coping skills taught in outpatient treatment is self-soothing. Self-soothing falls under DBT or the Dialectical Behavior Therapy. It is used when a person is feeling distressing, and when situations and emotions are overwhelming. Self-soothing is also known as a deterrent to self harm, because instead of doing something to hurt yourself, you’re doing something that gives you comfort and pleasure. These suggestions can help you feel better, calm down, and even feel relaxation or pleasure. Self-soothing most often uses the 5 senses; touch, taste, sight, smell and hearing. Try a variety of these items until you find a combination that works for you.

SIGHT: Be mindful of every sight, but do not linger on any. Allow the sights to calm you.

  • View pictures of family/friends.
  • View pictures of your favorite vacation spot or place you wish to go.
  • Look at art or go to a museum.
  • Go for a nature walk.
  • Walk through a pretty part of town.
  • Buy some flowers for your home.
  • Light a candle and watch the flame.
  • Watch an uplifting movie or video.
  • Be creative.
  • Painting, markers, crayons & a coloring book or sketch pad.
  • Mandalas (Coloring Castle, Free Mandalas, Printable Mandalas).

HEARING: When you are listening, be mindful, letting the sounds come and go. Be mindful of different sounds and let them flow through you.

  • Listen to relaxing music (via youtube, pandora, etc).
  • Listen to sounds of the ocean, forest, rain, or other sounds of nature.
  • Listen to a small animal.
  • Sit by a waterfall.
  • Play a musical instruments if possible.
  • Sing your favorite songs.
  • Do a guided meditation.

SMELL: Notice all the different smells around you and take in all the smells.

  • Smell a meal being cooked either at home or in a restaurant.
  • Walk in a garden or in the woods.
  • Breath the smells of nature.
  • Light a scented candle or incense.
  • Use essential oils.
  • Use hand lotion and/or drawer packets.
  • Use perfume or bath salts (Epsom salts).
  • Bake some bread, cake or cookies.

TASTE: Let the taste run over your tongue and slowly down your throat. Mindfully taste each new thing.

  • Cook a favorite meal.
  • Drink a soothing drink like hot chocolate or tea (especially blends for stress or anxiety).
  • Chew gum.
  • Eat hard candy or chocolate.
  • Go to a potluck and eat a little of each dish.

TOUCH: Take a bubble bath. Pet your dog or cat or cuddle a baby. Put on a silk shirt shirt or blouse, and feel its softness and smoothness. Sink into a really comfortable bed.  Float or swim in a pool, and feel the water caress your body.

  • Play with sand.
  • Use hand lotion.
  • Use a heating pad, back massage pad, or rice pack (hot or cold).
  • Play with modeling clay.
  • Dance.
  • Use a stress ball.
  • Play with silly putty.
  • Pet an animal or cuddle a baby.
  • Take a bubble bath.
  • Float or swim in a pool and feel the water caress your body.
  • Brush your hair.
  • Sink into a really comfortable bed.
  • Nap with a soft and furry blanket.
  • Use a weighted blanket (Bought Blanket; Sew-able Blanket; Tyable BlanketNo-Sew Blanket).

The entire point of self-soothing is to do something that is comforting to you and to continue doing it until you feel better.

DBT Self Help: Self Soothing

Mental Health Awareness Month

May is Mental Health Awareness month. So I am trying my best to make that awareness known. I am excited to be speaking to three church congregations about my journey and how they can help those with mental illness. I’m also extremely nervous to start public speaking but I’m hoping that these first three speeches will lead to bigger and better things. As Lao Tzu once said, “A journey of a thousand miles begins with a single step.” I guess speaking could be considered a second step, with this blog being the first.

Mental health is a serious matter, whether you suffer from an illness or not. It is always good to care for your mental state and your emotions. Being aware of your feelings and emotions makes you more in tune with yourself.

So in honor of mental health month, I’m going to ask you to wear a green ribbon whether it’s your mental health or in honor of a friend or family member. And when asked about it, explain why you wear that ribbon. There is no shame in mental health. Spread the word!!

May Mental Health Month Slideshow Final_0

To My Parents

To my Parents:

I write this after having blown up at you and accusing you of not caring about my mental health on Easter. I am sorry that this occurred on a holiday. Especially a holiday spent with the family, but I have to acknowledge that it is something that would have occurred sooner or later.

Often times, I feel like you don’t care about my mental health. And honestly, the fact that I haven’t heard from you since that day, after accusing you of not caring, only reinforces that opinion.  I’m struggling all by myself and it feels like you have no idea, nor do you care what I’m going through. You don’t realize that the smallest thing could trigger me, like it did on Easter.

Lately, I have been feeling like you’ve only been taking my mental health halfway seriously. It frustrates me because you can’t or you refuse to see what I’m struggling with daily. It bothers me when you make fun of me for doing my dishes for the first time in over a month, because I look at that as a positive. Yes, I should be doing my dishes daily, but right now that’s not a goal I can convincingly set for myself, so in all reality, I’m very proud of the fact that I did my dishes despite wanting to just lay in bed. Many days I have to be proud of the fact that I even managed to get out of bed.

I wish you would/could understand what I’m going through and where I’m coming from. Sometimes my brain is not my own. It is often taken over and controlled by my depression and all I can do is try my hardest to fight something that’s been deeply ingrained in myself for so long. I am trying to change. I am trying to use my coping skills and learn how to redirect my thoughts, but something that’s been so natural for me and so repetitively taught for years, will take years to undo.

When I call you, it’s often not because I want to talk to my ‘parent’. I’m 24 and live on my own, and while I often would like advice from your vast experiences, I will ask when I want advice. I may still be your daughter, but I also have my own life now. When I call you now, it’s because I want to talk to you. It’s because I need to talk to someone and because I have only one friend, I know I can turn to you for support and care.

Right now, I don’t need a parent. Right now, what I need and want is a friend. I will always be your ‘little’ girl, but I’m not so little anymore. I want you to look at me and be proud of what I’ve become and what I’ve done in my life so far. I know it’s not what we originally thought would happen, but as you believe, ‘all things happen for a reason’.

I need you to realize that I’m not the person I was, but I’m hoping to become a stronger person than I am. All I want is your support and it frustrates me that you say things in family sessions but then don’t follow through Some things will never change, and in some ways, I’m still that little girl who needs her parents, but in another I’m a grown up who has taken control of her own life. All I ask is for patience, understanding and support.

Despite the fact that you don’t understand and don’t know how to react to the person I am currently, I love you.

Prove It

Outpatient Treatment Center

To make the next few posts easier to understand, I want to describe to you the treatment center that I was admitted to, the various programs they have and the types of therapies we learned about.

At this center, there are three levels of treatment; Inpatient Hospital Treatment, Partial Hospitalization Program, and Intensive Outpatient Program. There is also a residential facility for patients with eating disorders. In all of these programs, the adults are separated from the adolescents.

With inpatient treatment, there are various units to which a patient could be assigned. This includes the Special Intensity Unit for patients who are experiencing more acute symptoms of their mental illness. While in inpatient care the doctors, therapists and nurses work together to address the patient’s disorder and work towards long-term recovery. After discharge from inpatient treatment, the patient continues care with the Partial Hospitalization Program or PHP.

Partial Hospitalization Program or PHP, is considered the highest level of outpatient treatment. PHP is a full day program that consists of group, individual, family and other various therapies. PHP is the follow up to inpatient treatment but can also be the starting point for another patient. Each patient is placed within different programs where it is deemed that they will receive the most amount of beneficial therapy.

Intensive Outpatient Program or IOP, is a half day program that helps patients transition to life outside of the program. It is often a follow-up to inpatient treatment and PHP. IOP offers group, individual and family therapy along with transitioning to daily routines. It is considered the lowest level of outpatient treatment for the program and transitions patients to life outside of treatment including setting up schedules and appointments with outside therapists and psychologists.

The center also includes an after care program which is a once a week group therapy session. This allows for continued group therapy alongside your individual outside therapist and doctors.

Each day started with our morning check-ins. With these, we described how we felt at the moment, any questions or concerns we had with medications or therapies and how our previous evenings had occurred. After check in, we had our one hour group therapy session which met daily. During these sessions anyone was free to talk about anything and everyone was allowed to talk, discuss and suggest ideas and solutions. After group therapy, we would either have expressive (art) therapy, music therapy, medication education, emotional regulation, or weekend planning depending on the day. The last hour before lunch, which was also the last hour for the IOP patients, was spent learning about different therapies, issues and ideas dealing with mental health or if you were fighting an addiction, learning about co-dependence on drugs and/or alcohol Many of these classes have given me ideas and information to use for posts.

After lunch the PHP program would continue with two more class periods. During the first class period, patients would learn about distress tolerance, cognitive behavioral therapy or CBT, expressive therapy and anger management. During the second class, patients learned about mindfulness skills, healthy alternatives, communication skills, expressive therapy, and interpersonal effectiveness. Expressive therapy is taught often because it allows patients to express how they feel in a safe environment. Please read Alternative Medications & Therapies for more information on expressive therapy. During the day, we are also pulled out by our doctors, therapists and APNs for meetings and check-ups.

At the end of the day, we would fill out our daily wrap up sheets, detailing how we felt and if we felt we could stay safe during the evening. After the program, our doctors, therapists and staff would meet to discuss our continuing treatment and eventual discharge.

The program I attended is an accredited program within the nation. But if you think you need more help than a weekly therapist appointment please check within your area for a program that can teach you to manage your mental illness.

Love

How can anyone love me? What is there to love? I can’t even like myself. How can someone like me, care for me, love me, when I can’t even love myself? What do they see in me that I can’t find? Do I even deserve love?

These are questions that I wrestle with daily. I had great examples of functioning relationships while growing up. My grandparents, family members, but especially my parents showed me what a working, functioning relationship should look like. I know that life isn’t about riding off into the sunset after the wedding and I know that happy endings are always happy every day, but no relationship is perfect and you have to be willing to work to maintain a relationship.

Is it because I’m too hard on myself?

This is another question I wrestle with. I know in my head that I am a pretty awesome person. I have great ideas and plans. I am a nice person and I’m always willing to help others, but knowing and believing are two very different things. I have a hard time believing in myself and I’ve had enough situations occur where I’ve felt unwanted that today it baffles me when someone shows an interest in me.

What do they see that so many others can’t?

I have the hardest time making friends, so it’s difficult for me to believe that someone could fall in love with me. My dad used to say that he would say “good luck” to any guy that asks for my hand in marriage. And while I understand why he would say that, because I know I can be a handful, it still hurts to hear him say it.

I want love. I want a husband, a family and a home. I want to be able to come home to someone who loves me for me and I want to feel life grow inside me. And I struggle with the question who would want me, because there are days, often many of them, when I don’t even want myself because I have this little voice in my head that tells me that I’m not good enough for anyone or anything.

Right now, I have to focus on myself. If I don’t, I’ll never have a healthy relationship with someone else. I have to be more comfortable with me and everything that entails. I have to be comfortable knowing that I’ll have my good days and my bad but that it doesn’t change who I am. I just have to remember that I am an awesome, caring, giving person who has so much to offer the world and the people who want to be in my life. And I would also like to share that with others.

I know this isn't true and I know that I will be everything one day to someone, but often I feel like I'm not enough for anyone.
I know this isn’t true and I know that I will be everything one day to someone, but often I feel like I’m not enough for anyone.

More Changes

As I related earlier, I was taking a step to see my doctor and find a new psychiatrist to get on medication to help my depression. I saw my primary care physician for a full physical and blood work to ensure that my depression was not related to thyroidism or a physical issue.

In some ways, I feel lucky because everything came back normal. I’m not suffering from a physical medical issue. At the same time, I feel like treatment would be easier if it had been a thyroid or blood sugar issue. Mental issues are harder to diagnose and medicate. While there are tests to diagnose mental disorders, they are genetic and extremely expensive.

After getting the all clear from my primary care physician, I made an appointment to see a psychiatrist on the recommendation of my therapist.

Less than a week before my first appointment with the new psychiatrist, my therapist decided that the process needed to be expedited. After getting my parents involved with the situation,  they accompanied me to a hospital with an inpatient and outpatient treatment center where I was evaluated for their mental health program for the second time.

This time, I am considered a candidate for the program. I am enrolled in a program (IOP – Intensive Outpatient Therapy) and I start tomorrow.

I’m nervous about it. At this point, I just want change. I want to be happy again. But I’m also afraid that this program won’t work. My depression is telling me that I’m never going to be happy again, that it’s just not possible for me to be happy and healthy. At the same time, I’m hopeful that this program will ‘fix’ me and help me learn to get better.

“Hey! How are you?”

One of the easiest phrases people use today is, “Hey! How are you?”. But when it comes to this question, they aren’t actually looking for a serious, honest answer. For them it’s a formality, a courtesy to get out of the way before either moving on with the conversation or walking away. For those of us with depression, ‘how are you?’, is a loaded question. Do we answer honestly? Or do we follow formality and courtesy and just say fine, all while hiding how we really feel?

Asking ‘how are you’ is the easiest question, but can actually mean so much to a person if you’re asking it honestly. Maybe you won’t like to hear the answer that they aren’t feeling well, or mentally they are struggling, but they’ll feel so much better being able to tell you the truth instead of hiding how they feel. But there are good and bad ways to ask someone if they are ok.

The first step is to ask the question, “Are you ok?” or “How are you?”. Be honest, and try to get the person to open up. Sometimes they need to talk, but don’t know what to say when confronted with the question, “how are you?”. Continue asking questions about them, and their life. You may have to work a little to earn their trust so that they will open up to you. This may be one of the hardest steps, especially if they don’t know how to respond, but it is also the most important one. It starts a conversation about the person’s mental well-being.

The second step is to listen without judgement. The first sign that the person feels like they are being judged, they will shut down and you have completely lost their trust. Don’t give advice, just listen. Just like you occasionally need to vent to someone about work, life, etc, so do they, especially because they have a disease that makes it difficult for them to be happy or see the good in their life. Also, don’t try to solve their problems. While that might be easier for you, it could be detrimental to their recovery. Depressed people have to face their problems if they’re going to get better. And let them know that you’re there for them whenever they need to talk.

The third step is to encourage action. Ask them what steps they’re taking to get better. Encourage them to see a doctor, psychiatrist, and/or therapist, if they are not already. Ask them if they need help with anything. Don’t let them become fully reliant on you for everything but help them when they’re stuck in a certain situation, environment or dilemma.

The final step is to follow up with them. Depressive people often have a hard time following through with actions that have been put in place. Try to make time for them, not so much that it interferes with your life, but enough so that they know you are thinking about them and hoping that they are taking the right steps to work through their depression.

These steps can be taken face to face, over the phone, over text or even over social media. When you are talking to them, make sure that they are the center of your attention for that moment. Take any threats of suicide seriously and get them to seek help immediately. Think carefully about what you post, or say about that person to others. It will often be seen as a breach of trust and at the very least make that person uncomfortable, especially if they haven’t gone public with their illness.

These steps are good for talking to anyone, not just a depressive or mentally ill person. So next time you say “Hey! How are you?” to someone, be genuinely interested in their answer. You never know how much of a difference that could make.

Facebook Page for R U Ok Day

R U Ok? Organization

DBT: The Skills

This post is written in conjunction with DBT: Dialectical Behavioral Therapy.

There are four sets of behavioral skills taught in DBT; Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Acceptance is emphasized through mindfulness and distress tolerance, while change is emphasized through interpersonal effectiveness and emotion regulation.

Mindfulness is one of the primary coping skills that is taught in my outpatient program. According to DBT, there are 3 primary ways to refer to our states of mind; emotion, reasonable, and wise mind. Emotion mind is when our thoughts are being controlled only by our emotions and therefore our reasoning and thought-process can appear illogical. Emotion minded people are also known for being ‘hot’. Reasonable mind is when our thoughts are logical and rational. In reasonable mind, our thoughts are fact based with no emotion involved and these people can be known for being ‘cold’. Wise mind is the combination of emotion and reasonable mind. Wise mind is part emotion, part reason and is often considered a sense of intuition.

The three ways to achieve wise mind are to observe ourselves, our environment and our situations, describe the things we observe and participate in the moment, in a way that makes us forget about everything else. We should also consider a non-judgemental stance not only towards others, but also towards ourselves because it can affect the way we view ourselves, our environments, our situations and other people.

Interpersonal effectiveness is the ability to increase the changes that you will reach the outcome you are looking for in a specific situation, while not hurting the relationship you have with others or losing self-respect. This includes using objectiveness, self-respect and relationship effectiveness. Objectiveness effectiveness in known as DEAR MAN, and will be covered more in depth in another post. Relationship effectiveness is known as GIVE. Give stands for be Gentle, act Interested, Validate and have an Easy manner. Self-respect effectiveness is known as FAST. Fast stands for be Fair, no Apologies, Stick to your values and be Truthful. The point of interpersonal effectiveness is to be able to effectively communicate your needs in a healthy manner.

Emotion Regulation is being able to identify what you are feeling in the current moment. It is also being able to recognize when you because angry, frustrated, depressed, distressed or anxious and focuses on the tools that can be used to deal with these intense emotions. Emotions come from our reactions to things and people in our environment and our reactions to the things going on inside ourselves. There are also primary and secondary emotions and while neither of these types of emotions are good or bad, to get to the original problem and work on solving it, it is necessary to deal with the primary emotions. To deal with emotions, we also need to reduce vulnerability, using PLEASE. Please stands for treating PhysicaL illness, balancing Eating, avoiding mood-Altering drugs, balancing Sleep, and getting Exercise. It is also necessary to build positive experiences, be mindful of current emotions, letting go of painful emotions, and practicing opposite to emotion.

The final behavioral skill is distress tolerance. This can also be known as Crisis Survival Strategies. There are 4 sets of skills for dealing with the distressing activities and events in our lives. These 4 skills are distracting, self-soothing, improving the moment and thinking of pros and cons. Distract uses the acronym ACCEPT to find different things to engage your mind and move on from the issue. These are distract by Activities, Contributing, Comparisons, Emotions (opposite to emotion), Pushing away, Thoughts and Sensations. By Improving the moment, you can use Imagery, Meaning, Prayer, Relaxation, One thing at a time, Vacation, and Encouragement (IMPROVE). Other distress tolerance coping skills include using pros & cons, accepting reality and radical acceptance.

Many of these coping skills will be discussed more in depth in a future post.

DBT Selp Help -A website written by people who have been treated with DBT

National Alliance on Mental Health – Fact Sheet

Mayo Clinic– Facts

The Linehan Institute: Behavioral Tech – DBT Overview

National Institute for Mental Health

Dialectical Behavioral Therapy Skills Handbook

DBT: Dialectical Behavioral Therapy

I previously posted a little about Dialectical Behavior Therapy or DBT in the post, Therapies for Depression. However, I would also like a chance to explain it more in depth as it is the foremost therapy that is being taught at my outpatient program.

DBT was developed by Marsha M. Lineham in response to research regarding the use of Cognitive Behavioral Therapy (CBT) towards people suffering from Borderline Personality Disorder, or traits of such. After realizing that CBT, a change based-strategy therapy, offered no validation, DBT was developed to bridge that gap. DBT still focuses on change, but that change was now based on the comfortability level of the client. In DBT, the therapist assures the patient that their behaviors and feelings are valid and understood but that negative or unhealthy behaviors needed to change for the benefit of the patient’s life.

This therapy is designed particularly for people vulnerable to emotions, which is why it is particularly effective for those people suffering from depression and anxiety. The term “dialectics” refers to resolving contradictions that exist between competing demands and wants. The assumption is that emotionally vulnerable people experience the major contradiction of needing acceptance or validation but also desiring change in their behaviors and lives.

There are four sets of behavioral skills taught in DBT; Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Acceptance is emphasized through mindfulness and distress tolerance, while change is emphasized through interpersonal effectiveness and emotion regulation.

Because I don’t want these posts to get too long, I have split this post into two. This first, will be followed by DBT: The Skills.

DBT Selp Help -A website written by people who have been treated with DBT

National Alliance on Mental Health – Fact Sheet

The Linehan Institute: Behavioral Tech – DBT Overview

Dialectical Behavioral Therapy Skills Handbook