Caught between Two Minds - the problem of 'Apparent Competence'

'Treating someone with borderline personality disorder can be one of the toughest challenges a [social worker] encounters. Life for such a client is like trying to drive a car that is constantly careening out of control. Emotional vulnerability, fear of abandonment, and a seemingly invalid environment push the car from one side of the road to the other. The tiniest stressors can force the car into a ditch.'

Quote from: Dialectical Behavior Therapy — Treating Borderline Personality Disorder
By Christina Olenchek
Social Work Today
Vol. 8 No. 6 P. 22

I have found myself grappling with some old familiar 'friends' (or rather enemies) this week. If I may borrow from the quote above, anyone observing the ‘car’ of my life would have seen significant progress. Success in life, even. I had achieved academically, I was a champion swimmer, I had managed to hold down highly responsible and well paid jobs, for significant periods of time. However, look closer at the ‘driver’ and any casual observer could see the panic as I struggled to keep my ‘car’ from careering from one side of the road to the other. My life had developed into a pattern of emotional collapse, which resulted in my resigning jobs, selling houses and usually prompted the dissolution of all relationships.

As I learned more about BPD and particularly the research and therapy of Marsha Linehan, who developed Dialectical Behaviour Therapy, I came across a phenomenon known as ‘apparent competence’. This relates to the ‘Swan Effect’ where on the surface I was not obviously struggling with life, but underneath I was frantically trying to keep myself going, paddling wildly against the waves of emotional distress which threatened to drag me under.

Paradoxically, whilst constructing a mask of competence and coping with excessive levels of stress and responsibility, I would vilify those closest to me along with medical professionals for not seeing my real needs. Effectively, I would blame everyone around me for not being mind readers. This is one of the greatest challenges to professionals trying to help those with BPD who display apparent competence. I will not openly tell you about my emotional distress, but I will hold you accountable for not seeing 'through' my mask of competence and I will make you 'suffer' as a consequence. My outward co-operation as a service user was tempered by a harsh assessment of those seeking to help me, particularly if I felt they couldn't see through my outward competence. If anyone failed to ask the 'right' question, or misread my mood on any given day, then progress for that day would be painful if not halted. Of course this is another example of my own self defeating behaviour prior to DBT. A practitioner is not responsible for the management of my BPD, I am. If I frustrate the learning of those skills which will help me manage my emotions, then I am going to end up frustrating myself. I managed to reflect on this when I was hard on DBT facilitators a couple of times and was helped by my one to one therapist to recognise when I was in danger of preventing myself from moving forward. It was a hard learning curve, but absolutely necessary for me to learn to manage my BPD.

The other issue is that there are times when I really can cope, when I do possess the skills to manage - to undermine that competence by putting me in an environment which patronises me is to undermine my sense of self validation. So, for me, my treatment plans have all stated clearly that inpatient treatment is detrimental to my progress, no matter how desperate I may be at times, admission to hospital at this stage of my life would be retrograde, except in the most risky of circumstances.

The problem comes for me when I do need help. I have had to learn how to ask for it effectively. This has been one of the most challenging DBT skill sets for me to learn. Interpersonal Effectiveness includes the ability to break down my mask of apparent competence so that I can be honest with those around me about the times when I know I am BEGINNING to struggle. If I wait until the point where it becomes painful for me to keep going, then I am likely to swing to the other end of the dialectic and expect the rest of the world to sort me out.

In the past week I have found myself swinging back to this see saw, despite having real encouragements in my voluntary work. When I consider the past six months with my 'wise mind' I can see that I have achieved a lot and it is real competence, not just apparent competence, because I have found myself enjoying the moments of success, without short circuiting them, or trying to negate them by self-defeating statements or actions.

However in the past couple of weeks in my role as Mental Health Volunteer, I have had meetings with other service users who are also going through recovery and discharge processes. I have found myself asking 'Why don't I get that level of support?' 'Does my experience not rate in being acceptable to professionals looking for 'lived experience?' 'Why do I have to forge my own path?' 'Can't they see that I need support and help too?' Maybe these thoughts are familiar to you. A friend who was discharged before me reminded me that, 'aren't we lucky that we don't need ongoing support workers? And isn't it great that it's been over two years since you were last near an A&E or phoned the crisis team?' And, in the cold light of day, of course it is. My life is good, I have managed to devise and write a Mental Health well being, course that has been running for nearly a year. It has helped people with a range of mental health problems, as well as some who are family or friends caring for them. I have a strong network of friends and support that has no links with Mental Health services. My therapy group, however supportive, was not and is not my main social group.

For many who are coming to the end of their contact with services, due to much of the stigma around mental health and, perhaps, the intensive nature of the treatment offered, the skills and time needed to build up support and social networks outside of services has not been possible. A number of people who came through services with me, felt really bereft when contemplating discharge, because of this. I am grateful that from day one of DBT I was prepared for the day the therapy would end, that the main goal of my treatment was to prepare me for a life without professional help.

That is what I need to remind myself of, when the 'apparent competence martyr' rears her head. If I need support and emotional validation I need to either find it in reminding myself of how far I've come, or seek the reassurance of those who I am accepting care for me and love me as I am. I love the fact that many of my friends are straight talkers, they have earned the right with me to challenge my faulty thinking in much the same way that my group facilitators and therapist did when learning DBT skills.

Instead of feeling invalidated because I am meeting other BPD sufferers who have support workers and are being offered ongoing treatment and counselling, I should really reflect on the fact that I have come a long way. I do have competence in the skills that are keeping me on an even keel. I would be frustrated by having to refer to someone else, or go through a team for approval of my plans. I am trusted to manage myself in my role, with some management support. It is validating to be trusted to develop my own ideas and resources. The skills I have built up over many years in a number of arenas are now helping me to move from unemployment to voluntary work and hopefully on to paid employment. Essentially, I was ready for discharge, I have not looked back since I finished the skills acquisition of DBT and I am actively building 'mastery'. It is still an ongoing battle with the voices from the past who tell me I am unworthy, but slowly I am able to validate myself and know that my competence has moved from 'apparent' to real.

My DBT Classical Music Playlist

Despite my love of music, I grew up in a house where listening to any kind of music was not routine. My parents did not have an extensive selection of music from the fifties and sixties. As regards classical music - there was absolutely no reference. They had never been exposed to the beauty of music and its ability to express emotions, so as children we relied on school for our classical music education.

At Primary School, I was enthralled by Prokofiev's Peter and the Wolf. It was a revelation to my creative mind that music, as well as words could tell stories and I loved the fact that I could follow the characters through their adventure as each instrument became identifiable.

At University I was finally exposed to the joys and intricacies of the classical canon. It helped that two of my closest friends were professional musicians, one had been trained at Wells, then the Royal Northern and continued to earn a living as a harpist both in orchestras and as a soloist. I often accompanied her to her concerts as a kind of 'roadie' helping her to unload her 'big harp' (technical term!). As I experienced live music, I was exposed to an emotional depth in music that popular music, which I equally love, can only dream about reaching. One of my musician friends tried to explain the technical reasons why particular phrases and cadences appealed to me. I really didn't care - what mattered to me in my late teens and early twenties was that there was a form of music which was capable to reflecting the waves and crashes of my internal life at the time.

I find it fascinating that during the period (some eight years) when I found myself feeling nothing but numbness, I could not tolerate listening to any classical music.

As I have moved through treatment into recovery, I have 'rediscovered' my love of classical music. I have used some pieces to help me manage waves of emotion through mindfulness exercises. Unlike pop music which may have one or two emotional notes in a three minute period, most classical music moves through nuances of tone, and uses dynamics, like waves to build to a crescendo before receding into quieter periods. One of my favourite pieces to use in mindfulness is by Rachmaninov and it lasts 17 minutes. That is a good period of time in which to manage many of my emotional waves. So here are some rediscovered gems which have helped me to use my DBT skills recently.

This is my current classical playlist:

1) Bach Unaccompanied Cello Suite No. 1 in G Major - Prelude. This is a good starter because it will be familiar from ads etc and features, as stated one solo instrument and therefore one simple melody to focus on. For some people listening to classical music can seem daunting perhaps because of the number of instruments and the different, sometimes competing melodies and counter melodies.

2) Rachmaninov Symphony No 2 in E Minor - Adagio. This is my current favourite for practising mindfulness 'in the moment' and 'emotion' and 'thought' diffusion exercises. It has a very strong, emotive central theme which recurs right at the end - in the meantime the rise and fall of the melody can be used to track my emotions, as they build up and fade away. I was getting annoyed with my parents on a long car journey recently and successfully used this piece of music to focus on my breathing and let go of my angry feelings. Incredibly soothing.

3) G F Handel - Arrival of the Queen of Sheba. Just really enjoyable and uplifting.

4) Vivaldi - Concerto for Violin and Strings - The Four Seasons - Winter. This is a piece of music which allows you to imagine winter creeping up. I defy you not to be able to imagine ice creeping up on winter as you listen. The final movement reproduces stamping feet, ice skating and the impact of the creeping ice on both man and nature - love it!

5) Faure Requiem - In Paradisum. Amazingly soothing calming.

6) G F Handel - Zadok the Priest. I recently was delayed on a plane flight and was 'participating' so much on this piece of music that I forgot I was standing in a line waiting to be 'herded' onto my EasyJet flight - until I opened my eyes and found several people staring at me. It was the epitome of mindful 'participation'.

This is a relatively short list, but if I don't set a limit I could keep going for a very, very long time.... I am absolutely certain many others reading this will have their own favourite classical pieces that are helpful in managing emotions.

Why Not Me?

Yesterday I was discharged from Mental Health Services after four years. Unlike many people I read about on here my discharge was well managed and took account of some moments a few months ago when it was not appropriate to end the relationship. So it was a positive ending of a relationship with my Care Co-ordinator. I was able to express my gratitude to her and she in turn reinforced the positives in my progress. My week began with a visit to a Breast Cancer Unit following a routine screening which revealed some suspect lumps. In one way I had to laugh - timing was perfect - one week bookended with physical and mental health issues - I'm nothing if not equal opportunities with regard to illness!

In the past the uncertainty caused would have resulted in a whirlwind of thoughts and emotions centred on my (imagined) ability to mind read, predict and anticipate the future. At some points I found myself 'reading into' the kindness and professionalism of the clinic staff as confirmation of the worst news possible. I certainly felt the shock of the speed of appointments offered - not to mention the fact that within the space of two hours the clinic had: confirmed the presence of five tiny lumps, the fact that they couldn't tell from the range of tests whether they were benign, and then to have them removed, a dressing applied and instructions given about care for the small wound and details of the appointment to receive the results of the biopsy taken. However, I found myself using my mindfulness skills to keep me focused on what I knew, which was exactly what I had been told by the consultant, and what my senses could tell me was happening around me.

In the past I would have collapsed under the weight of the uncertainty, whilst being swamped with the pain of every trauma I had lived through in my life - quite an emotional burden, I'm sure you'll agree. I would also have been plagued by the constant thoughts centred around 'Why Me?'. Such an event would have confirmed my life role as 'victim'.

This week, though, something had changed - the pain of the past is where it belongs - in the past. I really don't need to be carrying all of that as I deal with life as it is in the here and now. After all as the Bible says 'Today has enough trouble of its own.' (Jesus on the Sermon on the Mount). The other thing that has changed is that I have learned that I am not some toxic person who attracts trauma. Unfortunately, the term Borderline Personality Disorder does seem to confirm this thought, but just because that's the label they've chosen doesn't mean that it has to be a prediction of who I am or who I can become. I may have been a victim of circumstances, or other people in the past, but right now I am not a victim anymore. I am a human being who is experiencing the sort of difficulties that any other human can face. My thought has changed to 'Why not me?' In a week when children and whole families have been indiscriminately murdered in the Middle East and Ukraine, why not me, why should I escape the pain (both emotional and physical) of life in this world?

Pain and suffering is not something I have sought out. The trauma I have experienced throughout my life, has been survivable. The burden of guilt from the abuse perpetrated by others is where it belongs - with them. If they have any conscience about their actions, then it is only right that they bear the emotional burden of their own guilt - not me. Again, I continue the journey away from feeling guilty for the actions of others towards me. The pain and the emotional scars that were left have FELT as if they would kill me, but they didn't and they haven't. I have grown stronger through the life experiences I have gone through and today, along with all survivors, I am one strong 'Mama'.

My current health concerns have a physical pain associated with them - I have managed to cope with needles going into a sensitive part of my body. I know there are many who suffer unending physical pain, so why would I complain about something that has hurt only for a time? And yet I need to acknowledge that this is my pain, I have a right to feel it. My ability to cope with it is different from everyone else. I do not know what the limits of my coping are until I reach them.

With my mental health issues, though my biggest battle will always be with my emotional impulses and the circular thinking that has fed them in the past. I am learning through this experience that the DBT skills that have helped me to manage my emotional issues are helping me cope with the physical discomforts of my current experiences.

Keeping my "Life Train" on Track

I have recently been building new routines. Due to the turbulence of my life with BPD I have always sought out certainty and routine as a way of feeling more in control when my emotions are anything but. This may seem to contradict other aspects of my life which seem chaotic to the casual observer. My problem in the past has been that I have not been able to sustain life structures that help me live the life I want - or even to be the person that I wanted to be. This is symptomatic of the lack of emotional and personal stability that is the hallmark of BPD.

One of the benefits of having gone through lengthy periods of turbulence when I left behind previous jobs, relationships and areas is that I have had the opportunity to rebuild my life many times. I used to think I was good at it. But the lives I rebuilt before obviously were sustainable. Somehow this time is different. For the first time in my life I have stayed in one area of the country for over a decade. For the first time I have stayed put even when friendships and relationships have become difficult. This pattern continued until diagnosis and treatment, due to the fact that I had reached an age when mortgages and progress in my chosen profession made it difficult for me to uproot my life and move on. Effectively, my circumstances meant that I was forced to face my emotional instability and to take time to explore the reasons behind my turbulent, emotional and mental life.

So, I have found myself in unfamiliar territory. For once, I am not rebuilding my life from the foundations up. The basics of life, a home, relationships, the means of putting food on the table are already in place and have been allowed to mature over the past twelve years or so. There is another difference, in that I now know what I have been fighting against all my life. I have learned that some aspects of my condition and responses to the world will not change. My attitude to my condition and to myself have changed. I now have skills that are not self defeating to manage my emotions and my relationships.

As I've been thinking about what kind of life I want, I have found myself thinking in terms of trains. The engine is what provides the power to move the rest of the locomotive. The engine requires fuel and both engines and carriages require maintenance. No metaphor is perfect and there will be inevitable flaws in this one. However, I have found it helpful to think of my current track to recovery in these terms. Here is how I see my life train (once you've finished laughing at the poor artistry feel free to read on about how I think the parts of my life fit together):

1. The Engine - What I believe about myself and the world around me is essential to giving meaning and hope to my life. When my emotions drive me, my beliefs about life are vaguely in the background. Due to the twisted impression given to me about myself by an invalidating upbringing I am having to relearn self acceptance, care and compassion. In effect this builds on my beliefs about how I relate to others - the challenge is can I show the same compassion to myself as I can show to others? Do I really accept what my faith teaches me about my place in God's world? Can I absorb what I am taught about how much I am loved? In rebuilding my life it is essential before I put anything else in place that I develop and practice my beliefs about who I am and how my life fits into the world around me.

2. The Fuel Truck - My beliefs help to determine the nature of my spiritual practice. I need to maintain those beliefs and this means that I need to maintain myself spiritually. I need to pray, I need to maintain my relationship with my God, this helps me to relate to others and to my day to day life according to how I believe I fit with those. So my daily activities include: prayer, maintaining my understanding of my beliefs by being part of a Church family, meditation on positive beliefs about who I am in my God's eyes and how that impacts on how I live my life.

3. The Emotions - With BPD I need to keep my emotions regulated. This means a combination of skills, including making sure I get enough sleep, food and water. It also means that I show myself compassion when I am emotionally sensitive. Within friendships and relationships I need to maintain my DBT interpersonal skills - ensuring that I do not allow my over sensitivity at times to prevent me being wise in my reactions to things that happen. Above all, I need to be kind to myself and keep learning about what it means for me to live with the symptoms of BPD.

4. My Physical Well Being - I have begun looking after myself - this is one sign that self compassion and self care are beginning to become a habit for me. As I have lost weight and am enjoying being part of a gym and a group of others trying to feel better, physically, I have found that the other parts of my life are improving.

These are the basic components of my life. They need to be linked together and need to work as one for my life to be more effective. All of which means that in every day of my life there is a basic framework which means that I attend to the spiritual, emotional and physical needs and that my life consists of holding these parts of my life in balance.

How Time Heals - a meditation from Henri Nouwen

I read one of these meditations from Henri Nouwen every day. It is one week to go until my final discharge. So today's meditation I found very apt. Sometimes glib cliches have become glib over time and due to over use. Because my diagnosis only came in my forties I have had a long time without help to manage my condition, not always in the best ways for me. That means that I need to grasp hold of the truth that I need time to let the new skills I have developed through therapy to help me manage my BPD need time to bed in. When there has been a lot of pain and distress in the past, I also need to acknowledge that time passed does not mean those things suddenly cease to hurt. I found these words from Henri Nouwen say it so much better than me:

"How Time Heals

"Time heals," people often say. This is not true when it means that we will eventually forget the wounds inflicted on us and be able to live on as if nothing happened. That is not really healing; it is simply ignoring reality.... "Time heals" implies not passively waiting but actively working with our pain and trusting in the possibility of forgiveness and reconciliation."

I would add that due to the nature of so many past hurts there is only a 'possibility' of forgiveness and reconciliation. Sometimes we need to radically accept that those who have hurt us cannot accept our forgiveness, nor is it possible to reconcile the relationships, simply because usually those relationships were dysfunctional and destructive, and therefore can never, nor should they be, restored.