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.

Housework - the forgotten symptom....

My house I've realised reveals a lot about my mental health. When I'm up and when I'm down.... it's like a barometer of my emotional life. I remember a cartoon from my childhood with a dog called 'What-a-mess'. I loved that dog: I think I am that dog!

Most of the time my public face is usually fairly presentable, which is why anyone who looked inside my mind or my home (at times) would probably be surprised to see the extent of my inner 'What-a-Mess'. Someone asked me today, 'do you think that you have a problem with people thinking that you're competent and confident?' Now, I know he doesn't mean, that people find me so overwhelmingly competent and confident that they can't relate to me. I think he meant that people have a hard time accepting that I could be suffering from complex mental health issues. Maybe if I were more like What-a-Mess, ie people able to see the extent of my 'disarray' then there would be less questioning of the fact of my struggles and perhaps more acceptance when I need 'space' from people and the world around me.

The thing is, when people have entered my home (which has happened on just four occasions in the past year) it is obvious that all is not well in the 'State of Denmark'. In fact, I am rather ashamed of my 'bolthole'. I realise that using all my energy to manage my 'public face' leaves me relatively little energy to take care of my most important environment.

I am realising more and more that this reflects the biggest struggle I have as I move forward towards full recovery - a lack of self validation. My home reflects the value I place on myself. All my energy seems to be directed at maintaining my competent image to the world outside. Would I be better served letting out my inner 'What-a-Mess' to the world outside, or is the answer about finding more balance in my life, between my public and private lives?

Balance is always preferable to living at extremes of different spectrums. I don't have to choose between being What-a-Mess and Aggie and Kim, I just have to be able to invest in my home so that it is somewhere that does not generate negative emotions like 'shame'. My aim is to improve the environment to which I retreat from the world to recharge my batteries. To do so means that I should be trying to have enough energy left in each week to allow me to take care of myself: cooking, personal hygiene, housework, relaxation etc. In practical terms, I need to see my physical environment as being part of the nurturing relationships that are helping my emotional life.

I need my home to be a retreat, a nest, a safe place, when my mind and emotions are very much 'What-a-Mess'!

Does being Competent at your Job Whilst being BPD confuse your Employers?

For many years I worked successfully in a highly responsible and challenging job. Then, in 2009 I was diagnosed with Borderline Personality Disorder. My caseload included a number of clients who were classed as MDOs (Mentally Disordered Offenders). In seeking to secure psychiatric interventions, rather than imprisonment for many of my BPD cases I was disheartened to receive the repeated response, 'this condition is not treatable' and in one particular case '....is so problematic to handle that they are barred from A&E admission in the local area'. The provisions of the Mental Health Act 2007 had failed to make it to the Foundation Trust in which I worked. So, when I received confirmation that I had BPD and that my local NHS Trust were willing to offer me support and treatment I knew I was lucky. I also had a decision to make about staying in work and what I would tell my employers.

I decided that I would be open and honest with my employers about the nature of my ‘issues’. Given that I had taken time off since 2007, as I struggled with what then was an unknown problem, I believed that this would be the most productive way forward. I had had experience of trying to mask periods of emotional instability from previous employers – helped, no doubt by the fogginess of medical professionals, who seemed to believe that my ability to hold down responsible jobs meant that I couldn’t possibly be suffering from a complex mental health condition.

As I have said elsewhere in this blog, I had always been open with my Line Manager throughout the period of uncertainty about my diagnosis to the final conclusion and have found that, on an individual level both my manager and my colleagues were willing to learn and try to understand my condition and how it affected my work.

However, the sickness absence procedures themselves were applied as a ‘one size fits all’ solution to long term sickness, regardless of the intrinsic differences between physical and mental illnesses.

I don’t think a Senior Manager would ask of a Cancer sufferer, ‘A year ago you told us the 'Chemo' would work, so why have you gone off again and are now telling us that you need Radiotherapy?’ Unfortunately, having remained at work for 8 months following a difficult period, when my initial treatment failed, I was signed off again in 2011 and I was asked by the senior manager why the first treatment I had tried had not worked and was asked ‘what guarantee do we have that the new treatment they are suggesting will work and that you will not be signed off again?’

Now correct me if I’m wrong, but even the most highly regarded medical training does not include crystal ball reading, I believe that’s only on offer at Hogwarts! However such questions betray an underlying suspicion, or even prejudice, about mental illness, and that is: it’s all in my head! If you don’t fit neatly into the procedures, which again and again, I was told were there to support me to remain in work, then employers seem to waver between wanting to help, and threatening me with capability procedures. In the end it became impossible for me to remain in work, even on a part-time basis and engage in the intensive DBT programme I was offered a place on. I took voluntary redundancy in 2012 - the first wave of redundancies which have marked the dismantling of the Probation Service as a public service agency serving the community. I will therefore not be able to return to any role which would make direct use of my skills and experience, but that's another day and another story.

So can such Sickness Absence procecures deal with the paradox of the worker with mental illness whose work is characterised as ‘excellent’?. In the present climate the pressure not to disclose mental health issues will grow, but how can we educate employers to view those with mental health problems in the same way that they view physical health problems? With the same level of compassion and support?

So...That was Then...This is Now...

I started writing this blog in 2010 - still reeling from finding out that my 'emotional issues' since childhood had a name and could be understood beyond my being 'oversensitive', 'overdramatic' and 'overstimulated' (amazing what comes out of angry confrontations!).

It has taken me three years to adjust to a diagnosis of BPD with a lovely side order of severe Clinical Depression. It took until the age of 42 and numerous periods of: instability, breakdown (of self and relationships), relocation and rebuilding to find that my life patterns had a cause and some hope of a remedy.

I am forever grateful to the CPN (still with me after all these years - possibly the longest adult relationship I've managed to maintain longer than three years) who saw through my 'apparent competence' and my 'high functionality' to see that I was screaming out for help. Patterns of Self Harm and risk of suicide associated with BPD distract some professionals from listening to the pain being expressed. I used to describe myself as being 'trapped inside my own head, screaming'!

For me no one knew that I self harmed (I was working with cases who tended to have the same patterns of self abuse and emotional stability as I was experiencing). My professionalism was a dam holding back the torrents of emotional distress tumbling around inside me. My biggest fear was losing my job, my raison d'etre, the only effective means of self validation I had at the time. So I knew that admitting that I had made detailed plans to end my life ironically, was the last thing I wanted to do. But in an assessment, begged for by my GP who fought so hard for people to look beyond the surface, for the first time someone asked me directly how far I had gone in planning to commit suicide - suddenly it was ok to let it all out and my life as I knew it came to a juddering halt...in time for people to recognise how much emotional distress I was experiencing. The mask was off and it was all there for anyone who cared to look to see.

Some of the most comforting words spoken to me around this time were - 'your response is understandable', 'it's ok to feel low' - I was allowed to struggle due to my previous experience of life. At that time suicide seemed like an answer to unbearable emotional pain, but to quote Tyrion Lannister from Game of Thrones 'Death is so very final'.

At the moment, I am attending a DBT graduate group - just like that! 14 months of DBT Skills Group and individual therapy have flown by and I recognise that I have come a long way since my juddering halt...so much learning has happened. One of the most freeing realisations has been that although I may be a product of my past, I don't have to remain as its prisoner! It is exceptionally freeing to recognise that the 'solutions' to my emotional pain, no longer have to be so final. Today, I am learning to accept each moment, with all its feelings, good or bad, while changing what can be changed in me.