Meeting the Challenge, Making a Difference (Oxford Health NHS Trust)

Excellent booklet outlining the challenges and effective approaches to involvement of PD sufferers in treatment, education and staff training. Produced with full involvement of Service Users. Just so refreshing and helpful. From Oxford Health NHS Trust:

http://www.oxfordhealth.nhs.uk/resources/2014/04/MeetingTheChallenge.pdf

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.

The Alien in the Therapy Group

We sat down in a circle, me and five members of staff. I had been left on my own in the 'group room' while the staff sat in a side office drinking coffee and, as far as I believed, discussing me. suddenly I burst into tears. I felt like a five year old, in the wrong clothes, doing something wrong, in the wrong building, on the wrong planet. It didn't help that I was new to Mental Health services.

I was still working four days a week while attending this group every Tuesday, all day. I wanted so much to understand my condition and to be able to manage it better than I had managed it for over 40 years.

When I arrived at the centre I made myself at home, making a cup of tea and arranging enough cups for everyone, very unselfish and 'functioning'. I entered the meeting room which was empty so, eager to please, I set out eight chairs in a circle. After a while of sitting on my own in the circle I plucked up the courage to knock on the closed office door where the five staff were talking - I assumed - about me. So I knocked, they opened the door, looked shocked, then closed the door, without telling me what was happening or when the 'group' would start.

Then they started, the stream of endless judgements and negative thoughts: why am I the only one? I knew it I've done something wrong and now they're punishing me, they don't get me, they think I'm wasting their time, they think I'm a waste of time, I am a waste of time, just look, they can't be bothered to come out and see if I'm ok, I knew I was a waste of space.

Then 30 mins late, they paraded out of the staff room and entered the room. 'Oooh, someone's put the chairs out, that's nice. Wonder who thought to do that?' Ignoring the Alien in the corner. It felt odd in a 'Miranda' kind of way: me, alone sitting in a circle of eight chairs and once all five staff members sat down, I was still sitting isolated, with no one either side of me. And then the stream of powerful thoughts gave way to an overwhelming deluge of painful emotions: anxiety, humiliation, embarrassment,anger, frustration, confusion. One after another they crashed on me, as my sense of alienation worsened. Suddenly, the waves of emotion were out of control and my sobbing broke through the matter of fact (patronising) repetition of the agenda for the morning.

Instead of stopping the farce they proceeded as if the whole group were present. I was clearly very distressed by now, but none of the professionals (or the Service User consultant for that matter) seemed to have the common sense to enquire as to the source of my distress. Being someone who had not had very much contact with Mental Health services, despite struggling with BPD for over 40 years, I didn't know if this was typical and to be expected. All I was aware of was that whatever this process was, it wasn't helping me: I had taken a reduction in hours and pay to attend, committed myself to it for the next two years and THIS was making me feel WORSE - not in any expected therapeutic or cathartic way, but in a way that felt like I was being traumatised.

Suddenly, it seemed a member of staff noticed ME - the large eyes and green skin must have betrayed my presence! 'Maybe the number of staff here are making Alma feel uncomfortable'. No Shit Sherlock! Still, no one thought to ask me what was upsetting me to such an extent - not that I was capable by that stage of articulating anything resembling an accurate picture of what was going on inside me. Eventually, I was left alone with two members of staff, who then proceeded to deal with a recalcitrant child. No mean feat as, by that stage, my willingness to open myself up to further pain and distress, had disappeared.

Perhaps, professionals reading this may recognise the brick wall of resistance in my response. Perhaps, it helps to suggest that professionals don't try to break through this wall, by the time I have constructed it you would be on a hiding to nothing. I would suggest to staff how about acknowledging there is a problem in the relationship and suggest a restart.

I am glad to say that this false start did not put me off persevering with other treatments, but certainly, it reinforced a number of my defences and made it harder for me to open up to staff in succeeding therapy. I am also pleased to say that my experience of DBT has been positive, with staff being consistent, human and willing to acknowledge when they don't have the answers.

Here are some thoughts and suggestions for staff when dealing with someone feeling like an Alien in the Group:

1) Even if a service user presents as really together and confident - please don't assume that is the full picture. If I have been assessed as suitable for treatment then there must be more than meets the eye.
2) If you misinterpret the situation or a person's mood, don't be afraid to apologise, start again and ask for the person's help to understand. Above all listen to the response.
3) Be aware of how your locking yourself away in an office appears to patients, particularly from an individual person left in a group room. Remember, you are often dealing with people who are super sensitive to rejection, ridicule and paranoia.
4) Ask yourself how you would feel if you found yourself in the situation that seems to be distressing to the person you are trying to help - your answer may give you an idea what questions to ask.
5) If you are trying to get someone to open up who has closed down - please give them time to answer, don't jump in with your assumptions as these may well be wrong.
6) Even if you have some idea what is wrong, don't put words in the other person's mouth - all of us have our own ways of explaining things and even if you are close to the truth your experience will not be the same as mine.

Above all, show the person that they are not aliens, but individuals with real needs that deserve to be met and that merit the best of your skills and professionalism.