Nanny McPhee and the Therapeutic Relationship

"When you need me, but don't want me, then I'll stay. When you want me, but don't need me, then, I'll have to go" Or words to that effect. It has only just struck me that this quote from Nanny McPhee sums up the crux of the therapeutic relationship. I am into the second month since full discharge and have been reflecting on the transition from needing the support of services through wanting it more than needing it, to finally realising I no longer need the levels of intervention I have previously required.

I recently had an interesting discussion with a friend of mine who is also a service user. He now works as an Expert by Experience and told me about a psychologist colleague who had been arguing with him about the nature of the therapeutic relationship. She believed that such relationships should not be considered as friendships. My friend and I both profoundly disagreed with her. Boundaries and professional distance are essential to ensure the efficacy and the emotional health of both the practitioner and service user, naturally, that's a given. However, there is an emotional bond, or at least there has to be in order for 'unconditional positive regard' to have any hope of developing. If there is not an emotional trust, based on some aspects of friendship, then the relationship may well work to an extent, but, certainly in working with Borderline Personality Disorder, at least, a level of warmth is essential in order to bring about progress. Otherwise how can I learn what a positive relationship established with effective boundaries, but also warmth and compassion, looks like?

I guess it depends what you consider 'friendship' to be. I recognise in my friends different needs and different gifts to me from each one. Some meet my basic social needs. Some are based on shared interests and enthusiasms. A handful are deeply rooted in genuine affection and deep emotional bonds. As someone with BPD much of the therapy I received was focused on my relationships with my therapists. DBT as a therapy model, recognises this and builds in these relationships and working through the ups and downs as they develop to its methods of working.

I find it interesting that when Nanny McPhee first arrives into the chaos and mayhem of the unkempt and undisciplined children, she appears hideously ugly to them. I'm not saying that all therapists are ugly! However, it is a truism when discussing therapy that 'things get worse before they get better'. Part of this process is the setting of boundaries, and the inevitable challenging of behaviours which are generating real distress and pain on the part of the service user. So, in a way there are times when I may find it hard to 'like' my therapist, and vice versa. Such is the stuff of developing relationships of any ilk. If the relationship is allowed to continue and works in addressing the key characteristics of my emotional issues, then my perception of my therapist is likely to become more positive. So with Nanny McPhee, her warts and whiskers disappear, as genuine affection replaces her challenging discipline and the children blossom under her care.

I don't think friendship as an element of the therapeutic relationship need be a threat to the professional. It is a natural part of genuine positive regard and compassionate practice.

Horses for Courses - One Therapy Cannot Fit All

This blog primarily shares my experiences of my practice of Dialectical Behaviour Therapy skills. After a lifetime of undiagnosed Borderline Personality Disorder symptoms, it was a huge relief to find a therapy that fitted with me and my needs. Having experienced as a Probation Officer the brick wall times of belief that BPD was 'untreatable', it seems that DBT has broken on Mental Health services as a sudden revelation, that 'something' can be done to offer a way forward for BPD sufferers. Great! A solution....except it's not that simple is it?

I know I bang on about how much I have benefited from DBT, but I am not so blinkered that I cannot conceived that this is not the whole or only therapy which can offer help for my condition. There is, nor can there be, one size fits all solutions for any Mental Illness - even if everyone engaged with Services had all of the same symptoms.

To advocate that DBT is the best and only way forward for everyone with a diagnosis of Borderline Personality Disorder, is to deny the complexities inherent in helping people to manage disorders and conditions which impact on every aspect of our beings. I was clear on discharge that completing the eighteenth months intensive therapy was only the first step in managing my BPD for the rest of my life. I have needed to address issues around my physical health following the impact of my emotional symptoms over the past 20 years.

Acquiring DBT skills also does not mean that I no longer suffer the symptoms of my condition. My discharge plan includes the continued prescribing of two medications to help me maintain my emotional stability. This is primarily to manage the accompanying Clinical Depression and Anxiety that I live with alongside the symptoms of BPD. I am only one person, I cannot hope to represent every person with the same or similar symptoms. Therefore, just because this combination of interventions is working for me at the moment, does not mean that it can be applied to all who may share my experiences of mental illness. Nor, does it mean that this combination will continue to maintain my stability forever. But for now, it is the right treatment path, for me.

A major problem faced by NHS Mental Health service providers is the pressure to 'justify' spending on intensive therapies. At this point numbers, rather than people, take priority and compete with what professionals know is best practice. Many NHS Trusts are hamstrung by funding issues which mean that they have to decide on one treatment pathway for individuals with the same diagnosis. Although research and practice indicates the complexities of helping human beings to manage complex conditions, funding issues seem to dictate basic, solutions. Or to put it simply, one size has to be made to fit all.

Reading other service users' experiences of what is on offer locally for BPD, I realise that in the UK there is a vast gulf between different parts of the country. In my area, I am lucky that there have been two evidence based therapy paths, both vastly different from one another, on offer via the local NHS Trust. Many other areas, are still grappling with managing people 'like me' without any specialised therapy on offer. I have gone through the trauma of 'failing' at one model, but thankfully there was another very different and more suitable model that has really helped me. How many people with various mental health conditions have that luxury?

Having said funding issues are the main reason for not considering a more integrated approach to Mental Health treatment, it is difficult to avoid the conclusion that such money saving approaches are short sighted. Certainly, if inpatient beds are perceived as being too expensive to continue to invest in, why is investment not then being made into developing a range of treatment options which can be adapted to individual needs? If you remove the 'place of safety' for people, where is there a safe place in the community if the one treatment on offer to some, is not effective.

I know I am looking at things rather simplistically, however, I am currently benefiting from the support of a physical fitness team run by the same Trust who run local Mental Health services. I get free gym and swim for three months along with an individual programme that is realistic and takes account of my emotional needs. I am in the process of dealing with my obesity in order to prevent long term illness and disease. A good investment? I think so, I feel so much better physically. In addition, taking care of my physical well being is one of the DBT skills for emotion regulation. Looking after my physical health is definitely supporting my ongoing practice of DBT and emotional stability.

We are all complex beings, unfortunately, the politics of funding seem to have swamped the instincts of best clinical practice and research. While the NHS is still in existence there is an opportunity for different teams to work together in co-operation with one another, rather than being made to compete for ever dwindling pots of money. If the focus can move away from numbers (referred to services, or successfully completing treatment compared with others) back to the whole person, there is maybe some hope that service users will be able to be treated more effectively.

Believe it or not, I actually recognise that just because DBT works for me in managing my BPD, does not mean that I expect it to work for everyone else with BPD. Although, I will keep sharing when I find something else that has worked for me in DBT...cos it excites me when I continue to be able to manage my emotions.

Whatever Happened to Gratitude?

'Yes, it's so rare to receive thanks from people, that a bunch of flowers, one time, made our team cry.' I was sitting with some friends, sheltering from the rain during a good old British BBQ. I had started the conversation because I had been taken aback by a comment from an NHS Manager, who was asking me to tell him about my recent experiences in Mental Health Services. I mentioned one or two issues that had happened during my five years in the local area, but overall I expressed my profound gratitude to my Care Co-ordinator, my DBT Therapist and my GP practice. His response was such shock, that he stopped me in the middle of my story to tell me that such positive stories of treatment are unusual. It was then it occurred to me, it wasn't the first time I had come across this shock at gratitude when talking to healthcare professionals. My friend at the BBQ is an OT working in Palliative Care, she confirmed that thank you cards, etc are exceptionally rare.

As we discussed whether or not we give thank you cards or small gifts to people helping us, we came to the conclusion that as a profession, Teachers do really well from thank you gifts, compared with other public service professions. I know this from my own time in teaching. Teenagers, in particular, are very good at saying 'Thanks' (at least to anyone outside their immediate family who they feel helps them) and I still have so many cards and thank notes from my students. The chocolates and flowers are long gone. I was a Secondary Teacher for only five years.

When I completed my DBT skills group I gave the team a large box of chocolates to share and a thank you card. I did the same for my one to one therapist and for my Care Co-ordinator. I have always given Christmas chocolates or biscuits to my GP and continued this with my Care Co-ordinator and Therapists. When I was finally discharged from Services in July I gave my Care Co-ordinator a small gift and some chocolates. After a relationship both of us had committed to for over four years, not saying 'thanks', to me would have been unthinkable. Yet, once again, she told me it was so rare to even get a thank you card from Service Users.

To me it is not just polite and good manners, although it is. It actually acknowledges that we were all committed to helping me manage my condition. I wouldn't have learned my skills, or managed the ups and downs of the last four years without these people. I give gifts to my friends. The relationships we have with those who care for us are equally as important, for the time we need services. That is why discharge is such a painful process. Especially if it is effective, both sides have invested emotionally as well as in terms of time and effort. I expect to be praised for the progress I make in managing my condition, why shouldn't my Care Co-ordinator expect to be praised and thanked for her part in that process? We absolutely know when things go wrong, we are willing to let anyone who will listen know about it. However, when things are going well with our treatment, I think sometimes it is easy to slip into the 'They're only doing what they're paid to do' view of good practice.

I think there is a wider principle that affects us in our therapeutic relationships. Gratitude generally has fallen out of favour in our society. In the US customers are better at complaining directly for bad service. In the UK, we think we are less forthright, but any time spent on any social media, or bus, will tell you that we are no slouches in the complaining department. Another of my friends told me she recently felt she should phone customer services at TESCO to tell them that she really felt their online service was a godsend. She spoke to a call centre worker, who did a double take, then thanked her for her comments. Later on that day, she received a phone call from the Supervisor who was checking she had made the call. Again, she was told that gratitude was so rare.

Don't get me wrong, I think pointing out when things are wrong in the service we receive, is important so that others don't suffer from poor service. We need to be able to know when things are going wrong in order to fix them. How often, though, do we feedback when we have received good or excellent service? It is all very well for services to speak to one another about 'best practice' but in operation, what does best practice look like?

When I read on social media the many stories of those who experience lack of people skills, lack of compassion and lack of professionalism in the care they have received, it makes me more grateful for the good experiences I have had.

I was brought up to show gratitude. We never went visiting, or for a meal without bringing something for our hosts. I witnessed my parents buy gifts for staff in hospitals that were thoughtful, hand creams, chocolates, things to be shared among teams. We gave Christmas bonuses (or boxes) to the milkman, paper boy etc. And we always gave soap or chocolates to our teachers.

I wonder if it is a practice that is dying out. I do know that when I was at the beginning of my battles with BPD and Depression I was not emotionally equipped to think about the people around me, I was too busy just struggling to get by. But today, I have made such progress that when I am able to look back and recognise how far I have come, I am also able to acknowledge the part that the healthcare professionals involved have played in my recovery. Why wouldn't I say 'Thank you'? My whole life has changed, with their help.

The NHS is under attack from all sides. When I look at the alternatives I realise that, whilst there are problems and services that are performing below par, overall I am grateful that I have been able to access five years of intensive treatment without a huge debt burden to worry about. The NHS means that I can access physical health services that enable me to manage my emotional health more effectively, again, without having to worry about finding the money to access this help. I want to be able to highlight the good practice and positive relationships I have experienced in my relationships with healthcare professionals. If you haven't done so in a while, look at your therapeutic relationships and try saying 'thanks' when things are going right. It may just reinforce best practice.

How does Your Mindfulness Smell?

Smells - I'm sensitive to them. I used to be plagued by regular severe migraines and strong smells, either pleasant or not, could trigger them for me. Since I've been practising mindfulness and managing my life stresses more effectively through DBT skills, I have found that I am only suffering migraines about two or three times a year. As a result I am re-acquainting myself with the power of smell. I am learning not to fear this neglected sense.

When I started practising mindfulness I would focus on sound, sight, touch and taste. It's easy to focus on really enjoying the touch, sight and taste of chocolate, for example. I can really savour the moment, taking my time to taste and enjoy the melting, soothing flavours. But how often do I stop once I have unwrapped it to really absorb its smell? I've been slower to first notice and then learn to practice smell as a mindful practise. Yet, along with listening to music, this is probably the most evocative and vivid of my senses. Who can resist the smell of cooking bacon? There is a reason why supermarkets pipe the smell of freshly baked breads. Even more unpleasant smells can bring us quickly into the present. The 'country' smell of manure definitely grounds me in terms of where I am, geographically.

As I have developed my awareness of the world around me and my own experience of the present moment, I have found myself building up a bank of smells which have different emotional impacts for me:

1. The smell of freshly ground coffee beans. This smell has become part of my daily morning rituals. I find I am beginning to be

able to detect different 'nuances' in different blends and roasts of coffee beans. I am drinking less alcohol than I used to, so freshly brewed coffee from freshly ground beans has become one of my regular luxuries. It is an important part of my self soothe routines. It also helps when I am finding myself facing overwhelming feelings of grief. I get a bag of fresh coffee beans from the freezer (best for keeping that freshness) and I stand and inhale the gorgeous aroma. This also benefits me because it is another way for me to practise mindful breathing whilst combining it with self soothe skills. I also love the smell of the fresh brew when I return to my house - it is definitely better than some of the rancid smells that used to greet me when I was too overwhelmed to care about myself or my environment. As I have recovered smells in the house are an important indicator of how much I am caring for myself and my home.

2. The smell of grass in the summer. For a long time this was a problematic smell for me as my Dad was a landscaper and the smell of freshly cut grass mixed with oil, became an ambiguous scent for me, evoking some unpleasant feelings. Now, though, it is part of the freshness of spring and summer. As I am learning to leave my fear of these seasons behind (I think these times of year seemed to be times when I was more vulnerable for reasons I have never explored) I am learning to really savour the smells of summer plants and water, like rivers through woods etc.

3. Citrus smells. There is nothing better for making me feel fresh and clean, than the smell of lemons, oranges and limes - preferably fresh ones. I can just cut a lemon in half and stick my nose right in and really inhale - way to go in getting me awake!

4. The smell of my dog and cat when I snuggle my face into their (dry) coats - it is safe physical affection and the warmth of the touch along with the smell just reeks of comfort. My dog is just the right size for me to lie beside and envelope her in my arms, whilst burying my face in her wonderful furry coat. I need to feel safe with touch and my pets are helping me to enjoy the safe touch and smell of another creature.

5. The smell of my favourite 'smellies'. I love perfumes, soaps and bubble baths. My favourite shower creams and gels are usually from aromatherapy ranges and I love standing in the shower enjoying the smells of my soaps and shower gels. I have always worn perfumes and love that blast of aroma through the day as I move about. It is a pleasant reminder of self soothing baths and showers, again a good way to practice self care.

Other smells I love: fresh cotton sheets, shirts; fish and chips; curries; any Mediterranean cooking smells; nutmeg; all spice; Vimto; melons; fresh paint (yes, paint); the sea;

Of course the sense of smell is most powerful when it is combined with the other senses. Touch and taste in particular enhance my experience of smells and help me to be mindful in my experience of smell.

So go on, get your olfactory juices flowing and really stick your nose into some things that are just passing you by at the moment. You might find yourself rediscovering some old 'friends' along the way.

Me, My Dog and Tigger

I have an inner Tigger. I know, another myth about depression and anxiety sufferers hits the wall! I believe this aspect of my character - the irrepressible, fun, bubbly part of me, has helped me to keep going when I really felt like giving up completely. I love Tigger's refrain 'The wonderful thing about Tiggers is Tiggers are wonderful things, their tops are made out of rubber, their bottoms are made out of spring!'. For me, the rubbery, springy part has been my ability to bounce back - both emotionally and physically.

The problem with Tiggers (T-I-doubleG-er)is that we bounce into rooms and situations without really 'reading' the people involved and sometimes there can be a backlash. I have a Tigger dog too. Recently, she was involved in a couple of incidents when she became aggressive towards other dogs - or so I thought. I continued to observe her interaction with other dogs both known and strangers. With her best friend, Farai, a black lab, there are few problems - except when Farai has something that Smilla wants. I will admit this could be my fault, she suffers from only child syndrome and she is spoilt. When it comes to stranger dogs though, she has always got on well with all sorts. She is not an aggressive dog, although I have often heard people remark about the 'Snow Wolf' approaching - she is more likely to lick you to death than anything. So, these incidents when she became angry at other dogs baffled me.

Then I came across an interesting article by an american writer on dog behaviour. It spoke about 'Impolite Dogs'. These are dogs who bounce into another dog, or group of dogs and immediately launch into (often boisterous) play. No butt sniffing or nose touching to introduce herself. With relief I recognised my Tigger like dog in this description. When an impolite dog bounces into a situation without reading the other dogs' signals she/he is likely to be met by defensive and aggressive reactions. This did explain her out of character reactions. Now I have to take control and help her to introduce herself to a new dog or group of dogs. I also check out with other owners if their dogs can cope with a Tigger-like playdate!

Once again, my dog has taught me about my own mistakes in social situations. Another parting piece of advice from my DBT Therapist was to learn to read rooms before I launch myself into social situations. I am still learning the skills of reading my own and others' emotional responses. I have been known to be able to change the temperature in a room. For either good or ill. Most times I have been oblivious to this 'power'. What I have noticed is that I may be perceived as an 'impolite human'. I don't stop to 'sniff butts' (so to speak) and take stock of where others are. Back to the awful moment at school, aged fourteen, when a friend and her whole family had been killed in a car accident at the weekend. It had been all over the local news. On Monday morning, I bounced into the normally buzzing lockers, looked around at my obviously distressed friends and said 'You all look as if someone has died!'. Ouch, I felt bad about that for ages. But it demonstrates my tendency to leap in where angels fear to tread.

Of course there is always a flipside to being Tigger. Tiggers can lift a mood, when they are up to it and when it is needed and appropriate. Again, though I still need to be aware of the mood and therefore the likely response of my 'audience'. Sometimes I have used this ability in running groups or in teaching to bring a group along with me and encourage some participation. On a personal level, I need to be self protective in when I choose to bounce in and enthuse. When I don't have the protection of a professional role to maintain, I am likely to expose myself to very negative responses, if I am not careful to become aware of the signals of others in a group. I realise this tendency of mine to launch myself into group situations without first assessing the emotional temperature, has resulted in very painful moments, when groups as a whole, or individuals have rejected the Tigger in me. When you are feeling down or shy, or uncertain, then a Tigger can be annoying at best and unbearable at worst. I need to be able to control my inner Tigger not only for my own sake, but for the sake of others.

The irony is that I am emotionally sensitive and so can recognise what is going on around me emotionally, but I need to give myself time to weigh up before bouncing in.

A plea then, to bear with me when my inner Tigger bounces into your presence. I will always feel bad if I have misread the situation, just tell me to come off the ceiling. I am good at receiving advice and will always consider it carefully - as well as being a Tigger I am also a bit of a Pooh (so to speak) for 'I am a bear of very little brain, and long words bother me.'

How on Earth do you 'Deal with the Past'?

This is a question that used to really vex me. For years, because of a lack of understanding about my underlying emotional sensitivity in many counsellors and practitioners dealing with me, I came across comments like 'you need to get over the past', 'you need to simply acknowledge what was done to you', 'you need to recognise the hurting child inside' - simples, huh? Except no one seemed to be able to recognise that there was something missing in my ability to even recognise my emotional responses to my abusive past.

One rape counsellor, who I think was compassionate and probably usually effective in her work, became frustrated with my lack of ability to acknowledge the trauma I experienced as a child. Firstly, I tended to either describe my remembered experiences without any outward evidence of any emotional attachment or response to the experiences being described. Secondly, because they were my experiences, I did not perceive them in the same way as my hearers, because it was me, I minimised the trauma.

It was around this time that my GP and a Graduate Mental Health worker who was offering me brief CBT for work stress, began to ask if I thought that there was more to my emotional issues than met the eye. So began my journey to discover what my diagnosis was and how that related to my childhood experiences.

I have referred before to the description by Marsha Linehan of people with a Borderline PD diagnosis as having 'emotional third degree burns'. I have always assumed this refers to the unbearable emotional distress experienced by those with BPD. I think to an extent this aspect of the picture is true, although it was when watching a documentary about a burns unit, that I learned more about 3rd degree physical burns, and thereby shed additional light on Linehan's statement. 1st or 2nd degree burns are extremely painful, however the damage done when someone suffers third degree burns is so extensive as to destroy all normal physical sensations, this means that there is a point at which the pain is so severe as to render the wound site numb to all sensation. When I applied this aspect of the original image to my own experience of the emotional impact of my past on my psyche, it made absolute sense.

I have previously described how I was not aware I was experiencing high levels of distress prior to the crisis which prompted me to seek help once and for all for my emotional 'issues'. I was incapable of feeling anything at all, either good or bad. There had been times when the pain of my life was excruciating, but I had passed through first and second degrees to the third degree, in order to survive. Many survivors of childhood abuse recognise this distancing from the experiences they have survived. Dissociating or depersonalising my own experiences helped me to survive the experience of abuse in the past. It causes problems in the here and now because I have been so successful in separating myself from my experiences, that I am unable to connect in any meaningful way with my experience of life as an adult. Either good or bad.

In a very real way for most of my life, emotionally and mentally, I remained trapped in a loop reel, whereby the most traumatic experiences of my life were on constant replay, regardless of how long ago they happened to me.

"In a sense Music, along with the sense of smell tends to be the most powerful of ‘time machines’, usually with a default to the past....Mindfulness training and DBT exercises were focused on bringing me to and keeping me in the moment. However, one of my true pleasures in life was in danger of inadvertently causing me to ‘time travel’ to the past. I didn’t want to lose out on one of my real pleasures in life, just because of my overwhelming emotional responses to it. Not every memory is painful and it’s important to acknowledge that, even before recovery, my life was actually made up of shadows AND light." (from Blog: Music My Own Special TARDIS )

With this never ending stream linking me to the past, even the most seemingly everyday problem or difficulty would connect to the torrent of emotional distress just below the surface, so that terms like 'overreaction', 'out of proportion' and 'drama queen' were applied to me. For those on an emotional 'even keel' it seems almost impossible to imagine the almost physical pain caused when I face disappointments, dilemmas, arguments and problems which are the stuff of everyday life. For the survivor of childhood abuse these experiences are reminders and directly connect to the emotional pain of the abuse perpetrated. Everything seems to rip the scabs from the wounds over and over, so that even the most benign of human relationships becomes a minefield of anticipated terrors to be avoided.

The wrong thing to tell me is 'to just get over it'. Recent exposure of the issues around victims of historical abuse has brought to light the reality that for survivors of abuse, you just don't or can't 'get over it'.

Having survived my abusive life, I continue to be in the process of leaving it behind. I always thought that once I had gained the skills I needed from DBT I would be in a position to finally, 'deal with the past'. I assumed this would mean some form of Trauma counselling. However, I have found that the very practise of mindfulness and the emphasis in DBT on Acceptance of life ('It is what it is'), in this moment seem to be enough for me to feel I have begun to leave my past behind.

This blog post reflects my own journey, it is not a blueprint for dealing with the impact of trauma - my symptoms of trauma are my own and my path through is my own. Hopefully, if you continue to deal with the stream of painful memories and feelings from the past, then this may offer you some hope that there is a way through.

1. I Finally Accepted That I didn't ask for or 'deserve' what happened to me. This means accepting that I am maybe worth better than happened to me - something that was an alien thought even six months ago.

Acceptance is an important group of skills in DBT treatment. The original version of DBT does not offer specific therapy for PTSD. (Recently, however, a specific DBT skills module for PTSD has been developed. I am not sure how widely this is currently available in the UK) The DBT skill of Radical Acceptance, allows me to accept what happened and to begin to leave my experience of trauma in the past. I have accepted that not only have I survived, but I have been strengthened by my survival. The abusers can only have power over me, if I allow myself to remain in the prison cell of the past. I carry the scars of the past and they may have shaped me, but I do not have to remain imprisoned by past experiences.

2. I have learned to trust my experience of the present as I have used mindfulness skills to focus on life as it is in this moment. I am no longer 'absent' - I've stopped 'time travelling' and am able to be 'present' - this means that I don't get bored as often as I used to. Also, it means I am able to give more effectively to those I am engaged with.

3. I have learned to name my feelings and to recognise when anxiety, fear, sadness, guilt etc from the past is distorting my perceptions of the present. I used to distrust pleasant feelings, like hope and happiness because they meant that the darker feelings and moments were more painful in contrast. Now I have learned to enjoy what I am able to enjoy for what it is. It has taken me a long time to say goodbye to the damaged child of yesterday and to reconnect with the adult I am today. That child remains a part of who I am, but her emotional paralysis no longer keeps me frozen in the past.

4. I have decided that the skills I have learned to manage my BPD are enough for me to accept the pain and grief about the past, without having to go back and relive it or do any sustained work on addressing what happened to me. Having denied and minimised it for so many years, the fact that I have been able to accept that I was a victim of abuse has been enough for me to be able to move forward.

It is important for me to emphasise that specific PTSD therapies are helpful for others as the symptoms of PTSD may continue become intrusive following other therapies for complex mental health conditions - each person knows their own needs better than anyone else.

'Dealing with the past' is not something that we can 'do' as a one-off-give me-the-silver-bullet solution. From the moment I first experienced the trauma I have been dealing with it. What I have learned is that at different points in my life I have developed strengths and skills that I have used to deal with the consequences of the past.

"When I finished my DBT therapy, my Therapist reminded me that I had begun the process of healing from the 3rd degree emotional burns, which are at the heart of the BPD experience of life. I have probably managed to develop a thin layer of emotional skin over deep, deep wounds..." (my blog 'Return to the Forbidding Planet:

I am pleased that I am no longer a hostage to a torrent of pain and distress streaming into my day to day life. Looking back I realise this is because of a process and time, along with the moment by moment determination to use my mindfulness skills to keep me focused on life in this moment. I have also permitted myself to enjoy the good things in life, gradually.

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.