ABC DBT

This past winter I decided to break up with my therapist, which was a terrible idea except it wasn’t. It was terrible because breaking up with your therapist is the WORST. It’s like breaking up with a really good friend, someone you have an established relationship with, who knows all of your deepest, darkest shit, and who has invested time and brain power in helping get said shit sorted out. And then you break up. I chose to break up based on the hope that I might find a friend I liked better and who liked me and who might be able to help with the sorting more effectively.

There’s no real good way to find a therapist, at least I haven’t found one yet. My insurance company directory is entirely unhelpful because most mental health care providers don’t take insurance. The system is prohibitively complicated and costly, in terms of time and resources, for sole practitioners, and even groups of therapists, to become certified as “in network.” So there’s Google and Yelp and Psychology Today and word-of-mouth and referrals. I found my very favorite therapist in the whole wide world through her ad on Psychology Today. But eventually she broke up with me because I was too crazy. I mean, she made a very thoughtful, professional, and kind decision to recommend I seek treatment from someone with expertise in bipolar disorder and even found me someone with such expertise, but samesies.

Still, she is my very favorite and if I couldn’t have her I wanted to know who she thought I should have. She gave me two names. One had a waitlist, the other is my new best therapist friend since January.

I like my new friend for many reasons but a huge plus has been the fact that she is a DBT therapist. DBT, or Dialectical Behavior Therapy, is a modified form of your standard, white bread Cognitive Behavioral Therapy developed in the 1980s to treat people with Borderline Personality Disorder (BPD). It has since been expanded to treat all sorts of disorders, including mood disorders like bipolar. It’s also super helpful with substance abuse and suicidal ideation, so I’ve got my bases covered.

DBT involves working with both acceptance and change through the principle of dialectics. Dialectics, in really basic non-philosophical terms, means two things that appear to be opposites, or at lease contradictory, that can both be accepted as true or reconciled in some fashion. My favorite starter example from DBT is: (1) I am doing the best I can, and (2) I can do better. These are both true. For me and, I’d wager, for most of us.

DBT is chock full of these seeming conundrums that are actually simply true. Two which are particularly apropos to me are the concepts of active passivity and apparent competence. Active passivity means I work really hard to get other people to make decisions for me. Apparent competence means I am really competent at certain parts of life and, therefore, appear to be competent at most parts, when in fact I am not competent at all. Fun!

DBT has four major components or “modules,” which are core mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. You had me at distress tolerance. 

Tolerate distress? Yes, please. Sign me up for how to do that because I have a zero tolerance policy when it comes to distress, particularly distress related to my marriage or my children. Also, my job and body image. Pretty much bad tolerance all around. Lucky for me, this was one of the first modules covered in my DBT skills group. 

To start, I was a bit dismayed to learn I couldn’t just distress tolerate my way through daily life, but was supposed to use my skills only for significant emotional crises. Apparently, living at crisis-level anxiety all the time requires making significant life changes. Go figure. Still, I have a lot of significant emotional crises and the skills I’ve learned have come in quite handy. Some also make great party tricks.

For instance, there is the TIP skill (DBT loves it some acronyms). The T in TIP stands for temperature. It’s based on something called the mammalian diving reflex and is a way to calm down quickly. So, if you’re having a panic attack, or want to impress your friends, grab a big bowl, fill it with ice and water, make sure your fitness tracker is working, hold your breath, and stick your face in. Stay down for at least 30 but as close to 60 seconds as you can get. Assuming you are a mammal, your heart rate will drop immediately and your parasympathetic nervous system will be activated, further prompting a relaxation response. It works. I’ve tried it. A number of times. Obviously, its not always possible or convenient to stick your face in a big bowl of ice water but when it is, do it. 

Another, less intense but perhaps even more useful distress tolerance skill is STOP. Now, this is probably going to sound really simple but in my experience it is not simple at all. It is not easy to do it or even remember to do it when things seem to be going to hell in a hand basket. But I try. 

For example, I have a tumor in my shoulder. A very small, very benign tumor that really, really hurts a lot of the time. I have not had surgery yet because my insurance company sucks (double bird salute Empire BCBS). In the mean time, I have been prescribed Valium, both for my anxiety and for the muscle spasms associated with the tumor. I was prescribed 3 pills a day but taking that much was really messing with my depression, among other things, so I decided to cut back to two. Except holy hell it really hurts.

So, this was my crisis. Pain. Physical pain and all of the emotional and psychological pain that I like to pile on top of it. A pain hamburger, with the works, plus fries. When it hits, and all I want to do is take that third pill, I try (not always successfully, but more often than not) to STOP. I stop, freeze, just stand there in the middle of the room half way to my prescription bottle. I take a step back, mentally and sometimes physically, from where I was going and from the overall situation. I observe, what I’m feeling, thinking, doing, what’s going on in my environment and with the people around me. I also think about my options (I know, cheating with the two o’s). What might I do do instead of taking medication that could possibly help me feel better/less overwhelmed/more able to get through the rest of my day? Finally, I proceed mindfully. I take all the inputs, thoughts, feelings and I choose a path that seems right.

My favorite/least favorite distress tolerance skill is radical acceptance. Again, radical acceptance is deceptively simple. Basically, you accept life as it is. But by that I mean you really accept it, mind, body, and heart, not only as it is but also as it is not. You accept reality is not and cannot be something else. There are no shoulds with radical acceptance. There are no whys or if onlys or buts or what ifs. What has happened is not reality. What might happen is not reality. Reality is the present moment, the present minute, and it is what it is. Period.

You must accept reality because (1) you have no choice and (2) it is the only way forward. You can only effectively live your life grounded in what is real and true and present. Flailing around because what is real and true and present isn’t fair or right or something you can handle because-you-just-can’t-with-it-right-now-so-please-make-it stop won’t work. It is just flailing. Even if reality isn’t fair or right or something you can handle, it is still true. And the only hope you have of changing it is to start from that truth. Otherwise, you’re just titling at windwills.

I struggle with radical acceptance. A lot. I like to tantrum about life, the big parts and the small. For six years, I have been having a low-grade panic attack because I have failed to accept that my house cannot be as clean as it was before I had children. I am currently failing to accept that returning to my job is is negatively affecting my mental health and my relationships. Instead, I show up each day conviced that its me, not them, and if I can just be better it will work out.

Once, I spent about six weeks not fully accepting the fact that I had two newborns. I kept talking about how much easier things would be if there was only one red-faced, screaming banshee attached to my chest or failing to sleep through the night until finally my mom took me (gently) by the shoulders and whispered-screamed, “There are two. You have two babies and, unless you plan on taking one back, you will always have two. So stop. You are only making it harder.” And I was making it harder, with my constant imagined scenarios of easy outings with a single stroller, or god forbid, a baby  bjorn, instead of a truckload of gear requiring two sherpas and a donkey. So, I stopped. And, eventually, it got better. It was still really, really hard to have two newborns, but at least I wasn’t living side-by-side with the imaginary world in which I had only one. It was hard, but not harder in comparison to what wasn’t real.  

There is so much more to DBT than distress tolerance. So many modules! So many skills! I go to therapy for three hours every week: one hour individual therapy and two hours group. I have skills homework due each Monday. I complete a diary card with approximately 15 categories of how I’m feeling and what I’m thinking on a scale of 0-5 every night. I talk to or text my therapist throughout the week. I am often exhausted of my own thoughts and feelings and distress and tolerance of said distress (or not). But it’s helping. I feel better in the sense that I see more of what’s happening and I can name it and be less judgy and instead give myself some grace and a better place to settle and regroup before I try again. I get up. Then I get knocked down, or I knock myself down. I get up again. I accept that this is my life right now. I am doing the best I can and I can do better. 

Please describe the source of your condition

I’ve been wrangling with some insurance folks lately. The title of this post, or some iteration thereof, has appeared in every request for information I have received: Please describe the source of your condition. I suppose if I had a broken leg, this might be a reasonable request, but for any mental illness, this request is practically, and most likely scientifically, impossible to comply with.

The first time I received a form asking me to describe the source of my bipolar disorder, I just stared at the form for awhile and then laughed out loud. The absurdity of the request was confirmed when I realized the form provided less than four blank lines to write my answer. Since then, some forms with the same request have allowed for the attachment of additional pages “if needed.” The best idea I could come up with to be as accurate as possible was to write nothing except “see [most commonly used textbook on mood disorders, most current edition]” and also maybe “Talk to my doctors. You already know who they are and have signed releases to speak with them. However, even they probably can’t give you a comprehensive or entirely correct description of the source of my condition; but they are a hell of a lot more qualified to try than I am.”

Recently, a real live insurance company person asked me to provide this same information over the phone. I asked, only half-jokingly, how much time he had. I also told him I wasn’t qualified to answer the question and that he should speak to my doctors instead. He insisted that I provide an answer to the best of my ability and so I did. My unqualified, minimally researched, extremely speculative description of the source of my bipolar disorder went something like this:

My Genetics – I have a family history of bipolar disorder on my father’s side. While none of the people with this condition are part of my immediate family (e.g., father, mother, brother) they are only slightly removed. All of them are women. I also have a family history of substance abuse, an indicator of possible bipolarity.

My Brain Chemistry – Some researchers believe that neurotransmitters, like serotonin and dopamine, don’t function properly in people with bipolar disorder. Given that I was diagnosed with unipolar depression and have taken some kind of Selective Serotonin Reuptake Inhibitor (SSRI) since I was 18, it seems highly likely my neurotransmitters are dysfunctional.

My Postpartum Experiences – Some researchers believe that suffering from a postpartum illness like postpartum depression (PPD) or postpartum anxiety (PPA) is an indicator of bipolarity. I experienced significant PPA after our oldest was born and may have had significant PPD after our twins were born until that illness combined with other factors to become bipolar disorder. Also worth noting is the fact that women with bipolar disorder (known or unknown) who are pregnant or have recently given birth are seven times more likely than other women to be admitted to the hospital for their bipolar disorder.

My Hormones – In brief, pregnancy screws with your hormones in significant ways. Some go up, some go down, some make you puke, some make you super flexible, etc. Logically, a multiples pregnancy results in greater hormonal changes. Researchers believe that, particularly in women, hormones may play a role in the development and severity of bipolar disorder. Some possible examples of my hormonal train wreck after giving birth to the twins are that my pin-straight hair became wildly curly (hormones change the shape of hair follicles); I had no cycle despite not nursing; and, I had no acne, not one pimple, for over a year. Once I stared my bipolar meds, my hair became straight, my cycle regular and my acne plentiful.

My Life Circumstances – Bipolar is exacerbated by lack of sleep, an irregular life schedule or structure, and high levels of stress. Beginning in August 2015, I had two newborns plus a three year old, no predictability to my nights or days, very little sleep, and a great deal of stress, both home and work-related. Additionally, I took very little time for self-care because I believed my time was better spent doing other things.

Take the above five factors, put them in a cocktail shaker and shake for about 14 months. Open, pour and out comes my bipolar disorder II.

As you can tell from the above, I do not believe that I have always had a bipolar disorder and been misdiagnosed and improperly medicated for decades. For a long time, I experienced symptoms of depression, but so long as I took my Zoloft things were okay; often better than okay. After the twins were born, my Zoloft stopped working. We tried other antidepressants, antipsychotics, everything that seemed potentially helpful. None of it worked. Finally, I left work to enroll in an Intensive Outpatient Treatment Program (IOP) and that’s when I was first diagnosed with bipolar disorder II. Perhaps that diagnosis could have been made earlier in the year, but I don’t think it could have been made before August 2015. In short, I believe my genetic tendency for bipolar disorder was triggered by my physical, psychological and life circumstances at some point during the 14 months after my twins were born. This triggering resulted in a full-blown illness.

So that’s my description of the source of my condition. It is not well-supported by my educational background or research. I could not testify as an expert about it in court; but I am the best possible fact witness.

From what I can tell, there is very little known, as opposed to hypothesized, about the source(s) of bipolar disorder. The symptoms are often easy to spot but why those symptoms arise in a particular person is, at best, indeterminate. The above explanation of what happened feels correct; it makes sense to me. And that may be as much as I can hope for, as close to the truth about the source of my bipolar disorder as I will ever get.

 

Limits are not weaknesses

It is fair to say I am not the same person I was before my twins were born. Any woman could say the same about the birth of any child. Becoming a mother, whether for the first time or the fifth, is life-altering on every possible level. Physically, emotionally, logistically, hygenically (which apparently is not a word but should be) — your life is different; you are different.

In my case, the changes following the birth of L and C were fairly drastic. Up until these past 16 months, I felt confident that I could achieve my goals and perform my responsibilities — whether academic, professional or otherwise — flawlessly, or nearly so. It wasn’t that I believed myself to be smarter or more capable than the people around me. I simply knew that I could and would put in the time and effort needed to be successful, no matter how great the time or effort required. If I needed to study for eight hours straight before an exam, fine. If a work project required me to stay in the office for 24 hours, not a problem.

My approach to motherhood and household management turned out to be much the same. Spending multiple nights in a row sitting in a recliner holding my sick baby upright so he could sleep despite his cold, of course. Taking night-duty seven nights a week for three kids while also working four days a week, fine. Caring for L and C for half of my “day off,” while also doing the laundry, cleaning, most of the cooking and grocery shopping. Yep, that was my job, too. I understood that I was taking on a lot of responsibilities in addition to my day job. I also knew that my standards for many things, like cleaning, were probably not reasonable. Even so, at the time, all of these tasks and their related high standards seemed achievable, if I just worked hard enough.

It is only recently that I have come to recognize my approach to life as perfectionist. I thought I was just doing what I needed to do to achieve what I needed to achieve in order to be the kind of person I was supposed to be. It never occurred to me, as a teenager or an adult, that pushing myself to do as much as I did to perform my life as flawlessly as I could might have serious consequences for my physical or mental health. Sure, there was that episode of anorexia in college, but that was over and done. At worst, I might get tired or irritable or even depressed, but so long as I took my antidepressants nothing seriously bad could happen.

Then, about three weeks after L and C were born, my antidepressants stopped working. My doctors and I could not find an effective replacement. In addition to depression, I began to experience overwhelming anxiety. A few months later, I had my first panic attack at work and then spent four days unable to get out of bed. This cycle of extreme anxiety/panic attack followed by debilitating depression/days in bed began to occur every few months.

Of course, I kept up appearances as much as possible, both at work and at home. I wiped my eyes and gritted my teeth. I sometimes laid on the floor of my office reciting my name, my location, the day of the week, etc., desperate to ground myself in the present rather than lose myself in a tidal wave of anxiety. I slept too much or sometimes not at all. I would hyperventilate at the sight of my own children and then berate myself for being such a terrible mother.

Finally, after over a year of feeling like a scared, incompetent, overwhelmed, irresponsible, failure every single day, I was diagnosed with bipolar II disorder while attending an intensive outpatient treatment program (IOP). Since that time, I have not returned to work. Instead, I spend my days driving my kids to various destinations, exercising, writing, visiting with friends, and having baby dance parties with our au pair — when I’m not out buying milk, cooking dinner for six or buried under a pile of laundry.

Given my past achievements and drive to succeed, my current lifestyle might look to some people like I am giving up, or like I have lost confidence in my abilities because of my diagnosis. Some people might even think I am using my illness as an excuse to avoid hard work, my responsibilities to contribute to my family and my duty to set an example of working motherhood for my children. Those people would be wrong.

I am not giving up. I have not lost my confidence. I am not using my diagnosis to hide from my life. I am living my life in the best way I know how, safely but bravely, facing each day with hope and humor. I am modeling for my children the importance of taking care of yourself so that you can take care of the people you love. I am showing them that it is okay to have limits, that limits are not weaknesses, and that recognizing your limits and living within them is the best way to ensure health and happiness — for you and the people who love you.

Giving up would mean letting my illness win. The easiest way to give up would be to simply resume my life as it was before IOP. I could go back to doing all the things I did before until, inevitably, I broke myself again. Or, I could give up by stopping my medications, my various doctor appointments, exercising, seeing my friends, structuring my days to avoid rumination, etc. In short, I could stop trying to live my life in a new way that will, hopefully, help me stay well.

There is nothing about my life that looks like giving up. My life is all about the hard work of fighting for a better way of being:

I am saying no (even when my internal, people-pleasing conflict avoider is screaming yes); I am saying yes (to things that make me uncomfortable but that I know will be good for me); I am having real conversations with my most important people about core values, shared beliefs and points of disagreement; I am asking for and accepting offers of help with humility and gratitude; I am practicing compassion, towards myself and others, as often as I can remember; I am making a conscious effort to be more mindful and present in my life, especially with my children; I am also giving myself permission to flee the premises when the chaos of our small-child centric world feels overwhelming.

Everything about my life feels like a work in progress and I have no idea what the ultimate outcome will be. However, I do feel more like myself these days, as if an old friend has unexpectedly moved to town and become part of my present life; not everything about us is the same, but I have missed her and I hope she will stay.

Clean Slate (or Crazy; Take Two)

After a year of fighting almost daily to reach some semblance of the “normal” many people wake up to without effort, I have learned that it was never a fair fight to begin with. It seems I have been bringing a knife to a gun fight every single f*ing day for over 13 months now. 

I have been doing ALL THE THINGS and nothing has worked, not for any sustained amount of time. And I had become so afraid that nothing we tried ever would work. That I would always have more bad days than good, more panic attacks, more days when dragging myself out of bed to make my small child a peanut butter and jelly sandwich feels like more work than I can possibly accomplish in a lifetime.

Turns out I, or we, or whoever is in charge of these things was wrong about what is (most likely) actually wrong with me. Also, what we have been using to try to make me feel better may actually have been making me feel worse. Double trouble.

And yet, my strongest reaction to this news has been relief. What I have been through this past year means so little compared to what my life might be like in a matter of weeks or months of getting the right treatment for the right condition. I had felt so hopeless in recent weeks, so uncertain of ever getting back to baseline, of ever feeling safe and stable and like myself again. But now, I am hopeful. A little freaked out, but mostly hopeful.

On Monday, I thought, at least fleetingly, that maybe a year of fighting was long enough; that I was too tired and too sad to battle my way back to normal even one more day. After my barrage of interviews and testing and ultimate diagnosis on Wednesday, I felt almost giddy with relief. On Monday, I knew that something was going to have to give, and soon. And it did, but not at all in the way I expected. 

It feels like the slate has been wiped clean. The past is done and gone. We are starting over, with better information and a higher likelihood of success. And while I know none of this is going to be easy, that in all likelihood I am going to feel worse before I can start feeling better, I also know I got this. 

We can do hard things, according to my girl G. And she’s right and I can and I will. And then maybe I get to take a break for awhile from the hard things and just be. That sounds heavenly.

Getting better all the time

The twins turned one last month — the fastest slowest year of my life so far — and I am feeling better. The anxiety, the fear of not being enough, the sense of having to work so damn hard just to keep my head above water, now and for decades to come, is still with me. But these feelings are less overwhelming in recent weeks, more like background noise that fades in and out and increasingly allows for me to hear healthier, happier thoughts. Like the thought that all of our kids are (relatively) healthy (for the moment) and they are all getting along. Sometimes they even play TOGETHER, which makes having more than one kid seem almost sensible. For example:

In other good news, L does a fully body squeal of delight whenever she sees her older brother H, even if he has only stepped out of her vision for a few minutes; C has started offering toys to L instead of just snatching them away from her; and, any concerns I had about attachment between myself and the babies, although I nursed them for a far shorter period and went back to work months sooner than with H, have been put to rest. They cannot get enough of me, which is such a relief and a joy, when it’s not a screaming, crying shit show. It is usually both.

I would not describe our lives as easier these days. We are still in it as far as parenting goes. This point was driven home at a recent gathering of our college friends, including two couples who started their family years earlier than us. We are so far from the promised land of butts attached to beings who can wipe themselves, drop-off only birthday parties, and overnight play dates, that I’m just going to have to pretend those things don’t exist. Nope. Either my husband or I (preferably both) still need to be on duty pretty much dawn to dusk, with a blessed break for afternoon nap.

Thankfully (and with a great deal of help from my squad, both professional and personal), I have found, or maybe re-discovered, my desire and ability to slow down, pull back from the day-to-day chaos of it all, and revel in what we have made together over this past year.

We have made a family.

My husband and I have given our children a stable, loving, silly, and safe home in which to grow. We have also given them each other, to love and challenge and annoy and play with.

My husband has given me, well, everything. He has been the rock to my raging river of fear and sadness and shame. He has proven me wrong every time I have determined myself to be unlovable.

And my children, my three tiny crazy people bursting with energy and sound and need and love, they have given me the gift of being broken. But for them, I might have continued to live the rest of my days rushing around doing all the things required to be “good” and “competent” and “enough” according to the unreasonable, if not impossible to meet, standards set by me. Or, more accurately, the standards set by the highly driven, near perfectionist voice in my head which, while helpful in certain circumstances (i.e. law school, taking three bar exams in four years) has proven herself downright harmful as a life coach generally, and particularly when it comes to parenting. It took just over a year, but I feel relatively confident that my kids have broken that part of me (or at least managed to tie her up and stick her in a closet at the very back of mind so that I don’t hear from her nearly as often).

All this is to say that there have been more days when I have felt happy, when I have been playful and sarcastic and spontaneous in a way that feels familiar but which hasn’t felt possible for a long time. My daily life is often still an unmitigated cluster of unexpected sickness, teething, tantrums, blowouts, and blown naps, but I am able to find humor in it, to laugh about it with my husband after the day’s catastrophes have been handled as best they could be and all the kids are finally asleep for the night.

Also, I have been listening to music more, crying less, and dancing. I forgot how much I love dancing. And now the babies can dance a bit in their baby way, and H will bust a move every now and then if I ask very nicely, and even Matt let me spin him around the kitchen the other night in between after-hours work and washing dishes.

Things are getting better. I am getting better. My circus of tiny crazy people (and their handsome adult supervisor) have managed to help me do what I likely never could have done on my own — they have saved me from that mean lady in my head. They have broken me free.

 

 

 

 

 

 

Fuck traveling with kids

So I’m still recovering but sometime soon I hope to give you guys  a more thorough rundown on some of the high (and low) lights from our trip from Denver to the very end of Long Island with our whole damn circus of diapers and teething and tantrums. There were trains, planes, minivans, and ferries both to and from our family’s home on Shelter Island, which has always been one of my happiest places on earth. It still is. But going there with kids instead of as one of the kids is way, way less fun. Shocking, I know.

As a preview, during our twelve plus hour return travels yesterday, the baby I was holding for takeoff both threw up on me and pooped just as we were taking off after a 45 wait on the tarmac. Then she finally fell asleep, after I’d been squeezing and shaking and singing my heart out trying to get her to stop crying and just fall asleep already since boarding. Thus, I got to sit in my vomit-covered, shit-smelling seat awkwardly holding my now blessedly sleeping baby until the captain finally turned the seatbelt light off, when I then had to wake her up to change her. Much screaming and crying ensued (from both of us and probably some of the poor people in the surrounding seats). 

Seriously. I could not make this stuff up if I tried.

On the other hand, there was this:

Brothers are just the best. Also, bless the people of SI for building this playground.
And this:

H showing cousin E his “big hits.”

And this:

I’ve started calling her “Smiles” because she just slays me with those gleeful grins every time.

And this:

Captain Papa, H and me on the sunfish. I am so proud that my denver-born and bred boy loves the ocean as much as I do.

So, as with most things in life, there were some terrible parts but they were mostly made up for by the great parts in between. Give me a year and I might be willing do it all over again.

I don’t envy 

I don’t envy the women who never wanted children and therefore never had them.

I envy the women who though they might want children but had enough sense of self, even in their 20s or 30s, to realize they were not fit to be mothers, for one reason or for many. 

Had I had only one child I might never have realized my unfitness. Having three, it became glaringly clear, but also far too late. They are here. I am there mother. I am doing the best that I can. I am afraid. And sad, anxious, obsessive, compulsive, self-destructive, naracisstic, and everything else I was before I had kids times a million.