On Losing Skills

There’s this trope: the hero has agonized over their journey, kept going by the knowledge that someday, they’ll go home to their friends, the simple life, their family, their time. But each decision has pulled and pushed and torn them away from the happy ending. A moment of truth, a decision that forces their hand, and they know they can’t have it. Even if you can go home, you’ll be bringing those memories, the hair-trigger emotions and learned sensitivities.

Continuum. The Pendragon books.

Doctor Who takes this as the underlying design: one man so wracked by the choices he made that he’ll run across time and space and forms.

And it’s a story we tell and have in recovery too. I spent–spend–so much time trying to find resemblance to what ‘used to be’. And slowly, I’ve realized there isn’t a used to be for this. I’ve never been a non-eating-disordered adult. I’m slowly learning that I can’t time travel my way back out of patterns of thinking and depriving and flinching at scales and calorie counts.

When I was younger, I loved to bake. I remember the adventurers of trying complicated recipes. Croissants, the perfect buttermilk biscuits (it took five different recipes, each claiming to have solved solved what the others got wrong), trifle, with the ladyfingers base made from scratch. Gingerbread sweet enough to eat, sturdy enough build houses.

In college, the game was trying to make versions of the foods my friends could eat: vegan peanut butter cookies, playing with different bread flours, finding finding an acceptable Nutella substitute.

I don’t know how to do this anymore.

I don’t know how to enjoy it, how to look, at recipes without floods of stress. Don’t know how to avoid spiraling for weeks if I push myself to make a batch for cookies. I can do it with help; having another person there means the panic is background noise. But…I don’t want to need that. I can bake!

Could.

It isn’t just reaching for a tool that’s no longer there. It’s rummaging about on the shelf because you’re sure it can’t have gone anywhere. It’s returning again and again because it’s just like learning to ride a bicycle, isn’t it?

And I’ll work my way back to baking someday, I’m sure. Reclaiming floury hands and hot-off-the-pan crumbly cookies. But it will be a newly acquired ability. I’ll read recipes a little differently, looking for the first edges of panic. I’ll check in, make sure I’m in a good place before I start.

And then I’ll learn the next skill.

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A Confusion of Choices, or Not Panicking People With Panic Attacks

I think a failure mode people often get caught in is trying to help panicked/anxious people by providing them with lots of helpful choices. So, say Joe is having a panic attack. The impulse is to give them the best thing that will make them feel the most cared for, right? Since Amy isn’t telepathic, she says:

“I’m so sorry you’re feeling awful! Can I get you anything? water? juice? I can leave? or get someone else?”

And now, Joe has to pick between ALL of those options while Amy waits on him to answer. That’s not less stressful; it’s more!

Instead, I encourage what I call forced choices. Amy can say

“I’m going to get you some water, and then I can sit here until you feel more calm, but you can tell me to leave if you want to.” [smiling at the end of the statement, and immediately moving to go get water.]

Now, Joe doesn’t have to simultaneously worry about showing anxiety/panic AND managing Amy’s emotions AND deciding what will make him feel better. Joe can focus on himself and managing his feelings, without having to worry about how his panic is making Amy feel, or accidentally snapping at her.

Additionally, the thing about anxiety is that the worry/fear is pathological by being loud: your entire experience is flooded with the anxious spiral. The marginal difference between juice and water (from the Amy-Joe example) is just such low priority that it’s impossible to pick. Simultaneously, Amy is there waiting and needing an answer, while your brain screams that you have to focus on the fear and anxiety. If Joe has a strong preference, one powerful enough to compete with the anxiety — for instance, he is stressed by the idea of Amy being out of sight while she gets water, he can speak up.

 

Help-Seeking and Status

Image credit: Rhoda Baer, National Cancer Institute
Image credit: Rhoda Baer, National Cancer Institute

[Related to How to Be a Good Depressive Citizen, this tumblr post and also this one]

I want to talk about something that plays out in the communities I love.

But first, I want to talk about schizophrenia.*

—-

There’s this feature of the onset schizophrenia that makes it extraordinarily hard to treat. We call the before-full-blown-schizophrenia stage ‘prodromal‘, and if you can catch it right in that stage, or close to it, your outcomes are much better.

Except.

Except that the big obvious signs of schizophrenia in that stage are negative symptoms: speaking in monosyllables, emotional flatness, anhedonia, disinterest in activities and relationships and friendships. And in most cases, this part plays out in relative silence.

Your friend stops reaching out to spend time with you, flakes out on group plans, seems bored in conversation. After a while, you stop being the one to call. They’ve found other friends, they just aren’t that into you, you’ve got other friends who put more work into the relationship. It’s quiet and it’s insidious, and I’d bet you don’t quite notice it until you run into each other at the store and wow, it’s been months since you hung out! 

For the most part, this is normal and natural–friendships do the slow fade* and fizzle and evolve. The vast majority of these things are not the result of an incoming bout of psychosis. So you can’t do much to address this. You could possibly make it the social norm to follow up on waning friendships until someone explicitly tells you they hate your company, but I imagine this as being hard to enforce and resulting in more excuses for ignoring other people’s boundaries. (If your solution is to only do this for friends you know are at risk for developing schizophrenia, then you may have even more forthright friends than I.)

So, what happens in most of the prodromal cases is that the person quietly retreats–maybe not even quite noticing that they are–and then when the positive symptoms of schizophrenia set in (hallucinations or delusions or magical thinking, etc), there isn’t a support system there for them. There aren’t friends there daily who can confirm that they’re going to work or taking medication. There isn’t friendship for friendship’s sake; relational interactions are important. And the extent to which this occurs is fairly predictive of outcome of the disorder. High social support means fewer episodes and hospitalizations, better medication adherence. Lower social support…doesn’t.

—-

And back to communities I love.

Communities have hierarchies. There’s variance in how much they’re enforced; there are levels of enforcement and policing and explicit/implicit acknowledgement of the rankings.

Except.

Except that this gets incredibly complicated in communities that are specifically about help-seeking, about coming together and supporting each other; the communities that are explicitly about Not Being Like The Rest of Society. Take, for instance, the mental health community. (Though you could almost as easily use the geek community, or other nerd/geek subtypes.)

The thing is, communities, even those created to be Not Like The Rest of Society, have values on multiple axes. Charisma, though perhaps a slightly altered definition, plays a role. Ditto for the halo effect, though attractiveness might be assessed slightly differently. And so through accidental privileges and intentional power-grabs, some people in the community end up more liked and more likeable.

I am not positive, but I would guess that it is somewhat harder to be in a community where you’re not supposed to be stigmatized, where your particular Problem isn’t unusual, and to have  all of that and watch them say “oh no, that sounds bad” and help everyone else more. And that this problem is magnified when the community you’re in is one you joined because The Rest of Society already did a bad job of caring.

And of course, people wish to prioritize helping their friends, and I think we mostly accept and encourage this. But it remains that some strangers will say “X happened”, and there will be an outpouring of support and love and empathy and praise. And you can have the same thing…maybe you have it worse, maybe you can’t afford to be so public about it, or don’t have the social support to let you present a showered and articulate and slightly-self-deprecating face. Maybe you don’t have the right language; you hate being crazy, you don’t know how to preface your anorexia-thoughts with how you know that healthy can be at any size, but sometimes your brain lies…because you aren’t at the place where you know it does.

And this is a problem. These are the people you want, in the abstract, to help the most–the ones who are new to the community, who aren’t already popular, who aren’t able to be effortlessly cared-about. They’re also the ones that can sound like they pattern-match for the people you’re in this community to avoid. They can be the ones who trigger you or make you slightly uncomfortable. And you joined this community to be safe and relaxed away from The Rest of Society, right?

—-

You can try to fix this, in these communities. You can assign people to make up the difference; to do the checking in and supporting. You can try to deliberately close the gap. Except that these communities also tend to put lots of value on being open and honest…and this sort of thing can quickly feel fake and dishonest. Not to mention, it’s work! You’re not being asked to comfortably inhabit your one safe space, you’re being asked to do emotional work to keep it. And The Rest of Society doesn’t do this, and weren’t you trying to carve out your own place that wasn’t emotionally exhausting?

But, in the mental health community, you’re in a community that’s explicitly about supporting people without ready access to society at large. So it might be even more important that you work hard to help more than just those who can passionately and lucidly explain their pain.

But…it’s easy to fall into patterns of identifying with charismatic leaders and using specific ingroup vocabulary, and helping the people who can tell you exactly and clearly what they need (with the implied understanding that if you’re busy or unable to help, they’ll get support some other way). Because there’s a difference between someone looking up at you and saying I need everything and I’m mostly okay, but could you do this one thing?  and diffusion of responsibility is a hell of a drug.

I…don’t have a solution to this. I’m not sure I even have part of one. But I do know that in my community, in the wide, tumblr and blog and activisty mental health community, there are those who get help, and those who get helped more.


Two notes: One, I’m not talking about privilege here in the classic social justice sense, because I see this replicate across homogenous groups who align on the commonly cited axes of privileges. For instance, I’d expect the phenomenon in a small group of equal-income, same-aged, same race friends. Two, by note One, I’m not saying we should ignore the role privilege plays, just that I had a word limit. 

*This…happens in real life more than I care to admit. 

**For the record, The African Violet of Friendship is sometimes a much better idea than the slow fade.

The [….]’s Guide to Getting a Therapist Masterpost

I ran a series last week about the finnicky steps of getting a therapist. This is the masterpost, with links to every part of the series. It will end up as a new tab on the top of every G&H page as well.

The [….]’s Guide to Getting a Therapist: Getting Started

The [….]’s Guide to Getting a Therapist: Reaching Out

The [….]’s Guide to Getting a Therapist: Your First Session

The [….]’s Guide to Getting a Therapist: Miscellaneous

Go forth and sit on couches!

The [……]’s Guide to Getting a Therapist: Miscellaneous

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?
Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section in Part I.

<< Previous Post: Your First Session

Part IV: In which forgotten things are unforgotten.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

If you have had previous experiences where you found it hard to tell someone in person what had been going on, you might consider bringing in writing or notes. I have done this! It was very helpful, and meant I didn’t accidentally get too tangled up in my emotions and forget something important. Write poetry or journal in the moment and feel okay sharing it? Also a thing. Even my clinical training scenarios have included stories of clients bringing in such things, and if it means giving your therapist a clear picture of the issue it seems worth it. With one therapist, I showed up to our first meeting with data: a calendar reflecting how often I’d had trouble with my ED and significant events around each episode.

I’ve found it very helpful to avoid scheduling therapy between daily tasks. Sometimes there are surprise!emotions and I’ve felt much better when I had an hour or so to process the experience before interacting with people.

Despite liking my therapist(s) and seeing improvements as a result of therapy, I’ve often been tempted to skip sessions when I was having especially bad brain days. (If this sounds like a terrible plan, you’re correct!) My solution to getting around this was twofold. First, I set up a reminder in my phone to go off an hour before I had therapy. It read something like “Past-Kate wants you to remember that therapy makes you feel better and is worth doing” Secondly, I asked my partner to, if he ever thought of it, remind me of times when I felt really great after therapy, or point out progress I’d made. So far: success!

Sometimes insurance only covers a certain number of sessions (or your budget will only get you X amount of meetings.) I strongly encourage telling a therapist about this up front or as soon as you know—it can give them important information about structure and prioritizing how you meet, as well as allowing them to prepare you for termination of treatment.

What else would you add?

—-

<< Previous post: Your First Session


I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within. 

The [……]’s Guide to Getting a Therapist: Your First Session

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?
Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section in Part I.

<< Previous Post: Reaching Out

Part III: In which couches are sat upon, forms are filled out, and intake is had.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

Your first session:

The first session is an extension of the “Do you want to tango?” testing-each-other thing. The therapist wants to know if they can help your particular case, and you want to know if you feel comfortable/matched with them. It’s a first ‘date’ and if they’re metaphorically rude to the waiter, or you just don’t click, it’s okay not to start a relationship.

You might have to fill out some forms. This can vary a lot from place to place, but generally forms can include:

-acknowledgement of the confidentiality policy: therapists will keep nearly everything confidential, but they are bound by law and ethics in some very specific circumstances. If you want an idea ahead of time, here’s the gist.
-if you have medical or other psychiatric information that they might want or need, there’s a potential for signing releases to allow them to have this information. I’ve signed releases so that my medical info was accessible to my therapist and releases to allow therapists to have my previous therapists’ files on me. I was glad I did both these things, but you aren’t required to do so.
-In larger establishments like a health services center or such, it’s common for there to be initial diagnostic questionnaires, like a depression measure.

This session will likely involve very little Classic Therapy ™. Your therapist will be trying to get a feel for your issues and circumstances and might asks things like “Can you tell me what brought you here?” and ask about your previous mental health history.  I’ve also been asked if I was suicidal or had a history of suicidality and whether or not I had a history of being sexually assaulted or raped. The latter might be as a result of where I was seeking therapy—a women’s center, but I’m not certain.

The therapist should tell you about their approach and training. The American Psychological Association has a list of questions your therapist should be able to answer in your first session here—I highly encourage you to seek this information (and take it as a great sign when said therapist provides it without me asking.)

Therapies can also look quite different from practitioner to practitioner–one might be very structured and use lots of forms and worksheets (not necessarily a downside–I like these!), while another might be more informal or conversational. You can ask things like “What does [X therapy] look like in practice?” to get a better sense of this.

—-

Some thoughts on the experience of getting therapy for the first time:

Intake–the first session or the pre-first session–is exhausting. It’s telling all of what makes you need therapy and answering a fair number of invasive questions. I strongly recommend that people plan something relaxing and low stress (if you’re introverted, something that does not involve human interaction) for afterwards. Even thought I usually know what intake should feel like and have done it multiple times, I have to spend ~3 hours decompressing afterwards.

Most of the rest of therapy is not like this, but in order to have the relevant information, the therapist needs to have lots of starting knowledge about you. This is well worth it, but if at all possible, do not put your first therapy session between other scheduled and important actions.

—-

Some things to notice:

Does the medium therapist communicates with you in align well with how you prefer communication? I had phone-phobia for a while–therapists who didn’t use email weren’t worth it, because I’d never be able to get around the ugh field to call them and reschedule.

Does the therapist let you direct the session or do they initiate most angles or discussion? There’s not a One True Way. I prefer therapist-initiated angles of conversation (though I will sometimes point out that I’d like to focus on something time-sensitive), some people prefer the opposite. Noticing what you prefer here can improve future therapy.

 

Next post: Miscellania
<< Previous post: Reaching Out


I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within. 

The [……]’s Guide to Getting a Therapist: Reaching Out

<< Previous Post: Getting Started

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?
Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section in Part I.

Part II: In which emails are sent, scripts are given, and therapists are contacted.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

So you have a therapist (or several) in mind:

An introductory email or phone call is your next step. I find emails take less activation energy for me, as I can use the same default text over and over, and send them at any time. (update: see this comment)

You want to convey these things in your initial contact:

Who you are. (Not the deep philosophical version of this–your name will suffice!)
What you’re looking for (presumably, an appointment, but possibly a referral)
A general sense of your schedule (particularly important if you only have a few set times you are free)
A general sense of what problems you have, if you’re comfortable disclosing
Your insurance type and any other payment concerns.

Optional other information:

Previous experiences (have you seen a therapist before? Do you have prior diagnoses? Are you currently on psychiatric medication?)
Did you get a recommendation from someone?
Specific parts of your identity that might be worth disclosing (language preference, if the therapist speaks several, sexuality, etc)

Therapists sometimes aren’t taking clients or might not have experience in your relevant issue. For instance, if you write that you have trouble with OCD, and the therapist knows they haven’t got relevant skills, they might not want to take you on as a client.

Further, since therapists have a set of people they see with some regularity, they might not have a free space to add you. I’ve found it helpful to think of the initial interaction as asking someone to dance. You say “Hi, would you like to tango?” and sometimes they say “Tango? Fantastic!” and sometimes they say “Mmm, you seem lovely, but I only know the waltz.” or even “I love to tango, but I only know how to lead, and you only know how to lead and this sounds like it would be a problem.”

Scripts for contact:

(As a general note, therapists are Mr/ Ms/Mrs., psychologists and psychiatrists are Dr.)

Sample email (feel free to duplicate)

Hi [therapist],

I’m [name] and I’m interested in an appointment. Are you taking clients? [Because clients often are seeing a therapist weekly or every two weeks, timeslots can fill up, and therapists occasionally aren’t able to accept new cases]

I am experiencing trouble with [issue, with as much or as little detail as you’re comfy starting with/previous diagnosis]. Do you take [insurance type]? OR Do you negotiate sliding scale payment rates?

I have [work/school] on [days] but could do [general sense of free time, such as “weekends” or “Monday-Thursday afternoons”] If you’re not accepting clients, do you have suggestions for other therapists who might serve my needs?

Please let me know,

[name] [additional contact info if you prefer a phone call, etc]

Here’s an adapted version of an email I’ve actually sent:

Hi [therapist]

I’m [Legal Name], and I heard about you from [Campus Service]. I’ve had previous problems with an eating disorder (anorexia, currently well-managed EDNOS), and I’m looking to do some additional work on my coping mechanisms. I’ve had lots of success with CBT, and you list this as a modality you use. I was seeing [therapist at location], but with the new school year, am in need of a new therapist.

I have school on Monday-Thursday from 8-3, but am free after that and Fridays and weekends if you take weekend appointments.  My insurance is [Name of Insurance], and you list this as one of the ones you take.  Do you have availability? If you’re not accepting clients, do you have suggestions for someone else who might serve my needs?

Please let me know!

Kate

Next post: Your First Session
<< Previous post: Getting Started


I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within.