I spend five days on the short-term unit; two of them are over the weekend, when nothing happens. You sit and stare at the TV. You look at old Vogue, GQ, and InStyle magazines. I’ve never understood how ogling the home decor and perfect bodies of the rich and famous helps anyone feel better, especially mental patients sitting around in hospital johnnies. The only distraction on the unit involves “walks” where we’re led around the campus in a grouping shaped by the disorders possessing us: the manic ones rushing ahead and racing back, the depressed dragging their feet, the paranoid skirting the edges. By the second day, my privilege level is raised, so I can go on the walks, which I immediately love. They’re so measured and routine as we wend around the stately brick buildings and the green lawns like kids at camp following a counselor through the thick summer air.
Come Monday morning, Dr. M sits down with me again. We go over my medication options and he adds a non-lithium mood stabilizer. Then I’m passed on to a social worker, who, looking at my chart, notes that the time in the hospital seems to be helping. I’m starting to understand why people say that hospitalizing borderlines is a bad idea because we get addicted to the care. Of course we do! We’re watered, fed, and walked, and it is a balm to every aggravated nerve. Plus, for the first time in years I don’t have to put on a public face and pretend that everything is okay. As a result, I’m actually at ease with the other patients and with myself. By the beginning of the week, I’ve started greeting the new arrivals like I’m the STU welcome wagon. I make flowers out of napkins and coffee stir sticks. I’ve also developed a full-blown crush on one of the young guys on the staff. The last thing I want to do is go home.
“You’re going home,” the social worker says when we meet next. I wonder if she’s got a message from Dr. M: “Get rid of this one. Now!” All the comfort of the past five days drains away and tears well up. It’s like being cast of out of the womb prematurely. Wait! I’m not developed! My toes aren’t yet fully formed!
“I really don’t think I’m ready.” I have the same horrible image of my lifeless body on my bed, and then my mother’s face.
“We’re going to put you in a day program here,” Carol says, handing me a folder.
“Is it for borderline personality disorder?”
She shakes her head. “It’s for mood and anxiety disorders. Looking at your chart, you certainly qualify.” She asks if I can handle showing up every morning for a day of intensive groups. I nod. Although I haven’t been able to get out of bed regularly in close to a year, I’ve had little reason to. Besides, being on the hospital grounds for a day program is almost like being on the unit. Maybe I can tag along with the patients as they’re being walked and no one will notice.
The program I’m placed in is called MAP, for mood and anxiety program, and is based on cognitive behavioral therapy (CBT). Every day from 7:30 a.m. to 4:00 p.m., I attend groups inside a questionably air-conditioned three-story wooden building. Now I can’t complain that I’m not getting enough therapy. And even though the focus isn’t on borderline, I know I’m among kindred spirits. If ever there were a dumping ground for the middle-class dispossessed, this is it. Forlorn housewives, wrecked businessmen, spastic college freshmen, midlife crack-ups, despairing elderly, haunted young women—all are herded from one forty-five minute meeting to the next. At the end of each session, a bell sounds, and depending on level of meds and type of disorder, we dash, stumble, or meander toward the next room, with a few venturing out into the heat for a few drags off a cigarette or a cell phone call.
I’ve never seen so many groups happening in one building. We meet for cognitive behavioral skills, assertive communication skills, depression and anxiety (I’m level one, the beginner’s group), behavioral scheduling, relapse prevention, and impulse control. There’s also stress management, self-assessment, mood regulation, positive events scheduling, family issues, life transitions, community meetings, treatment planning, and contract writing. After I’ve met with Scott, my case manager, and signed a contract committing myself to goals and groups, it dawns on me that I’m no longer just in therapy; I’ve entered cognitive behavioral therapy boot camp.
The techniques in this program are very similar to the change strategies of DBT. The focus is primarily on how to manage and control your thoughts as a way of modifying behavior and feelings. Susan, the tall blond woman who runs my first CBT group, says, “If you come away from this program with anything, this is what you need to remember: How you think affects how you feel and behave.” At first this sounds like a new age platitude: Think good thoughts and all will be well! But when Susan takes us through an exercise showing how a thought like “I’m fat” can lead to a behavior like starving oneself, the importance of thought grows clearer.
It takes some time for me to adjust to the new language of CBT. Here we’re taught about the CBT triangle of thoughts, feelings, and behaviors, whereas in DBT we were always referring to the intersecting circles of emotion mind, reason mind, and wise mind. But if you strip away the terminology and some of the details, both come down to the same thing: To regain control, we need to develop awareness—and not just about childhood issues. Whether it’s called “mindfulness” or “self-assessment” or “grounding,” this is the first and most critical step toward understanding the forces that are tearing us apart. In CBT, some of this awareness involves observing, but the focus is on analysis and assessment. We rate our feelings, look at our thoughts for common types of distortions, strip our experiences down to the facts, and generate new strategies to substitute for habitual reactions.
By the end of the week, I’m more saturated with CBT theory than I was after six months of DBT. It makes my DBT group, with its one and a half hours of rambling group sessions and weekly homework assignments, seem like Sunday school. Now I’m in the seminary and there’s another gospel. It’s all about change. We’re here to fix ourselves, and that takes work, work, work. I love creating the little graphs and diagrams and lists; it makes me feel more in control of what’s happening inside me if I can map and record it visually. But for some of the other people, it’s too rigorous and brain-twisting, especially when meds and sleep problems make focusing difficult.
Even though I appreciate the approach and can grasp these ideas, I can barely tolerate sitting in the groups. Distractions as small as a woman tapping her foot grate my nerves, and the small, hot rooms are a breeding ground for claustrophobia. There’s a lot of discussion around triggers, or what DBT calls “prompting events.” A large part of developing new awareness and changing behavior involves seeing how situations, and our interpretations of them, cause habitual reactions. Being in a small room with other people is one of my biggest triggers, it appears. My heart races, I start to think people are staring at me, and the pressure builds until I feel like I’m going to explode. All I want to do is escape the room, and I often do, going to the bathroom to splash water on my face and sitting on the toilet until my heart stops racing. Bathroom escapes are probably one of my first and most enduring emotion regulation strategies, but given that I’m in a program full of people with similar problems, I seem to always be standing in line.
I soon realize that my triggers go beyond simple social encounters: being alone, thinking about the past, dealing with money, feeling ignored… In fact, I’m growing more convinced that almost everything has the potential to trigger me into being upset. It’s a lot like Dr. Linehan (1993a) described it: Having no emotional skin leaves me raw and vulnerable to even a feather’s touch. And as my life falls apart, my defenses against these triggers seem to diminish, so that, increasingly, I’m almost always upset.
With the prompting of the counselors, I try to be aware of every thought and reaction: My favorite counselor doesn’t smile at me and I’m sure she’s mad, even though I have no real proof of it. I think about my parents and how they don’t care about me, and then I remind myself that their idea of care differs from mine. I try to name and rate every emotion that comes along, and true to my
borderline nature, they come fast and furious, and are often contradictory. It’s like riding a bull, this kind of mindfulness.
For a couple of weeks I’m holding on quite well, until one of the guys in the program starts to get under my skin. Rather, I want him under my skin. Todd, who must be ten years younger than me, is heavily medicated due to an extreme case of bipolar mania, Jesus-style. He’s also unselfconsciously very cute and reminds me of the boys I knew during the Grateful Dead days, singing Bob Marley songs to himself and wearing an occasional tie-dye.
I’d been immune to him at first, but during lunch, as I sit under the large, dying oak outside the cafeteria, I hear Todd’s voice on the patio. I put on my sunglasses and stare at him: hair in his eyes, muscular legs, wearing a faded T-shirt and flip-flops. A cigarette burns down toward his fingers as he describes, too loudly, how he’s going to replace Kurt Cobain and bring Nirvana back together as soon as he can convince Courtney Love he is worthy.
Something in me melts. Don’t ask me why. I do a self-assessment. I can’t believe it, but I feel the stirrings of an idiotic, misplaced, and inappropriate lust for Todd. No, wait, there’s a judgment in there—which calls for another self-assessment. Sexual desire: Scale? Burgeoning. Unbecoming. Pathetic. Why not at least have a crush on a doctor? On a scale of one to ten, what’s the rating? Three, thank goodness. But that could shoot up to ten like one of those carnival games if the hammer finds its mark.
I try to practice awareness of this sudden infatuation with Todd because I know that desire is a huge trigger for me. Even a fantasy can strip me of self-determination. And even though I’m being all insightful and self-assessing with this Todd feeling, I don’t want to change it. After six months of nonstop pain and despair, my body has suddenly come back. I’m almost tingling, and, to be honest, I don’t want it to stop. I feel alive: I feel the grass under my fingers, I smell the aroma of cigarettes and French fries wafting over from the patio, and I’m starting to remember the comfort of being held by someone else.
But as it turns out, I don’t need to worry. Apparently Todd hasn’t been taking his meds. “Jesus doesn’t need lithium,” he declares in self-assessment. “Jesus is full of love. On a scale of one to ten, I am the love-meister. Jesus lives to love.” Soon he’s back in the hospital and I can buckle down again. And oh, how I do. With five groups a day, even my writer’s fingers ache from taking notes. Then, at the end of the third week, the news arrives: My insurance has cut me off.
8
Dancing with Demons
It’s like going through withdrawal. After I’m discharged from the program, I languish in bed for a couple of days. When I finally get up, I discover that all of my therapists are gone. It’s August, apparently the month every psychiatrist, psychologist, and therapist in Boston takes off for Cape Cod, a craggy hook of beach land on the coast of Massachusetts. As soon as the calendar page hits August 1, they pile into their Saabs and Volvos, loaded with kids, dogs, and spouses, and drive away from us, their patients, inching their way down U.S. 6 in a mass exodus they call vacation.
Anna is off for two weeks. Dr. M, who graciously agreed to replace Dr. B because I fired him after the lithium experiment, is away for the entire month. The DBT group I’m about to return to, the cornerstone of my “life as usual,” has been put on hold while Molly suns herself for three weeks. As I am now fully aware, having problems with being left behind is part of being borderline. And despite knowing what a cognitive distortion is and how to observe and describe my feelings, in less than a week into this black hole of “nontherapy” I’m against the wall again. One night I eat half a gallon of pistachio ice cream and then make myself throw up—something I haven’t done in years. Then I walk back and forth between the bedroom and the bathroom half a dozen times. I know there’s a packet of plastic razors in Marcy’s drawer. In my head, the usual images of me finally at rest and dead on my bed conflict with the imagined shriek of anguish I can already hear erupting from my mother’s mouth as she finds out.
What has gone wrong? Once again I want to blame the therapy and the people, but if I believe that, then I have nothing more to hold on to. I’ve tried everything, and I know that isn’t a distortion. When I get this worked up, my insides go hollow. I’m numb and feel unreal, and I want to raise blood to the surface. I know I’m in emotion mind. I’m aware of the urge to cut. At first it’s because I want pull myself back into my body, and then as the night goes on, I want to go further and cut until I can leave my body entirely. I cast around for some alternative, but my brain cannot do one more fucking worksheet assessing and reframing my thoughts. All the skills from DBT glom together, a mass of acronyms without any meaning. I pull out the DBT books and paw through the pages. Something has to help. Then I find these words: “The lives of suicidal, borderline individuals are unbearable as they are currently being lived” (Linehan 1993a, 107).
I instinctively reach for a highlighter when I read this. Maybe that’s the moment I undergo a fundamental shift. I don’t grab the razor; I reread that one sentence and feel the same relief I felt when I discovered the borderline diagnosis. It’s the balm of truth. Why doesn’t anyone else recognize this? The programs I’ve been in keep insisting I’m going to be fine, even when I’m constantly on the edge, and then they push me out. But Dr. Linehan knows: We borderlines are in a living hell, even when we look okay. I am so relieved at reading this that I start crying. I remember again Linehan’s description of borderlines as emotional burn victims (1993a). I’m on fire again, I tell myself. Just get someplace safe. I call my insurance company and then drive to the hospital with a packed bag. I am immediately escorted upstairs and interviewed by a doctor. When he notes that all of my therapists are on vacation, he signs the papers and I’m let through the door into the STU, and even into the same room.
My second stint on the STU lasts only three days. But something finally happens. And though it seems insignificant, it changes everything. The social worker, Carol, meets with me again and says, “If you keep this up, you’re not going to end up at a nice hospital like this.”
“What do you mean?”
“I mean, people on disability who keep coming through eventually get sent to the state hospital and,” she drops her voice, “you would not be happy there, I can assure you.”
Does she think I’m happy here? I try to explain for the millionth time that I’m not a slacker. I really do want to get better. I just feel safest here.
“Who is your therapist?” she asks, flipping through my records. I say she’s on vacation.
“No, who is she? Has anyone here talked to her?” I can’t say there’s been any contact. Maybe secret phone calls take place, but I doubt I’m that important.
Carol keeps flipping through the notes and then looks at me incredulously. “Why don’t you have a therapist?”
“I thought Anna was a therapist.”
“She’s a drug and alcohol counselor. You need someone trained in DBT.”
“I was told there were no DBT therapists available.”
Carol shakes her head and gets up. “Yes, but there are people outside of this place.” She looks angry. “I’m going to make some calls.” The next morning Carol finds me in my room and hands me a piece of paper: I have an appointment at another DBT program, located in Cambridge.
“I’m going to tell you a little secret,” she says, closing the door halfway. “You’ve never been in a real DBT program.”
“I don’t understand. I’m in the skills group.”
Carol runs her hands through her hair and shakes her head. “A DBT program isn’t just group once a week. In a proper program, you have a trained therapist, you get phone coaching when you need it, and you have a skills group. You’re not getting what you need.”
I can’t believe I’m hearing this; it’s insane! I finally get the BPD diagnosis, and then no one will talk about it and Anna still denies it. I’m told DBT will help me, and now it appears I’m not even getting real DBT. And all along,
I’m asked why I’m not getting better—what I’m failing to do. Who can I trust in this process? What if Carol is just as deluded? Does anyone know how to help?
“Listen,” she says, “this isn’t going to be easy. At this other place, there’s a waiting list for therapists and the DBT group, and the intake isn’t even for another month. But you’ve got to change something. You might not end up here the next time. So whatever you do, don’t miss that appointment.”
It’s probably the fear of being locked up in a back ward in a state hospital that makes me agree to keep this appointment, because at this point, even a non-borderline would throw in the towel. It pushes me in a new direction, so I try to hold on—and hope that my insurance will let me stay in MAP until the next leg of this insanity begins.
I’m discharged from the STU into MAP again, with a new set of contracts and groups. This time Scott, my case manager, is more concerned with my aftercare planning, as it’s obvious I’m not going away easily. He agrees that getting into another DBT program is the best direction to take. And he wants to get my family involved, especially given that I have no money and don’t feel safe where I live.
The idea of asking my family for help, or even just revealing what I’m experiencing, feels like reopening a giant wound in my chest—a wound I’m always sewing up with barbed wire and hiding from sight. And if my past has shown me anything, it’s that my illnesses trigger all kinds of negativity in my family: fear, anger, blame, rejection. I’m not willing to add any more of this to my life, so I tell Scott my parents are too far away, and that isn’t a lie. My reality and theirs do not coincide.
But I do need to start preparing my mother, as she’s returning from Bali for the start of the school year. In the few phone conversations we’ve had, I’ve explained to her, in the least graphic detail possible, the facts of my decline. Now, as soon as I tell her about my latest hospitalizations, a painful and familiar chain reaction occurs: All the way from Bali her voice trembles, and on the edge of crying, she asks me what I’ve done to fix the situation. It’s like she’s channeling Scott and the doctors in the STU, only with my mother my failure to thrive isn’t just a self-inflicted burden. It oppresses her because she feels my pain so intensely that it’s overwhelming for her. So she turns away.
Buddha and the Borderline Page 7
