Saturday, October 07, 2017

Outpatient program, part four

You might start with Outpatient program for depression and anxiety, part one.

Fifth session (Oct. 5, 2017)
This morning I found the first hour disturbing. We did the usual check-in with the facilitator asking everyone about sleep, appetite, suicidal ideation, self-care and what the goal for the day is. (My depression has gone into remission, so I've just been reporting that my mood is up and my habits are good and stable.) Two people were really in a bad place, but the protocol here just doesn't allow for truly caring for them in the moment. Each time all the usual questions got asked. Obviously, the facilitator could see these people weren't doing well, so she asked "What's going on?" Each time the person choked out an answer and got a few minutes of focused attention, but not much more than that. One person was told that the facilitator would talk to them personally later, which was good, but the other one I felt really bad for. So much emotion, but this just wasn't the place for it. There's a problem when a program that's meant to help people with mood disorders can't take extra time to care for someone who's clearly struggling.

Then, funny enough, we finished the check-ins early and had extra time! The facilitator asked if anyone had anything else they wanted to talk about. No one said anything. She asked again a few minutes later if anyone had anything else to talk about or if we should take an early break. Still no one said anything, so I spoke up.

"I think it's really lucky that I pulled out of my depression during my first week here because if I had been coming to this program while in depression, this really wouldn't have gone well. I would have felt angry about how things go here and every time you gave us one of those handouts I would have wanted to hit someone and every time we worked on these skills I would have wanted to punch a wall. And I wouldn't have understood why we can't just talk about how we feel, especially when someone clearly wants to just burst into tears or just wants to kill themselves. So it's really lucky that I'm not in a depression or this just really wouldn't have gone well."

I don't remember exactly what the facilitator said, but it was something about how they're working on incorporating more discussion. Then we took our break.

One thing that was really nice was that after the break, the facilitator led us through some breathing exercises. One was called 4-7-8 breathing: you inhale to a count of four, hold the breath for a count of seven and exhale for a count of eight. We also did belly breathing and morning breathing, which involved standing up and bending over. These breathing exercises were great. They gave us actual, practical techniques for managing our emotions during the day and helping us fall asleep at night, plus we all just felt better after doing them. Many of us have trouble with sleep, so these were valuable exercises. The facilitator looked surprised and happy that they went so well.

After the break we did a handout on assertiveness. Clearly I don't need any help with that, so this was another activity that I didn't get much out of, except to learn how many of my colleagues have trouble with ideas like "you have a right to put yourself first sometimes" and "you have a right to have your own opinions and convictions." Um, okay.

I'm realizing that over the past 28 years, I've done a hundred tons of work on my inner mechanisms and behaviors, mastering assertiveness, confidence, honesty and boundaries, and yet I still suffer from horrible depressive episodes. This program's cognitive behavioral therapy (CBT) approach is good, but it doesn't offer much to someone like me who needs hands-on techniques for managing sadness, rage, despair and hopelessness in the moment when I'm experiencing them. The limitations of this program still disappoint me, but I have to accept them. This is the state of American mental health treatment.

Sixth session (Oct. 6, 2017)

Today I had a little extra to say in the check-in. I said again that my depression went away last week and I'm feeling good, but that I'm baffled by what makes it come and go, although sugar consumption seems to be part of it. So, like a detective on the case, I'm starting a daily log of how much sleep I get, how much sugar and caffeine I have, exercise and other things (I've since decided to even include the weather, although I'll leave out planetary movements). I said I hope this will reveal some pattern I can use to manage my depression.

The facilitator said, "That's great. I think that's a really good approach. So you're going write down each day how much you slept and how much you exercised and things like that and then that will give you a nice amount of data you can work with. And then you can use that to try to see if you can find out any ways to help your depression."

I said, "You don't have to repeat everything I just said."
She said, "I'm just making sure I heard you correctly and that I understand."
I said, "Yeah, I know, but it just doesn't work for me. You don't have to do it. I think you've got it."

She repeated that it's part of having clear communication and I just looked at her with exasperation. There's really only one facilitator I like. The rest of them just chirp too much. Instead of saying, "Okay, good," they say, "Okay! Good!" They talk to us like we're children and it feels patronizing. I wonder if any of them have mental illness themselves because they don't seem to have any idea that the more cheerful you are the angrier it can make someone who's already suffering from anger and alienation. I sense little empathy coming from them. Or maybe they're people for whom being in a bad mood is helped by cheerful people and they have no idea that such an approach does not work for everyone.

In fact, when I tell a friend I'm depressed and part of their response is to smile or try to joke, it makes me want to hit them. If they try to lighten my mood in any way, I want to say, "Fuck you!" Their behavior suggests to me that they aren't taking me seriously or they live on a planet where things are never very bad. I feel a canyon of space between our worlds which makes me feel even more isolated, helpless and alone.

Again: it's a good thing my depression didn't last after that first week. I imagine the staff thinks I'm enough trouble in a good mood.

The second hour we did the hole-in-the-road exercise. You know that story that starts with the person falling in a hole and taking a long time to climb out, etc? We read through it and talked about where we feel we are in that story, which is to say, where we think we are in our recovery. I said I'm still on chapter one because I have no idea what brings on the depression or makes it leave and I feel overwhelmed and bewildered by it. We also discussed what strength is and how feeling your emotions and/or falling apart still means you're strong.
hospital orange

After lunch (turkey sandwich and an orange, my first repeat meal), a facilitator who seemed nervous led the session: he spoke with a lot of "um" and "uh," and struggled to find words. It seemed to me that he didn't have as much of the other facilitators' ease. We filled out a handout that led us to imagine our future selves: how they look, how they act, how they handle problems, etc. It was an okay exercise, but either it or the counselor didn't inspire people to talk and the hour dragged. 

In the previous hour, during the discussion of strength, the facilitator had offered her view of what strength is. I appreciated that. She and Dr. B are the only two who seem comfortable adding their own opinions to a discussion. Everyone else keeps the focus fixed relentlessly on us, with phrases like, "What do you think?" and "Does anyone else...?" and "How does that sound?"

When people stopped talking, the nervous facilitator switched from the handout in front of us to the subject of strength versus courage. Things continued to drag, and I'd like to hear what the facilitators think, so I asked him, "What do you think the difference is between strength and courage?"

He said, "That's what I'm asking you."
I said, "Right, and I'm asking you what you think."

He stammered through a response that didn't tell me much. Dr. B tends to float in and out during the last hour of the day and this was the hour he did that. At this point, he stepped in and presented us with another way of looking at the question and the discussion picked up.

I have a part-time job, and on the days when I go to the program, it's a long day for me. To spend the morning at the hospital and the afternoon working feels like a lot, even though I only go three days a week. I'm glad I now have two weeks of IOP (Intensive Outpatient Program) under my belt and only two weeks to go. 

They acknowledge your last day in the program and people applaud you. When this happened earlier this week, someone joked, "Where's the cake?" So I'm going to bring cupcakes on my last day.

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