Tag Archives: BPD

Anger, violence and mental health: a response to Deborah Orr

I’d noticed some outrage on twitter about a comment piece by Deborah Orr, published on Friday afternoon, but had avoiding reading it until this morning. The headline is incendiary enough, but it was a sentence in her final paragraph that made me really furious:

It seems to me that lack of mental health, not gender, is the defining motivation of all violence.

At its most basic level, this statement is unsupported by evidence. Women are 40% more likely than men to have mental health problems, and yet over 85% of perpetrators of violent crime are men. If there really was a causal relationship between poor mental health and violence, we would expect women to be the majority of perpetrators of violent crime.

It’s in attempting to make such simplistic causal links that Orr’s analysis falls down. Fifteen years ago, Lori Heise proposed the now widely used ecological framework for explaining violence against women. Heise’s model recognises that men’s use of violence cannot be explained by identifying a single causal factor, but that it is the interplay of personal, situational and socio-cultural factors that result in violence.

Ecological model | Image from Centers for Disease Control and Prevention, 2004. Sexual violence prevention: beginning the dialogue. Atlanta, GA: CDC.

The ecological framework doesn’t discount poor mental health as a factor, but it makes it one tiny piece of the puzzle. And like any puzzle, one piece can’t operate on its own. When a person – usually a man – makes the choice to use violence, that decision is a product of factors at the individual, relational, community and societal level. In a country where the state is sanctioned to use violence to resolve conflict through overwhelmingly male military and police forces, where perpetrators of violence against women are rarely convicted for their crimes, and where sex and relationships education isn’t mandatory on the curriculum (let alone education about consent), identifying poor mental health as the primary causal factor for men’s use of violence seems absurd.

So Orr’s argument frustrated me in its absurdity. But it made me furious because it’s personal.

I was diagnosed with Borderline Personality Disorder in 2004. The first time I’d ever heard of it was when my male psychiatrist gifted me with the label. The diagnostic criteria for BPD is changing, with the publication of the DSM-5 last month, but in the previous version (DSM-IV) there were nine criteria. One in particular stood out and made me believe the diagnosis was incorrect: “inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).” I was being told that not only was I angry, I was potentially violent. That I was a danger to others.

Earlier this year, I requested my patient file from all those years ago. It shows that we discussed the diagnosis over three sessions and although I strongly resisted the diagnosis, after three sessions the psychiatrist’s notes still recorded that I met 6 of 9 criteria for diagnosis and a letter was sent to my GP informing her of the diagnosis. The barely legible scribblings over the many following sessions contain notes like “gets angry – self harm”, “holds anger in onto self”, “showing anger by rebellion, appearance; passive aggressively; repressed.”

And this leads me back to Orr. The pathologising of my anger and being told that I was potentially dangerous to others was about the least helpful thing anyone could have done for me. While my psychiatrist interpreted my anger in his notes, I did my best to avoid addressing my anger in therapy, because I didn’t want to meet the diagnosis I’d been given. I dropped out of psychiatric treatment after 18 months and got on with my life. But I never dealt with my anger.

Nearly ten years later, I’m back in therapy again. I have another diagnosis: moderate depression – an improvement on the BPD, major depression, alcohol dependence and anorexia nervosa I was labelled with last time. Hopefully older and wiser, I’ve found a female counselling psychologist through Mind who I know doesn’t do diagnosis. And what have we been working through over the past several sessions? Finally, after all these years, my anger.

So guess what, Deborah Orr? I’ve got a mental health problem and I’m angry: but I’m not violent. I choose not to be. And that choice has nothing to do with my mental health and everything to do with hundreds of overlapping personal, situational and socio-cultural factors in my life.

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This is a new day.

This time last week, I felt pretty rubbish. The counselling I’d been waiting for for five months had fallen through after I found out that my counsellor and I knew each other professionally. That evening, I told my partner (P) that I was thinking of giving up on counselling. I felt that that even if they found me a new counsellor who I don’t know, I may run into them professionally at some point in the future. I would find uncomfortable and compromising.

Our conversation went badly, to say the least. Given that I’d admitted that I’d also stopped my medication, P was anxious about me abandoning treatment altogether. He tried to engage me in a ‘rational’ discussion about pros and cons, and challenged me on whether it’s really such an issue if I know my counsellor professionally. I clammed up and the conversation ended when I burst into tears. I felt like he thought I was overreacting and that he was making no effort to understand how difficult the experience that afternoon had been. I felt isolated and alone. The discussion may have been helpful in a few days time, but a few hours after the abandoned appointment, I needed someone to listen to how upset I was.

The following day was a friend’s wedding, which was lovely, but socialising with lots of people I barely know is draining and at weddings I always drink far too much free wine, leaving me feeling even lower for the next couple of days.

I started the week with a plan to call Mind and take myself off the waitlist. I figured it would be weeks before another evening slot came up anyway and I didn’t want to risk the blurring of my personal and professional life again. But before I got around to it, the counselling coordinator called me with an offer for a slot with a different female counsellor, starting next week. It caught me by surprised that this felt like good news, and I accepted the appointment. I start my 12 weeks of counselling with Moira* on Thursday, and I’ve been feeling more positive since then.

And I got some more good news: a job interview. It’s a dream job and I’d submitted an application with the attitude of ‘you’ve got to be in it to win it’, but not expecting to ever hear from them. But I’ve got an interview. And if I was successful, I would be much less likely to run into my counsellor in that role. I know it’s still a long shot, but it reminded me that there are other jobs out there and that abandoning counselling because of my job is probably not the most rational solution to my problems.

I walked out of work on Friday evening, the sky was blue and the sun was shining. I was listening to Sally Seltmann, and with this song, I felt like things might just get better.**

 

* Still not her real name

** On the borderline is a pretty problematic song. Seltmann says that she wrote it as an ode to Princess Diana, who apparently had BPD. Whether Diana had BPD or not, the lyrics suggest Seltmann’s complete misunderstanding of what it feels like to have problems with low mood, seeming to prescribe to the notion of ‘drag yourself out of bed by thinking happy thoughts.’ Nevertheless, for some reason, it worked for me on Friday so I’m putting it here anyway.

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Today is the day.

Today is the day: my first counselling session. I would like to write about how I feel, but truthfully, I don’t feel anything. It’s been nearly five months coming, and today, I feel much like I did five months ago. Numb. Empty. And exhausted. Exhausted by the daily grind of depression, the heaviness of trying to get out of bed, the dissonance of putting on an enthusiastic face for the outside world, and the pressure of wanting to be ‘getting better’ for the people in my life who were so relieved to see me getting professional help.

I ran out of citalopram a week ago and can’t find the prescription slip to order a repeat. I could go back to my GP to get a new prescription,  but I’ve explained to myself that since I didn’t want to be on medication anyway, this is a good opportunity to see whether psychological treatment alone is enough. That’s the rational explanation. The truth is, the thought of seeing him again makes my heart beat through my chest, so I’m avoiding it.

Now today, I have to talk. But what to say? My life is good. I have a well paid, interesting job; a partner who I love deeply and have fun with; a nice flat in an area lots of people wish they could live in; good relationships with family; and lots of friends who I love and who care about me. There is no good reason for me to be unhappy. I could dig out supposedly traumatic events from throughout my life, but in my experience, that’s true of pretty much everyone. So that leaves me back where I started: what to talk about? In my last go at psychological treatment, I remember endless silences because I didn’t know what I was meant to talk about.

A couple of months ago, I requested a copy of my patient file from the psychiatrist I saw in 2004-5. It was hard seeing things written down about myself, things that I didn’t recall being spoken in the room. Words like “anorexia nervosa: partial remission”, “drunk today”, “borderline personality traits: see for further assessment”. There were also the letters between my psychiatrist and my GP, which I’d not seen before.

I feel she is suffering from a mild to moderate Borderline Personality Disorder. She describes a long history of labile mood, and has been self lacerating for the 2 years. She also bites her fingers to cause pain, and can also be reckless with spending and sex.

And a year later:

If she remains engaged in therapy she should continue to make slow but steady progress.

I dropped out of treatment a month after that last letter was written.

I feel reassured that this time I am seeing a counsellor without an official referral from my GP, so they won’t share information about me. But I know I suggested in an earlier post that it would be useful for them to share information. The point is, I want information shared in a way that includes me. I want professionals who are collaborating in my treatment with me. If they communicate, I should be copied in. Instead, I get a choice between uncoordinated treatment from two separate professionals who don’t know what the other is doing, or coordinated treatment in which I have no voice.

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A counselling assessment.

I had my counselling assessment on 7th January. Here’s what I posted on twitter straight afterwards.

Twitter 7Jan2013

I’d been referred to my local Mind, but I had a flat bike tyre and it took me 40 minutes to get there. It was an area I’d never been to, in a bleak housing estate. I was buzzed into a courtyard where a group of older men were smoking; I had to ask them for directions to reception. As I walked in, the receptionist signalled for me to wait while she finished a counting task. She finally asked my name, rang up for the counselling coordinator and asked me to wait. I sat down on the one seat available, squashed between a cupboard and a second chair which was taken up with a huge carton of sugar. Several more people came in. The tiny space got crowded and everyone else was standing, so it felt like they were all on top of me. The door was open; the room freezing. I took some notes as I waited:

This feels like a place for people who are sicker than me. It feels like all the places I walk into through my work. I want to walk out now, go to work, find myself a private therapist and ask P to help me pay for it. This doesn’t feel like a place for people who work, it’s a place to go during the day if you have nowhere to be. I feel claustrophobic and like I want to cry.

I’m aware these feelings seem judgemental. What they reflect is my anxiety about being displaced from the position of ‘professional’, with the status that comes with it, into the vulnerable position of ‘service user’. This was part of the reason it took so long for me to seek help, and sitting in that reception, I felt out of control and wanted to run.

Perhaps the receptionist picked up on my discomfort, because she sent everyone else outside to wait and asked if I was cold and needed the door closed.

Eventually Liz* came down to collect me. She looked younger than she sounded on the phone, and seemed friendlier. She took me upstairs to a small but comfortable room. I noted that she positioned herself closest the door. I know that she does that is so she will have an easy escape if I turn violent. Liz told me that the only reason any of my notes would be shared would be if they were subpoenaed, which was a relief given concerns I’ve had about information being on my medical record. She asked detailed, difficult questions, but was gentle and empathic and I trusted her. I disclosed pretty much everything, and I cried a lot.

She asked if I’d been diagnosed in the past and I told her about the Borderline Personality Disorder. She later asked whether I’d been angry at that time. I said yes, and that I suspect that’s why I got the diagnosis: women aren’t supposed to be angry. She laughed and nodded, which I liked, and said, “We don’t do diagnosing here.” She clarified that their counsellors work from an integrative approach, which means they draw on a range of theories in their practice. I’d been worried they would offer cognitive behavioural therapy, which I’ve found unhelpful, so was glad she agreed that CBT wouldn’t be appropriate. As she said, I don’t know why I’m feeling the way I am, so I need therapy that allows me to explore where my feelings are coming from.

The assessment took 35 minutes and Liz offered me 12 sessions of counselling. I need a female counsellor in the evenings or on the weekend; she thought she would be able to allocate me an someone next week, but would call to confirm. I left wishing that Liz could be my counsellor, but feeling hopeful that her approach is reflective of the ethos of the service. She called back this week, but unfortunately can’t offer me a counsellor for another five weeks. I’m going on holiday then, so I won’t start counselling until the first week of March: three months after my first GP appointment.

*not her real name

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Making an appointment.

It’s Friday and I’ve got today off work. When I made the decision to seek professional help, I thought today would be the perfect day to do that. I would have the whole day off to myself, I could relax and prepare ahead of the appointment, and if it didn’t go well, I wouldn’t have anyone to put on a brave face for afterwards.

That was the plan. Since my GP practice advertises that you can get a routine appointment within 48 hours, I called on Tuesday to make the Friday appointment. So they could “deal with my call effectively”, I pressed 1 for the automated service. I prefer not to speak to a person if I can help it: people often inadvertently say the wrong thing, putting me off from following through. So I pressed 1 and it rang me through to the automated service. Except it didn’t. It just kept ringing and ringing and ringing. After about a minute, I accepted it wasn’t going to go through, hung up and rang back, this time pressing 2 to speak to a receptionist.

“Sorry, we haven’t got any appointments available on Friday.”

Oh.

“I guess you don’t have anything sooner, then?”
“No, we’re all booked up. Unless it’s an emergency. I can get you in on Friday if it’s an emergency.”

And there it was. The reason I use the automated service. That question I’ve heard from so many GP receptionists, so many times before: is it an emergency?

I never know how to respond to that question. How can I explain that I need help now, that I’ve worked up the confidence and resolve to get help now, and that if I wait, I might lose that resolve? I know that if I wait, I may end up telling myself that things aren’t so bad, that I can manage this by myself, that there’s nothing professionals can do for me that I can’t do for myself.

How do I explain that I have Friday planned out in my head, that it’s important to me that it’s Friday? If the appointment isn’t on Friday then I know I’m less likely to turn up, and if I do turn up, I’m less likely to actually disclose my mental health problems when I’m sitting there in front of the doctor. But the fact that it’s important to me doesn’t make it an emergency, does it?

And if I say it’s an emergency, what will the doctor think of me when I do disclose? I already worry about being viewed as a time-waster, an attention-seeker, a drama queen. I feel these pejorative labels keenly, associated as they are with with the diagnosis I was lumped with 8 years ago: Borderline Personality Disorder.

“No, it’s not an emergency. When do you have an appointment available?”
“I can do Monday for you?”

No good, I’ve got an all-day meeting on Monday, and I can’t be cancelling meetings for a GP appointment.

“I can’t do Monday. How about Tuesday? And do you have an early appointment?”
“I’ve got 9:40 Tuesday morning.”
“That’s fine, thank you.”

It’s not really fine. It’s a week away, 9:40 means I’ll be late for work, and I’ll probably have to put that brave face on. At least I’m never sick – everyone ‘knows’ that about me – so they’ll all assume the appointment’s something routine, like contraception or a smear.

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