I was texting my friends that my anxiety is “off the charts” today and one came back with a good idea in general – meditation. Meditation is often offered to those in distress (physically or mentally) as a coping skill. But for me it doesn’t work, just as yoga doesn’t work. Nor taking a bath or going for a walk.
Every psych ward teaches versions of 3 key “group” therapy sessions – Support Systems (healthy and unhealthy), Self Care (like preventive care for your mind), and Coping Skills (to deal with distress). These are all great topics. Staples of Cognitive Behavioural Therapy (CBT). In the first they encourage you to recognize who would be of support (like close friends) and who maybe is poorly influencing your life (huge focus here for those who have substance abuse issues). Self care involves things like taking meds, going to therapy, eating right, exercise, and sleep. They encourage in self care the idea of being “selfish” and prioritizing your needs to stay healthy (mentally and physically).
And then there are coping skills. Inevitably they hand out lists of either 99, 100, or 101 coping skills (I always joke when I get the 99 that those last 2 might make all the difference when I’m in crisis. And in this hospitalization they forgot to copy the second side of a list so I really only had 50 – I need coping skills to deal with the lack of coping skills).
These skills are meant to help you deal with stressful situations (but can also overlap to self care). They include things like (and I’m not making these up, they are on the lists): take a walk, draw a bubble bath, play with a balloon, rearrange furniture, try to do handstands or cartwheels or backbends, face paint, build a pillow fort, watch fish, collect rocks, chew gum, bake cookies (I assume gluten free), meditate, yoga, exercise, smile, paint your nails, light a candle, play a video game, text a friend, knit, etc. You get the point. Basically they are distraction techniques – the idea (the basics of CBT) is to change your behaviours so that it will improve your emotions and in so distracting yourself, your cognitions will also change and positively impact your emotions.
In Dialectic Behavioural Therapy (DBT; the standard treatment for borderline personality and used with increasing frequency for those with eating disorders among other mental illnesses and is a lot like an extension of CBT), they teach these coping skills too as part of a distress tolerance module. They talk about things you can use to distract and also to be more mindful. Again meditating is a huge part of this. For myself, I have a “care kit.”
People are always asking me why I have such a big purse. Besides the medical stuff in it (syringes, insulin, glucose meter and strips, voltaren gel, arthritis compression gloves, socks for when my feet with neuropathy get too cold, medications in case I get stuck somewhere, a coke for low blood sugars, a diet coke for highs, inhalers, and first aid (for if/when I turn to cutting and i’m not at home)), there are the normal things people keep in purses/pockets (wallets, phone, girly stuff) and backup cellphone batteries for when I get stranded in hospitals with my phone battery dying. And then my care kit.
I keep small toys in my bag like a bouncy ball, playdoh, a finger puppet, a little puzzle game. I keep pictures I printed out of things that make me happy – my cats, pics from Amsterdam and Bosnia, funny pictures from online. I have a scented pencil (DBT also encourages you to engage all your senses in an effort to stay mindful of and connected to the present). I have my iPod for music and then this tape recording of a girl I used to babysit saying the silliest thing and laughing. I have a crocheted heart from my friend Natrice, and kind notes and emails printed out and highlighted. I have a small baby blanket that is incredibly soft on one side and silky on the other to hold in my hands. I keep a pen and paper with me at all times so I can write (journaling can be soothing) I have all these things and use them all the time.
Here’s the thing about coping skills and care kits for distress tolerance – they don’t really work when the distress level is already really high. They work to an extent, but they don’t work like they should and like they do for most other people. My level of intolerance for distress, my emotional reactivity, my high anxiety and propensity to panic and be triggered by trauma mean that all the care kits in the world only be a bandaid covering a gaping wound. It may catch some blood, but it’s not going to stop the downslide in to dysfunciton.
Here’s the neuroscience behind it: In those moments that I need distress tolerance the most, my prefrontal cortex (PFC) – the decision making and higher order thinking area of the brain – is hanging on by a thread if at all functioning. My brain is operating at a baser level – with the amygdala and hippocampus taking control. The amygdala is implicated in our fear response (e.g. fight, flight, freeze, collapse) and is hyperactive in those with borderline personality disorder. Thus, once the PFC is offline (or near offline) and the amygdala is not just kicking in but on overdrive, the logical planning it takes to assess a situation, select a coping skill, implement said coping skill, and wait for said coping skill to take effect cannot occur. (note: at this point, my autoimmune system is running amok at the same time – most notably seen in blood sugars going up at first and then dropping with prolonged high levels of stress which also affects my ability to think clearly and act rationally. and if the cervicogenic headaches, occipital neuralgia, arthritis pain, endometriosis, and asthma kick in… all bets are off).
I still try. Believe it or not, before I took the insulin on November 5, I did use as many coping skills at my disposal. Including reaching out to others – which is why they found me. But as I’ll explaining here, all of those skills, and reaching out in that moment was taking too long for my brain which was cognitively offline but emotionally hyperaroused.
I live often in that space very close between having a little bit of time to implement coping skills and having no time to implement and wait for coping skills. I have them in place and at hand. I know how to use them and can sometimes get them to tide me over. But generally coping skills fail me. I could have a list of a million coping skills and in the moment I really need them – either my brain doesn’t have the ability to access them or i go through them so fast, unable to wait to see if they are working, that none help.
This is why meditation when I’m anxious only makes me more anxious. Because my brain doesn’t let me work in a mindful space. It’s not just a matter of needing to practice to strengthen the coping skill and get my brain to allow me to meditate (although there is that too) but in the sense that at a structural and chemical level my brain physically cannot work in the mindful space of meditation.
So then what are the options for me to deal with anxiety? Anti-anxiety medications would be great – but when my coping skill go awry, I end up overdosing on them because I’ll do anything to escape the chaos. (note: I have considered marijuana use of late which may be a real option but one I’m still a bit scared to pursue). Exercise – but then I activate my eating disorder and start overexercising (plus my diabulimia would have to be addressed before I’m allowed to exercise again). Activity like cleaning – but then I generally overexpend my efforts and end up overly depleted and accused of being OCD. Talking to others. This is probably my best bet – I need to talk. Talking helps my anxiety the most. But since i live alone and you are all far away and busy with families and jobs, I can’t depend on you all the time. All the suicide hotlines and all the “group therapy” in hospitals talk about having a robust support system so you have many people to call. I guarantee you though, I have had long long long lists of people in my phone and there are times when I can call every single one and no one is available (especially in the middle of the night). (Talking with the hotlines is never helpful in my experience). So then I’m alone without coping skills that work to regulate my emotions in a productive and meaningful way, I can’t use drugs or activity and my care kit is not helping – then what?
For me – to be honest – cutting is my best bet right now and has been for years. Cutting is complicated and intense and very very hard to explain to those who don’t do it. For me it is quick, the blood helps ground me, the pain doesn’t touch me because I’m so dissociated from it, internally the chemicals in my brain act as anti-anxiety drugs, and I can self soothe without the help of others. (more on cutting another time)
This isn’t really a sustainable solution though. The ultimate solution (in the absence of the FDA finding any medication or treatment to address the structural and neurochemical issues behind borderline personality disorder) is going to be finding a way to do the self soothing through things like exercise that are not overdone, address the trauma issues that contribute to the anxiety (which includes integration of structurally dissociated parts of the mind), finding stability in my life (i.e., a home and financial security), and to try and work on relationships with others (I need to find a way to develop secure attachments to combat the disorganized attachment of my past 33 years).
Right now, coping skills like meditation or taking a bath or going for a walk are not my best bet because they may just frustrate me more and increase my anxiety. Those are good skills, and they will be beneficial later on when my prefrontal cortex has enough mental energy to complete such tasks. Going into therapy is a really good solution – though it is limited at 2 hours a week. In that space I can work out some of the trauma issues and explore the attachment issues and try to figure out how to expand my window of tolerance so that coping skills can have an impact when I need them. Cutting may also be necessary to avoid full on panic attacks – I’m in survival mode and I have to access the coping skills that I know will work to get by.
Another coping skill for me right now – stuffing as many emotions down to deal with the stressors at hand. If I stop to think about the trauma of my past (from my childhood, from my young adult life, from the past 2 years, and especially from the past month and half), my cats, the physical pain, the trauma I just experienced, the seeming hopelessness of the situation before me I won’t be able to move. I won’t be able to breathe. I will implode again. If I take a bath or go for a walk or meditate – those are the things that my mind will ruminate on right now and I need to avoid because that kind of emotional dysregulation cannot occur without serious consequences.
The 99 or 100 or 101 Coping Skills lists are not what I need to cope in general when I live in a mind that is hyperaroused and neurologically dysfunctional. They may be useful when I address the issues above and increase my window of tolerance. But for now “planning my prom” is not going to stave off an anxiety attack, it’s not going to bring me back from the precarious edge between functioning and nonfunctioning.
Replacing my current coping skills of cutting and avoiding emotion is going to take a lot longer to develop and be a lot more complex. How I wish it were as simple as learning meditation or number 73: Play with a balloon.
But it’s not.
For tonight, I’m going to try coping skill number 32: Rip paper into itty-bitty pieces. So long coping skill list.