Course of Treatment: Treatment Options

There are a number of treatment options for mental illness, both in terms of types of treatment (medication, therapy, etc) and manner of treatment (hospitalization, weekly sessions, rehab). As part of looking at the course of treatment for mental illness, we’re going to take a close look at different kinds of treatment, their pros and cons, and how they will impact your polycule.

We’ll be covering:

  • Medication
  • “talk” therapy
    • psychotherapy
    • Cognitive behavioral therapy (CBT)
    • Family Systems therapy
    • others
  • Alternative therapies
    • art therapy
    • music therapy
    • animal therapy
    • alternative therapies to avoid
  • Alternative medicine
    • herbal treatments
    • massage
    • acupuncture
    • other
  • Home treatment
    • exercise
    • sunlight
    • dark chocolate
    • meditation
    • self expression
    • other
  • Treatment Intensity
    • Hospitalization
    • Therapy sessions
    • Medication only
    • Partial day programs
    • Rehab programs

Finding Treatment Options

Most pepole default directly to medication and talk therapy, exploring other options only if medication and talk therapy don’t work for them. This is the approach to treatment that mental health care in the US is set up for. However, you don’t need to feel trapped in one treatment approach. It may be harder to find resources for other approaches to treatment, but if it works for you, it’s worth it.

Some good places to find non-standard resources that are available to you, with or without insurance, include: you local hospital, your local welfare office (or equivalent), your local homeless shelter, your local Children and Youth Services office (or equivalent), your local halfway house, your local domestic violence shelter. Why these places? Your doctor, your shrink, and your insurance company will have all the information about the standard treatment options (medication and talk therapy). The homeless shelter, welfare office, and yes Children and Youth Services (and others I listed) are routinely needing to help the people that the standard treatment doesn’t work for, so they will often have a list of ALL local resources, and many of them are willing to give recommendations so you can avoid becoming one of the people they need to help.

This discussion is part of the Polyamory and Mental Illness Blog Series

Course of Treatment: Getting a Diagnosis

Once you’ve made the decision to get help, the first step is usually setting up an appointment with a doctor or counselor. Some people will go to a family doctor or general practitioner first, others will go straight to a psychiatrist. Some set up counselling through their employer, school, or religious organization.

In the US, insurance will only pay for psychological treatment if you are diagnosed with a mental disorder listed in the latest edition of the DSM (currently the DSM-5).[1] So for many people, getting a diagnosis becomes the crucial first step to getting the help they need.

There are several good references available for finding a mental health professional, so I’m not going to go into that here. I will say that if you have a bad feeling about a mental health professional, get the hell out immediately. I can’t speak for the rest of the world, but in the US mental health care is a seriously mixed bag ranging literal life savers, to people I wouldn’t trust to take care of a plant. I’ve heard finding a mental health professional compared to finding a babysitter–it can take several tries to find one who is actually worth the time and expense. I don’t recommend looking for a poly-friendly mental health professional unless you are in a large urban area. People advertising as poly-friendly just aren’t that common. You can often (thought not always) find someone open minded on the LGBT-friendly lists, or you can educate your own poly-friendly professional (I’ve usually had good results with this, including in rural PA and smack in the middle of the Bible Belt in Tennessee).

Getting Diagnosed

Most of the time getting diagnosed with a mental illness is scary simple. You meet with a therapist, doctor, etc, you describe your symptoms, and they say, “well it sounds like you have X”. There usually isn’t any testing. The famous Rorschach and other less famous evaluation tools rarely come into play. No blood tests, certainly no actual testing your biochemistry before declaring that you have a “brain chemical imbalance.” Just a review of your life history, discussion of your symptoms, and a diagnosis code you may end up carrying around for the rest of your life.

Simple, right?

What to Watch Out For

People unfamiliar with mental illness and mental health care often think that once you have a diagnosis the hard part is done. It’s understandable because this is actually the opposite of what you go through getting a medical diagnosis.

For five years my partner Michael suffered from pain, weakness, “false seizures” and a bunch of other stuff, to the point that twice he was told by doctors that if they couldn’t find out what was wrong and treat it, he’d be dead in a few years. Everything from rheumatoid arthritis to brain cancer to multiple sclerosis was tossed around. But no doctor would dream of diagnosing from reported symptoms alone. If they didn’t have a test to back it up, there would be no diagnosis and no treatment beyond basic painkillers. But as soon as he got a diagnosis, the doctors were able to pinpoint the most effective treatment, and he started improving. Because it took so long to figure out what was wrong, some of the damage is permanent, but once they found out what was wrong, the hard part was over.

This is what we expect from medicine. People who have actually dealt with long term chronic illnesses know it rarely works this way–getting diagnosed with multiple sclerosis is not the end of the struggle. But even with hard-to-diagnosis illness like multiple sclerosis, it’s understood that doctors ain’t doing shit until they have a verified diagnosis.

Mental health…doesn’t work like that.

So if you or your poly partners are just started to get treatment for mental health, you need to understand that getting diagnosed is at best a tiny step towards getting better. Sometimes, with an excellent shrink and a fair bit of luck, you can get the right diagnosis, find the right treatment, and start seeing real improvement in a few weeks.However, that is not the way to bet.

It is also important to be proactive in learning about and understanding the diagnosis. If what you learn about your diagnosis doesn’t fit your experience, talk to your mental health care provider. Yes, they are professionals who (should) know more about mental illness than you, but you are the expert on your experience. If they aren’t willing to listen to you, dismiss you out of hand, or in any way pull a “me expert-you stupid” schtick, get up and walk out. That is a huge red flag and sign of a horrible mental health care provider.

A good mental health care provider will either discuss changing the diagnosis, respectfully explain to you why they feel your experience fits the diagnosis or both.

This post is part of the Polyamory and Mental Illness blog series.



1. This is one of the major reasons “gender dysphoria” continues to appear in the DSM. In spite of the stigmatizing effect of classifying the experience of trans folk as a mental disorder, it vastly increases the treatment accessibility. Insurance companies can still refuse to pay for hormone treatment or surgery, but they can’t deny counselling and assistance in social transitioning, as long as there is an official DSM diagnosis.

The Course of Treatment: Recognizing You Need Help

For many people, one of the hardest parts of getting treated for mental illness is recognizing and accepting that they need help in the first place.

Several cultures have a strong stigma against mental illness. In the US this stigma comes in two forms: first the denigration of anyone with mental illness as crazy, unstable, delusional, dangerous, etc; second the belief that someone who is “strong” enough can “just get over it.”

These stigmas are either misleading or completely false. (Are people with mental illness delusional? Some of them due suffer from hallucinations. But there are other kinds of delusional–like my father expecting me to be able to pull thousands of dollars out of my ass. In my opinion, anyone who claims to know US history and claims the US was founded as a Christian nation qualifies as delusional. Three words: Treaty of Tripoli.) Are people with mental illness dangerous? People with mental illness are more likely to victims than attackers, at least in the US. As far as the idea that mental illness a sign of weakness or something you can “just get over,” it’s just ridiculous. Mental illness is just as much a “real” illness as diabetes, heart disease or a severe vitamin deficiency. And no one would expect someone to just “get over” those.

Because of these stigmas and false assumptions about mental illness, many people refuse to get help until they are backed into a corner. In fact, there are are actually parallels to addiction, and the way many people refuse to admit they are addicts until they hit rock bottom. Refusing to consider the possibility of mental illness until you lose your job, drive away your friends and family, or are contemplating suicide makes the entire process of treatment and recovery that much worse.
For people diagnosed as children, the problems and challenges of (re)entering treatment are very different. It is very common for children with mental illness to bounce from one shrink to another, often getting pulled away from therapists they like and have a good rapport with, as their parents search for a headshrinker who will “fix” their problem child–preferably without ever suggesting or implying that they may in anyway be responsible for their child’s problems.

This means, for children with mental illness, their therapist often is not on their side, is not working for and with them, and will betray their confidence.

When these children grow up, it can be very hard for them to trust mental health professionals. So while people who were diagnosed with mental illness as children don’t have the same problem admitting they have a problem (hell, the fact idea they have/are a problem might well have been pounded into their head until it’s become *part* of the problem). But like people who have trouble admitting they have a mental illness, people who were diagnosed as children may need to hit rock bottom before accepting help–after all, it never helped before.
Obviously, I’m painting a worst case scenario here. Some people who develop mental illness as adults are resistant to societal stigmas and start looking for help long before they are forced to by life. Some children have good experiences in therapy, and have no trouble continuing with treatment as adults (assuming they need treatment).

My own experiences were middle of the road. The therapists my parents took me too see never violated my confidence, and they all gave the impression, at least, of working for me and not my parents, but the one therapist I had a good rapport with, who was really helping me (and who incidentally wasn’t taking in by my parents BS) they yanked me away from as soon as possible, and replaced with a therapist who assured me (sincerely) that my problems were all due to a chemical imbalance in my brain and would all go away if I took the right pills.

When I was old enough to get my own medical care, first thing I did was call back that one shrink actually helped me and ask if he had an openings. I dedicated my first book to him, and credit that man with saving my life and sanity.

 

For folks in poly relationships, admitting you need help can create some big changes in your relationships. If your poly partners have been having difficulty dealing with your symptoms, then telling them you are getting help can you all a chance to step back, focus on the good, and looking for ways to make things better. However, if your poly partners have stigma against mental illness, telling them you’ve decided to look into getting treatment could cause a major rift in your relationship.

If one of your poly partners appears to be struggling with an untreated mental illness, be supportive, and make sure they know that you won’t think less of them or stigmatize them if they seek out treatment. You can’t force them to get help, and staging an “intervention” can backfire badly, but you can be there for them, help them consider their options, and generally be supportive.

 

Once someone with mental illness accepts that they need help, the next step (at least in the US) is getting a diagnosis.

 

This post is part of the Polyamory and Mental Illness blog series.

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Mental Illness: The Course of Treatment

I am seeking guest posters for “Living with” posts and “_______ Disorder and Polyamory” posts on schizophrenia, bipolar, OCD, and PTSD and other trauma-related disorders. If you are interested in sharing your experience, please contact me.

As I mentioned at the start of this series, getting treatment for mental illness can be a difficult process. So we’re going to take a few days to look at what you can expect treatment to look like, and how your poly partners can help the process (or at least avoid harming it).

This discussion will follow the “expected” process of getting treatment in Western-style psychotherapy/chemical therapy. I will touch briefly on other treatment approaches I have some knowledge of, and invite anyone with experience and/or knowledge of other approaches to mental illness to share information in the comments.

This discussion will cover:

Sorry for the short (and late) post. Sunday will be a double post to make up for missing last Wednesday.

This post is part of the Mental Illness and Polyamory blog series.

Anxiety Disorders and Polyamory

This post and others discussing specific mental disorders will reference the Diagnostic and Statistical Manuel of Psychiatry and Psychology, Edition Five (DSM-V). Apologies to my international readers, I’m just not familiar enough with the ICD to use it as a reference.

Please note: everyone’s experience of anxiety is different. This is general information meant to give you an idea of what to expect. Nothing in this blog is intended to diagnose or treat. Please see a psych professional if you or someone you love is suffering from depression.

The Anxiety Disorders

  • Separation Anxiety Disorder
  • Selective Mutism
  • Specific Phobia
  • Social Anxiety Disorder (Social Phobia)
  • Panic Disorder
  • Panic Attack (Specifier)
  • Agoraphobia
  • Generalized Anxiety Disorder

Other anxiety disorders are anxiety caused by medication or substance abuse, anxiety caused by another medical condition and two varieties of “other” anxiety disorders (specified and unspecified).

Anxiety disorders can generally be divided into two categories: those that involve anxiety (fear of something that will happen/might happen) and those that involve fear of something that is currently happening. Separation Anxiety Disorder, Selective Mutism, and Generalized Anxiety Disorder involve anxiety. Specific Phobia and Agoraphobia involve fear. Social Anxiety Disorder (Social Phobia, Panic Attack Disorder, and Panic Attack (specifier) can involve either anxiety or fear depending on the individual.

Selective Mutism is only diagnosed among children and appears to be closely related to Social Anxiety Disorder. Separation Anxiety Disorder is primarily associated with children, but can be diagnosed in an adult.

Symptoms of Anxiety Disorders

With the exception of Selective Mutism, the main symptom of all anxiety disorders is an inappropriate or excessive fear response. The form the fear response takes varies, and the way it is described in each disorder varies. For most anxiety disorders the fear response needs to be ongoing for a long period of time. Generalized Anxiety Disorder’s first criteria is “Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).”

My experience with anxiety disorders is a combination of generalized anxiety, social anxiety, and panic attacks. My Living with Anxiety post last week was specific to generalized anxiety–it involved a great deal of fear of things that might happen and the majority of the fears I describe involved everyday, normal situations.

Where Generalized Anxiety Disorder is a near-constant fear response to everyday worries, other anxiety disorders are more situational. Social Anxiety Disorder is obviously related to social stuff–the fear response can be triggered by anything from performance, to being in large crowds, to family gatherings, to meeting and interacting with a stranger. Panic attacks are an extreme fear response that last for a short time. Panic Attacks can be triggered by a huge variety of things, but usually each person will have specific triggers related to their past experiences, phobias, or anxieties. Someone with generalized anxiety disorder who is frequently anxious about money may have a panic attack at the thought of losing a job, for instance.

Agoraphobia is often found with Panic Attack Disorder because for many people the only thing worse than having a panic attack is having one in public.

Separation Anxiety Disorder is anxiety about being separated from something that is a personal anchor. This anchor can be a person, a job, a safe place, etc. Being separated from this anchor triggers a fear response.

Each anxiety disorder has other symptoms apart from the fear response, but it is the fear response that makes these anxiety disorders.

Let’s take a closer look at fear responses for a minute. A “healthy” fear response follows the fight-flight-freeze pattern. You get a jolt of adrenaline to boost your body to peak condition until the cause of the fear is dealt with. You respond either by becoming aggressive (fight), getting away from the cause of fear (flight), or hiding and waiting for the cause of the fear to pass (freeze).

Adrenaline is rough on the body. It jumps your heart and respiratory rates, puts your muscles on hair trigger, shuts down your digestive system and does some really funky things to your senses. It is the biological equivalent of putting nitrous in your gas tank. Huge boost now, but you pay for it later.

As we’ve said before, mental illness is what happens when part of the mind metastisizes. In this case, it’s the fear response that’s turned into a life-eating mind-tumor.

In some cases the tumor creates unending fear responses. I swear I got at least 10 hits of adrenaline during the one hour I wrote that anxiety post. And each surge of adrenaline had to be diverted, controlled, sat on, because there was literally nothing to respond to. Factor in the way adrenaline burns through the body’s energy, the shutdown of your digestive system, and the difficulty sleeping when you’re getting constant hits of adrenaline, and you have a recipe for a life that swings between constant on-edge fear and utter exhaustion.

In other cases, the tumor creates supercharged fear responses. Imagine an adrenaline surge so strong you feel like you are getting a heart attack. Imagine your respiration speeding up to the point that you are hyperventilating and not getting enough oxygen. Imagine your muscles being flooded with adrenaline to the point that you are shaking so hard you can’t stand up. Welcome to panic attacks. Of course, being physically incapable of responding to the thing you fear usually just makes the fear worse. Which means the body sends out more adrenaline, and the feedback loop is off to a perfect start.

Mild forms of anxiety disorders can sometimes be ignored or written off “I’m just a worrier.” “I’m not really comfortable in crowds, but it’s no big deal.” ” ‘I can’t stand the thought of losing you.’ ‘Hey, I’m right here.’ ” The point where “normal” worries and concerns end and a disorder begins isn’t easy to pinpoint, even for professionals, but if your anxiety or fears are affecting your ability to do normal, everyday stuff, it’s time to talk to an expert.

Treatments for Anxiety

Medication

There are two types of anxiety medications, the ones you take every day to control and manage the disorder, and the ones you take “as-needed” that can stop a panic attack in its tracks. (The one time I went to the hospital with a panic attack, they gave me a shot and I was down in ten seconds flat. It was beautiful. I went to my doc the very next day and said “Prescribe me this. Now.” The pill version was only effective before the panic attack actually kicked in, but it was still a wonderful, wonderful thing.)

As with depression, everyone’s responses to medication will vary. The medication that worked for me might not work for you, and the medication that made my anxiety worse (yes, this can happen), might be exactly what you need.

Medication is a managing treatment for anxiety. It can’t cure the disorder, but it can keep it under control so you can get on with your life. The effectiveness of medication in treating anxiety disorders varies widely.

Therapy

There are several forms of therapy that are generally used in treating anxiety disorders. Cognitive behavioral therapy (CBT) is effective 70-90% of the time in improving anxiety disorders, and creates “substantial” improvement in 30% of patients.

Other forms of talk therapy vary in their effectiveness, though none are as promising as CBT. The “talk therapy” of popular imagination is usually less than useless for anxiety disorder. Something called Intolerance of Uncertainty therapy has shown promise in treating Generalized Anxiety Disorder.

“Fringe” therapies (ie those that are not part of standard psych treatments and need more studies but has the support of most psych associations) such as art therapy, animal therapy, music therapy, etc may help anxiety disorders, there just isn’t enough information.

Alternative Treatments

Trained service animals are very helpful in managing Panic Attack Disoders and some other anxiety disorders. Cats seem to be a popular therapy animal for anxiety disorders, but small dogs and other “lap sized” pets are common.

Breathing exercises, meditation, and biofeedback have at various times been popular for treating anxiety disorders. Their effectiveness varies widely.

Herbal treatments such as chamomile and lavender are generally mild enough to be taken safely, but definitely talk with your doctor about possible drug interactions. I have personally found that in some cases calmatives make the feeling of anxiety worse–if you are suppressing anxiety in order to function, relaxing enough to be aware of just how anxious you are can make it seem like the calmative triggered the anxiety.

Human touch has been shown to be very effective in dampening the fear response. Some people have had benefits from regular massage therapy, others have used cuddling as a home therapy.  I’ve known a few people who when they started getting anxious would do each others hair, the social grooming acting as a calmative. Be aware that massage/cuddling/etc can have the same effect as herbal calmatives, relaxing you enough to really feel how anxious/afraid you are. Be aware also that given the sensory effects of adrenaline, some people cannot handle being touched during a panic attack or other anxiety episode. For these people touch may help to prevent or reduce anxiety, but only when the anxiety is not currently active.

Physical activity, whether going for a run or cleaning the entire house, can be a good way to deal with the burst of energy from adrenaline, reducing the stress of anxiety on the body and mind (and anything that lets you turn a mental disorder into a way to get stuff done is a good thing!)

When Anxiety and Polyamory Collide

Because of the many and varied forms of anxiety disorders, it’s impossible to succinctly sum up the way anxiety can impact polyamory. A phobia of dogs probably won’t affect polyamory at all unless one of your partners has a favorite pooch they want to introduce you to.

Separation Anxiety Disorder, if your anchor is one of your poly partners, can have some obvious impacts and may appear as jealousy or controlling behavior if people don’t understand what is going on.

Social Anxiety Disorder can make going on dates difficult, or turn meeting your partner’s new girlfriend into an absolute ordeal. SAD can also make a person seem abrupt or rude as their focus is more on not running screaming from the room than how to be polite which can make for awkward first meetings and misunderstandings. I once witnessed a 10 year friendship dissolve when one person developed extreme social anxiety. The friend with social anxiety was having trouble with their heater. The other friend asked a relative if they could help out. Having a stranger in her home triggered an extreme panic attack in the friend with social anxiety, who hid in her room the entire time relative as working on the heater.  Relative complained about rudeness, other friend was extremely offended and upset that her relative was treated so poorly when he went out of his way to do a favor for the friend with social anxiety. Their friendship never recovered.

Generalized Anxiety Disorder can turn the normal worries and fears associated with polyamory into an unending nightmare, or might not have an impact at all, depending on the kinds of things your GAD focuses on. The exhaustion common to GAD and other anxiety disorders can have a similar impact to the exhaustion/enervation of depression, depending on how bad it is.

Ways to Manage Anxiety in a Poly Relationship

The biggest and most important thing is to understand the impact of anxiety on your partner. Asking someone with social anxiety to go out to the latest night club doesn’t work. Obviously someone with a phobia of heights is not going to enjoy a trip to the top of the Empir State Building.

But this applies in more subtle ways as well. If your partner’s social anxiety makes meeting your new girlfriend a challenge, then maybe you need to be okay with them not meeting. Or maybe they can talk over the phone, or using social media first.

Know what to do if your partner has a panic attack, and especially how they want you to react if they have a panic attack in public. Understand that someone with anxiety disorder may need to cut an evening short because they just can’t take anymore, and it doesn’t mean they didn’t have fun, or that they are trying to ditch you, it means that their illness is acting up and they need to go someplace safe to deal with it. Maybe you can go with them and help them deal, maybe you need to let them have some space. Either way it isn’t personal, it doesn’t mean they wanted to leave, doesn’t mean they didn’t really enjoy themselves. Just means anxiety is a bitch.

Learn your partners triggers and how to help bring them down. Learn how to give aftercare for panic attacks (yes, it’s a thing.)

Probably most important in terms of impact on poly relationships: If anxiety manifests in ways that look like jealousy or controlling behavior, do not follow standard poly advice for dealing with jealousy. Learn to tell the difference between anxiety-induced and jealousy-induced behavior. Treat jealousy like jealousy and anxiety like anxiety. Your partner has tools for managing anxiety for a reason. Use them! Treating anxiety like jealousy just compounds the problem.

How has anxiety influenced your poly relationships? What ways have you found to take care of your relationships in the face of anxiety?

Disclaimer

This post is part of the Polyamory and Mental Illness blog series.

Living with Anxiety

(This is a completely unedited stream-of-conscious recording of a few minutes in a day with anxiety. Everyone’s experience of anxiety will be different, but I hope this gives you some idea of what living with anxiety can be like.)

The anxiety is moderate today. I can do what has to be done, but it’s hard. Any moment I’m not focused on something the fear comes back. I once read someone describe anxiety as “you know that feeling you get when your trip and you know yuo’re about to fall? It’s like that but all the time.” That’s not my anxiety. but like depression, everyone’s anxiety is different. My anxiety is like the constant feeling you’ve forgotten something. The sense that the other shoe is about to drop. The roiling nausea of knowing that your whole grade rides on this test and you forgot to study. It has me constantly looking over my shoulder, hunching in, seeking to protect myself from the horror that is always just about to hit.

I’m lucky in my anxiety. My anxiety is usually mild, sometimes bad like today. But my bad days almost never get past “moderate” anxiety. I’m not trapped in my home because meeting a stranger in the hall will trigger a panic attack. I can think clearly enough to know that the fears bombarding me are my illness and not in any way real.

“Breathe” I tell myself. A dozen times a minute, “breathe. Keep breathing.” It’s easier if I can hide. A computer game, a book, an interesting discussion, someone else’s problems. Anything to let me hide from the anxiety and not be aware of it for a while. But hiding is dangerous. I can get trapped in it. Stuck in a book and not able to come out because my mind knows that when I stop reading the anxiety will be waiting, so I can’t put the book down, can’t stop reading, and I don’t enjoy the book, I race through it, flipping pages like cards, trying to read fast enough, to distract myself enough, to push aside the looming cloud of anxiety waiting to ambush me the moment my distraction falters.

I’m nauseas now writing this. Thinking about the anxiety, being with the anxiety, and it grows to overwhelming and my gorge rises until I’m so focused on the nausea that the anxiety is…less of an issue.

Michael and our son running around the apartment and I want to shout at them to stop, to shut up, to be quiet because every noise makes me jerk and look, cringe away. Every toss of the beach ball is a disaster about the happen. Every happy squeal is a lighting strike going off next to my ear. I have aural sensitivities. My ears are…funky…and sounds are closely tied with my anxiety. Just the clicking of the keyboard as I type is (Breathe!) making me write faster, racing “away” from the fear in a parodoxical tic that just makes the fear worse as the keys click faster and louder. (Breathe.) The beach balls sails towards the window and I jump. It falls well short of the glass, but still for a moment I couldn’t breathe. I didn’t think “Oh my god, the window will break!” It’s faster than that, there’s no time for thought, no chance for ideas or words, or anything but that instinctly certainty that something bad is about to happen. But it doesn’t. The ball falls lightly t the carpet and my son moves on to practices summer saults and he asks me to watch and critique (Breathe) and everytime he pushes himself over I want to lunge out of the chair and grap him before he falls and it’s just a summersault which he’s done dozens of times before in the middle of an empty floor. But still my breath catches every time he grunts and pushes himself upside down to fall–“fall” a scant foot to a well carpeted floor where he laughs and gets up to do it again, each time pushing me closer to the edge of my sanity while he plays not knowing that his having fun being a kid is slowly destroying me. (Breathe.)

I cheer his summersaults hiding my reaction as best I can.

He gets tired of summersaults and runs into the kitchen to check the therometer we left in the fridge. We talk about tempature for a moment, and talking about ocld and hot and the way we can watch the thermometer go up now that it’s out of the fridge is safe. But soon he’s asking about the thermometer, does this come off or does that come off, or what happens if I do this… (breathe). And he’s not going to hurt himself, it’s a sturdy thermometer, and even if he does manage to damage it, it doesn’t have mercury or anything dangerous in it. But as my anxiety kicks in his voice begins to ring like someone is banging a bell right next to my head. I breathe and tell him I can’t answer any more questions, he needs to go play. He’s in the “why” stage and I can’t think clearly enough to answer his questions. I’m a bad mother. I should be encouraging him to question, encouraging him to learn, but I can’t think, and I can’t answer, and if I tell him I don’t know all he does is ask why I don’t know until I want to tell him to shut up just to get some peace and quiet.

Instead I distract. “Do you want a snack? Let’s get some crackers.” He wants peanut butter on his crackers, his favorite snack. My movements are jerky and unsure. My grip unsteady. My hands aren’t actually shaking, but the tics and twitches and constant jerks are even worse. Nothing that involves fine motor control–like spreading peanut butter on a cracker, or using a knife (I don’t care that it’s a fucking butter knife! My anxiety goes into really high gear at the thought of any kind of knife). So he gets crackers on a plate and a cup of milk, and I retreat to write some more, trying to breathe, to calm, to use the techniques that short circuit the anxiety. It’s still there. Reminding me of blog posts that need to be written, chores to be done, everything that I need to do and every disaster that could happen because I’m not doing it RIGHT FUCKING NOW. My anxiety whispers about the fact that some busybody claiming to be helping us could stop in at any minute and find something wrong with the apartment (they aren’t busybodies, they’ve helped us a lot and I’m grateful for everything they’ve done, but all my anxiety knows is that they can show up and find something wrong and then….logic is a weak log against anxiety. There is nothing wrong here. Our home is clean, we are fed and clothed, and making progress towards our goals. They’ve stopped by twice and said how great everything looks. And the more I talk myself down, reminding myself that there is no reason for a disaster, no reason to fear, my chest loosens and i can breathe because I can point to solid evidence–they’ve been here before and nothing went wrong. That doesn’t work so well other times. And this is why my anxiety is moderate–because I can talk myself down from the edge, because while my son is quite and there are no minor problems and headaches demanding my immediate attention I can work myself down to the point that I can write this, and I can make myself something to eat, and I can clean my son’s dishes without freaking out that someone will walk in RIGHT THIS MINUTE to criticize dirty dishes in the sink.

I prefer anxiety to depression. Anxiety is easier to channel into action. Anxiety is easier to to turn into adrenaline so I can get my ass in gear and get shit done. Depression shuts me down completely. Anxiety just makes me really, really, really fucking irritable. Unless I start hiding. If I start hiding it’s all over and I might as well be on Mars for all the good I’m doing myself or anyone around me. My anxiety is moderate, my depression can (though thankfully not often) become severe. Of course I prefer anxiety to depression.

But at the end of the day, it’s just a different kind of hell.

This post is part of the Polyamory and Mental Illness blog series. If you’ve found this blog series valuable, please become a Patron and support my work.

Polyamory Boundaries and Mental Illness

There’s a bit of a debate in poly circles about rules/agreements vs boundaries.

Short version:

  • Boundaries are personal–I will not date anyone who is anti-thiest. (I’m perfectly happy dating athiests, but if you are going to attack/belittle/look down on religions and religious people I am so fucking out of there.)
  • Rules or agreements are relational–Michael and I agree not to start any long distance relationships (we haven’t–we tend to fall on the boundaries side of the debate, but its an example).

For this post I’m going to talk about boundaries just in keeping with the KISS principle (keep it simple stupid). Most of this post applies equally well to rules in poly relationships, but rules get even more complicated because they involve/require the agreement of more people. Have fun with that.

One of the defining characteristics of mental illness as this blog series uses the term is that mental illness is not static. Where developmental disorders and personality disorders such as autism, ADD, and BPD are constants in a persons life and personality, mental illness is constantly in flux. One day you are so deep in depression you can’t get out of bed, the next you manage to go to work, even if you go through half the day in a depression-daze. While episodes of mental illness can last for years, even decades, within each episode there will be fluctuations, good days and bad days. Days where you can eat and days where you don’t dare go in the kitchen.

Polyamory (and most forms of non-monogamy) work because everyone is on the same page. If I think we all want an open relationship, and my partners want a closed triad there are problems coming. Massive ones. In poly, we tend to stay on the same page partly through constant communication, and partly through establishing boundaries and/or rules/agreements to guide the shape our lives and relationships take. These boundaries can be both a blessing and a curse to someone dealing with mental illness. Let’s take those one at a time.

Boundaries as a Blessing

Hard and fast boundaries are seriously fucking amazing when mental illness is rocking your world. Everything is out of control, your mind is tearing you apart, you can’t even manage to reliably dress yourself from one day to the next, and you just know that your job, relationships, and friendships could implode at any time because of your illness. In this mad chaos you have to have something stable, something reliable, something you can fucking control and cling to as a bit of sanity in an insane you.

Boundaries. You said that safe sex was one of your boundaries, and you would never engage in sex without protection. You also told me that that you would only be in a relationship with me as long as I had safe sex, if I ever chose to have sex without protection, you would stop being intimate with me.

I can hold to this. In a world gone mad I can know that this is solid. This thing you have told me that is one of the bases of our relationship.

Some people with mental illness will cling to boundaries, become obsessed with them, parse them and insist on defining them down to the smallest minutia. In a world where your very mind turns against you, knowing that you have something you can rely on is pretty damn awesome.

Boundaries as a Curse

On the other side of the equation, boundaries can be a fucking minefield. Remember what I said about mental illness not being static? One day I need you to not fucking touch me unless I ask you to. It’s a plain and simple boundary, right? Just don’t touch me. The next day I’m hurt and insecure because you never just come over and give me a hug anymore.

Am I playing games? Messing with you? Being manipulative? No. Yesterday my PTSD was acting up and the wrong kind of touch will trigger a flashback (what’s the wrong kind? It’s like porn, I know it when I feel it. But by then it’s too late.) Today I’m coming down off the PTSD, feeling vulnerable, and need to know that you still care for me in spite of my wackadoodle.

Poly partners (understandably) want the triggers and aids for our mental illnesses written out in a neat little “How-To” book. It doesn’t work that way. Stay the fuck away from my neck, except when I’m feeling safe and want it a little rough, and then my neck is fucking awesome. I can’t eat gooey or mushy foods, except when it’s mac and cheese, and no sauces, but ketchup and alfredo are okay, and oh I love a good pesto. Don’t touch me when I’m curled up in a ball shaking, except for when I need to you to wrap your arms around me and tell me everything will be alright. Don’t cater to my illness except when you need to take it into account in order to get anything done…

We can’t give you a clear set of boundaries regarding our illnesses. The best we can give you is vague semi-guidelines that work except when they don’t. And trying to provide clear boundaries for our mental illnesses just leads to problems in a relationship when “You told me it was okay to touch you there!” “It is, just not now…” or “You can’t do that, it triggers me.” “But yesterday you told me you liked it.”

Obviously a lot of this is highly personal stuff, but a lot of it can apply across relationships as well. “How come you said you can’t stand to be boxed in, but when we went out the other night you let Dave back you against the wall?” “Why is it that my asking you to the movies always triggers you, but you go out with Gina all the time?”

I’m not sure how much sense I’m making here. I expect a lot of people who have dealt with mental illness in poly relationships are nodding along, and a lot of folks who haven’t experienced mental illness are scratching their heads going “What does being backed against the wall have to do with relationship agreements? Who has boundaries about going to the movies?”

Mental illness. It fucks with your head in the weirdest ways. Like I said before, I tend to focus on a boundaries approach to relationships, but in my time I’ve had boundaries and rules about what I could eat for dinner, how and when I would kiss someone, how my SOs interacted, and even where I would sit when out at the movies or in a booth at a diner. All to cope with my mental illnesses.

For people trying to find ways to make boundaries and/or rules/agreements accommodate their mental illness quirks, I highly suggest using hard and soft boundaries as a starting point of the discussion. It won’t be perfect, but it’s a step in the right direction.

Before I wrap up let me briefly mention one other fun bit about dealing with mental illness and boundaries. Some people, dealing with some types of mental illness, will be driven to break rules and boundaries. I got no good answers for the kinds of mess this can cause. The law allows an insanity plea for a reason–in some cases people with mental illnesses really can’t be held responsible for their actions. But that doesn’t stop the damage those actions do. If you someone who is self aware enough to know your illness will drive you to break agreements, rules, and boundaries, I can think of two (probably not the best) ideas. First, try to be in relationships where everyone agrees to do without rules and/or boundaries as much as possible. Relationship anarchists and such might be cool with that type of relationship, and if there aren’t and rules or boundaries to break it’s harder to be driven into breaking them. Second, work with your partners to come up with lots of little rules and boundaries with the understand that in this case some rules are literally made to be broken, and it will be a no harm, no foul situation.

Anyone with ideas, suggestions, or experience dealing with rules/agreements and/or boundaries with mental illness, please share in the comments.

This post is part of the Polyamory and Mental Illness blog series.



Hard Boundaries and Soft Boundaries

Hey folks, sorry for the much delayed post. My family moved on Friday to a new apartment, the first time we’ve had our own apartment in several years, and we finally got internet in today. I had planned on posting from the library during the move, but unfortunately due to the holiday here in the US, the library was closed all weekend. So there’ll be two posts today, and we’ll be back on regular schedule starting Sunday. Thanks for your patience!

I’m going to take a semi-detour away from mental illness today to talk about boundaries. We all have boundaries. Some boundaries are, for lack of a better term, “hardwired.” Someone with a violent peanut allergy CANNOT eat the delicious peanut butter pie you made, and probably can’t have you bring it into their house either. Nothing that happens in life, in relationships, in anywhere will change this, barring a major medical break through. Other boundaries can change–once upon a time kissing was a boundary for me. It used to trigger my PTSD. Over time and as I’ve healed, kissing has stopped being a boundary in many situations.

Some boundaries are part of who we are–I can’t be happy in a monogamous relationship, don’t ask me too. Others are the result of life experience–Franklin Veaux will not be in a relationship that involves or includes a veto. He tried it once, it went very, very badly, he won’t do it again.

But there is one aspect of boundaries that doesn’t get discussed much in poly circles.

Some boundaries are hard, and some boundaries are soft.

I’m stealing terminology from the kink community here (hard limits and soft limits) because polyamory doesn’t have terms for discussing boundaries that are less than etched in stone. When we talk about boundaries it is either “No fucking way do you ever do this, or our relationship is over” or it is not a boundary.

As I may have mentioned before, I don’t believe in binaries. Especially human binaries.

I have some hard fucking boundaries. You raise your hand to me or my kids, there’s the fucking door. You try to come between me and my kids, there’s the fucking door. You try to make me choose between you and someone else I love, there’s the fucking door. Do not pass GO, do not collect $200, I hope the door hits you on your way out.

Franklin has a similarly hard boundary against vetos–you ask to date him when your primary relationship has a veto…well I don’t think he’d say “there’s the fucking door” but the meaning would be the same. Ditto asking him to agree to a veto in any relationship you have with him.

But some boundaries aren’t quite that firm. Some boundaries have some give in them. One of my boundaries is that I will not allow my partners to become dependent on me. I am not your bloody mother, don’t expect me to act like one. And yet when Michael got sick, he depended on me to the point that at times I helped him with his personal hygiene. And I never said, “there’s the door.” For me, this was a soft boundary. A boundary that can be bent, or circumvented entirely, sometimes, in the right circumstances, for a good reason.

Someone with a deadly peanut allergy may have a hard limit on peanuts in their house. But someone with a mild peanut allergy may have a soft limit–they may ask their partner who loves peanut butter not to bring peanuts or peanut butter over, but may be willing themselves to buy a peanut butter pie for their partner’s surprise party.

A soft boundary is not a boundary that it is okay for a poly partner to ignore. It is still a boundary, and it still needs to be respected. But a soft boundary is a boundary that you may choose to set aside in the right circumstances, and your poly partners can come to you and say “I know having X is a boundary for you, but A, B and C are going on right now, would you be willing to let X happen this once?”

You come to me and ask if it’s okay to make me choose between you and someone else I love JUST this once? There’s the fucking door. If we’re living together and you come to me and say “I know you keep kosher, and I agreed to that when I moved in, but my mom’s agreed to visit for the holidays and she always makes a Christmas ham. You know how hard I’ve worked not to ruin my relationship with her after coming out. Would you be alright with her bringing her ham?” Well, you’ll be helping me fumigate the house for the next week (the smell of ham makes me ill), but yes your mom can bring her ham. Tell your mom to bring her ham without asking me first? Well it probably won’t be “There’s the fucking door” but you’ll definitely be in the dog house with me for a damn long time.Next time you and your poly partners get to talking boundaries, you might consider discussing hard and soft boundaries, and how you prefer people to handle approaching your soft boundaries.

Next time you and your poly partners get to talking boundaries, you might consider discussing hard and soft boundaries, and how you prefer people to handle approaching your soft boundaries.

 

Okay, I said this was a semi-tangent from our ongoing series on mental illness and polyamory. I’ll be posting again this afternoon looking at the intersection of mental illness with rules and boundaries in poly relationships. If you found this post interesting or helpful, please share it using the buttons below.

Poly Advice for the Mentally Ill: “Communicate, Communicate, Communicate”

Standard Poly advice: Communicate, Communicate, Communicate

Nothing is more important to a healthy relationship than communication. If we aren’t keeping our SOs in the loop about how we feel and what is going on with us, then small problems will become big problems until someone comes home from work to find their stuff sitting on the front steps.

Right. A few years ago I wrote about when communication is a bad thing. Here’s one of the key takeaways:

good communication is when you are in control of, and expressing, your feelings. Bad communication is when your feelings are in control of you, and expressing themselves.

See, it’s all well and good for me to tell Michael I feel like shit, depression has taken over my brain, and I’m feeling neglected and needy. But everyone dealing with mental illness has times when we are just being irrational. Sometimes, especially when our illness is well managed, we can recognize that irrationality and discuss our feelings. Other times that irrationality can drive us into “communicating” things that we would never say when we were in control of ourselves. What we “communicate” when our mental illnesses are in control can be hurtful, damaging, false, or just plain misleading. Sometimes communicate is not the fucking answer.

Poly Advice for the Mentally Ill: Assess, Plan, Then Communicate

Mental illness loves impulse. Acting on your first thought is great for your mental illness, because it is much easier for the monster to control you when you don’t stop and check yourself.

Before you communicate, stop and assess yourself. Are you in control? Is your mental illness? Engage your logic circuits if possible. Maybe just take fifteen minutes to let yourself get past your immediate thought/reaction/idea.

For most part, DON’T try to be your you emotions. That’s an invitation for your mental illness to take over. Instead either A) think about what you want to say and why or B) do something to distract yourself for a few minutes and come back to what you wanted to communicate a bit later and see if you changed your mind.

If you find that what you wanted to say seems to be coming more from your mental illness than from anything else, you may still want to tell your poly partners, but make sure you tell them as an “this is how my mental illness is affecting me.”

Plan what you are going to say and how. Write out talking points, go over it in your head, whatever works for you. When you have a plan it is harder for mental illnesses to impulse-drive you into saying you’ll regret later.

When you’ve accessed and planned, then it’s time to communicate.

 

This post is part of the Polyamory and Mental Illness Blog Series.

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Depressive Disorders and Polyamory

Apologies for the late post. I had this typed up and ready to go yesterday, and then the internet gremlins ate it. Took me until this morning to be able to rewrite it.

This post and others discussing specific mental disorders will reference the Diagnostic and Statistical Manuel of Psychiatry and Psychology, Edition Five (DSM-V). Apologies to my international readers, I’m just not familiar enough with the ICD to use it as a reference.

Please note: everyone’s experience of depression is different. This is general information meant to give you an idea of what to expect. Nothing in this blog is intended to diagnose or treat. Please see a psych professional if you or someone you love is suffering from depression.

The Depressive Disorders

The DSM-V recognize four main depressive disorders:

  • Disruptive Mood Dysregulation Disorder (DMDD)
  • Major Depressive Disorder (MDD)
  • Single and Recurrent Episodes Persistent Depressive Disorder (Dysthymia)
  • Premenstrual Dysphoric Disorder (PMDD)

Other depressive disorders are depression caused by medication or substance abuse, depression caused by another medical condition and two varieties of “other” depressive disorders (specified and unspecified).

Of the four main disorders, three are recognizably “depression”: major depressive disorder (MDD), Single and Recurrent Episodes Persistent Depressive Disorder (Dysthymia), and Premenstrual Dysphoric Disorder (PMDD). While there are some symptom differences, the main distinction between these three disorders is the depth and duration of the depressive episodes.

These are the three disorders this post will focus on.

Disruptive Mood Dysregulation Disorder (DMDD) is only diagnosed among children and adolescents, and on the surface looks more like an anger/attitude problem than depression. However DMDD is usually a precursor to MDD or dysthymia, so it is included as a depressive disorder.

Symptoms of Depression

Given responses I’ve gotten, my post last week seems to be a very good description of many people’s experiences of a major depressive episode. (Diagnostically a major depressive episode (layman’s term) might fall under either MDD or dysthymia depending on how long it lasts). If you haven’t read it yet, take the time to check it out now.

The main symptoms of depression are depressed mood (sad or empty) and loss of interest in activities. One of these two symptoms need to be present for a doctor to diagnose depression. Other common symptoms are:

  • changes in sleep or eating patterns
  • restlessness and/or moving very slowly (sometimes both will be present at the same time)
  • exhaustion or fatigue
  • feelings of worthlessness or guilt
  • loss of focus, inability to concentrate, or indecisiveness
  • suicidal ideation (thinking about dying without making actual plans or attempts)

Dysthymia is often (though not always) a subtle disorder with symptoms seeming to just be part of a person’s personality. Low energy, lack of interest in activities and low self-esteem are easy to see as “part of who you are” when they don’t reach the point of interfering in life’s basic necessities. PMDD is, as the name implies, a form of depression that strikes during pre-menstrual periods. It can range from mild to extreme, and some researchers believe it is triggered by hormonal changes. MDD is a major depressive episode that lasts at least two weeks. If the episode lasts for or recurs regularly for two or more years, it is an extreme case of dysthymia.

Treatments for Depression

The most common treatments for depressive disorders are medication and therapy.

Medication

Medication is said to have around a 50% success rate in treating depression, though it often takes several tries to find the right medication. SSRI (selective serotonin re-uptake inhibitors) are the first line medication for depression. The idea is that depression is often accompanied by low levels of serotonin, so increasing the levels of serotonin in the brain should make the depression better. Personally I think it’s a bit of a chicken-and-the-egg problem–which came first the low serotonin or the depression? Regardless, many people do benefit significantly from medications–once they find the right one.

Therapy

The most effective form of therapy is cognitive behavioral therapy (CBT). Cognitive behavioral therapy focuses on identifying the recurring thoughts and mental patterns that form an individual’s experience of depression and re-training the mind to stop those thoughts and patterns, and develop healthy thoughts and patterns instead. It sounds strange, but many people I’ve spoken with have commented on how helpful CBT was–and my own experience agrees.

Other forms of “talk” therapy are more familiar: “let’s talk about what’s bothering” or “how is your relationship with your mother” type stuff. Family system’s therapy is very difficult to find, but focuses on the family as an interacting unit, and can be very helpful when depression is part of a long-standing unhealthy life pattern within a family.

Talk therapy (CBT or other forms) combined with medication are usually more effective than either alone, but this will vary from person to person.

Outside of talk therapy there are “fringe” treatments such as art therapy, music therapy, animal therapy, and group therapy. These treatments are fringe only in not having been studied enough to assess their treatment value for depression, they are largely recognized and supported by the APA for some, though not all, mental illnesses.

“Alternative” Treatments

Some studies suggest 2 ounces of dark chocolate a day is as effective in treating depression as SSRIs. As dark chocolate has been shown to increase the serotonin levels of the brain (explaining why it is so many people’s go-to for when they are stressed) this fits fairly well with the current theories of depression.

Getting sun, exercise, interacting with people in a healthy environment, meditation, and spending time with animals have all been shown to increase serotonin levels and be effective in fighting depression.

People with severe and lasting depression may qualify to receive a trained service animal (yes, there are service animals for mental illness. I’m most familiar with them in treating PTSD, but they can be “prescribed” for depression.)

When Depression and Polyamory Collide

Put a few of the common symptoms together–depressed mood, lack of interest in activities, low energy, low self-esteem–and it’s easy to understand how and why depression affects a poly relationship.

Dates and activities will be cancelled frequently as the depressed partner is unable to generate the interest or energy in going. Low libido will become a problem as low-self esteem, lack of interest and low energy combine to kill your sex life. Weepiness and other signs of a depressed mood can be off-putting to poly partners who don’t want to be “brought down” by hanging around someone who is never happy.

Perhaps most damagingly, for people who don’t know their partner is suffering from depression, or don’t understand depression, the limited sex life and frequently cancelled/turned down date nights and activities can seem like the depressed partner is no longer interested in them. In fact, depression does not affect how we feel about the people in our lives. It does curtail, severely, the ways we are able to express our feelings. And in a culture where “actions speak louder than words” it is very easy for a depressed person’s actions (or inability to act) to seem like a reality and their words of love an (at best) self-delusion.

Ways to Manage Depression in a Poly Relationship

Dates and activities are more likely to actually happen if they are low energy and low key. Needing to pick out a coordinated outfit, review possible restaurants, and take three busses to get to your meeting point are all major hurdles for someone with depression. Think of it this way: Getting done up for a night on the town is the depressed person’s equivalent of walking 500 miles to prove their love. It’s not something that can be done every night, or even every week[1].

Good dates or activities:

  • At home movie night curled up on the couch with popcorn
  • Sitting on the porch blowing bubbles or other sit-down outdoor activity
  • Eating out at a casual restaurant
  • Going for a walk

The closer you can bring a date to “throw clothes on, you are good to go” the less likely it is that your depressed partner will need to cancel due to their depression.

 

Don’t cancel a group date because a depressed poly partner doesn’t feel up to going. This can be one of the hardest situations for everyone. But canceling the entire date because your depressed partner can’t go will often just leave your depressed partner feeling worse due to guilt at ruining the fun for everyone. On the other hand, if everyone is going anyway, the group energy of people getting ready to go may help your depressed partner get motivated enough to come anyway–and in my experience we usually end up having fun after all. If they still can’t come, that’s okay. “We’d love for you to come, but we understand if you can’t” is often the best approach all around. No guilt, no pressure, and always welcome. If your depressed partner is always being left behind on group activities, work on coming up with group activities that are low-key enough they can join in, whether it’s a family picnic in the park or a night binge watching the latest Netflix release.

That said, the above does not apply if your depressed partner says “I need you to stay with me.” “I need you to stay” is very different from “I just don’t feel up to going out.” However much your partner needs you, only you can decide if the right thing to do is stay–there were times I asked my partners not to go to work because I needed them. I did, really and truly need them, but the bills needed to get paid too. Was I damaged when they went to work anyway? Yes. Was going to work the best decision they could make? Probably. The judgement call has to be yours.

 

Depression has a way of making you feel completely cut off from the world. Anything which bridges that gap–a hug, cuddling on the couch, reading to each other, playing a video game, holding hands, cooking a favorite meal–can make a big difference to a person battling depression. Incorporating small but regular interactions into your relationship can strengthen your relationship against the influence of depression, and help your depressed partner in their journey back to health.

 

How has depression influenced your poly relationships? What ways have you found to take care of your relationships in the face of depression?

This post is part of the Polyamory and Mental Illness blog series.