From the Inside Out

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The urge to vomit came back in full force as I opened the email Andrew had sent back to me and began to read:


Let me start by saying I commend you for seeking the help that you need and the help that you want. It can be next to impossible to navigate through the mental health system, especially if you are your own advocate. I consider your last email to be a “trauma narrative.” When telling the narrative one might experience “flooding,” or having a rush of memories and the associated emotions that go along with them. I also assume that you felt some feeling of safety too when writing this. It can be liberating to let these things out, and not have to hold on to them. Knowing when to let them out can really only be determined by you. It is totally normal to regret writing it too, because you feel vulnerable. Now that I have a better understanding of your life experience I can definitely tailor our treatment to meet your needs. The following is how I see the treatment plan going.

· Phase 1: Achieving client safety, reducing symptoms, and increasing competencies. This is the skills building phase, and we will be using Dialectical Behavioral Therapy to improve emotion regulation, increase distress tolerance, mindfulness, interpersonal effectiveness, cognitive restructuring, behavioral changes, and relaxation. This phase will help move you out of crisis to prepare for the next phase.

· Phase 2: Review and reappraisal of trauma memories. There are different techniques for doing this, we will be using EMDR (Eye Movement Desensitization and Reprocessing). This is a method of processing your trauma in a brief and non-invasive way. We’ll talk more about that when we get there. People with complex trauma may need more time with practicing skills and building support in order to be ready to process their trauma. We are in no hurry.

· Phase 3: Consolidating the gains. This is when you will apply new skills and adaptive understanding of yourself and your trauma experience. This phase can also include “booster” sessions to reinforce skills, increase professional and informal support systems, and create an ongoing care plan.

Again I commend you for seeking the help that you need. Things will improve from here. ––Andrew

It took me three whole hours to find the courage to open up his email and read it. I think I was expecting him to tell me that I had way too many issues for him to take me on as a client. I just knew that he would reject me. I was pleasantly surprised by the fact that he didn’t seem repulsed by me. I’d opened up and told him some very hurtful things, but these things didn’t even touch the tip of the iceberg. Maybe if he was able to handle that so well, he could handle all of me. Maybe Andrew would be the one to save me from myself.

Over the course of the next few months, I didn’t share any additional memories from my past. Instead, Andrew and I worked on D.B.T. skills to help me come up with more acceptable ways to cope with my feelings. Usually, I used food and hurting myself as a means to help regulate my emotions. My relationship with food was definitely unhealthy and a large part of the reason I couldn’t gain control of my weight problem. Anytime I would become extremely upset, I would eat and eat until I was physically sick and in pain. Some days I could do this a few times a day and other times I could go a week in between my binges. If I wasn’t binging, I would hurt myself. My favorite way of hurting myself would include me lighting a candle and waving a stainless steel fork back and forth against the flame of the candle and pressing the hot fork against the flesh of my thighs or stomach. This would provide the relief I needed, even if only temporarily. Andrew knew this. It wasn’t really that I wanted to hurt myself; it was just that the physical pain provided enough distraction from my emotional pain––except the distraction is temporary, but I much prefer hurting physically than emotionally.

During the time I saw Andrew, I wasn’t working and I wanted to change that. I’d left my job at the clinic a few months after the armed robbery. I worked part time at a home health agency after leaving the clinic, but had to leave that job to homeschool Ryan and Amber once the bullying situation escalated. I couldn’t afford to leave the job, but my children’s mental health depended on it. However, they would be going to a new school in a town nearby starting in August, so I began looking for employment again. I had interviewed many places but had no luck. Then I interviewed at a local doctor’s office and I felt good about it. I had a feeling that I would be offered the job. I went home after the interview confident that the job was all but mine. The same day, I received a Facebook message from Michelle, one of my former co-workers at the substance-abuse clinic I’d used to work in. She asked me if I was willing to come back to work at the clinic. I’d loved working there. My first time there I’d started in February 2012. I loved my co-workers and the clients. Then on October 1, 2012, when I was robbed, I could no longer effectively do my job. I made so many mistakes and each time the door would open and a client would come in, my heart would be in my throat. Immediately following the robbery, the wonderful owners of the clinic installed security doors that would only open if I pushed a button to unlock it, installed security cameras so that I saw everyone that walked to the door, and even gave us all panic buttons. Still, I resigned a few months later. I’d never wanted to leave and missed it so I agreed to come back.

Andrew and I discussed which job invitation I should accept. The doctor’s office offered more hours, higher pay, and benefits. But they only paid monthly. The clinic offered shorter hours and I liked the close-knit atmosphere and I knew what to expect. I understood my job duties. These things are important for someone who suffers anxiety as badly as I do. Andrew’s concern was how returning to the clinic would trigger my trauma. Returning there did trigger my trauma, but I was able to work through it thanks to Andrew’s help. Being able to meet with him weekly and being able to email him when I needed to and call him during specific hours were the tools that I needed to help me get through the more difficult parts.

Just two weeks after beginning my new/old job, I was hit with some pretty devastating news. I was contacted by a detective at the local police department. I was instructed to come in to meet her to discuss a case of identity theft in which my name had come up. I wasn’t expecting a call from a detective but it didn’t surprise me. The year before, I made a terribly bad decision that had come back to haunt me. Typically, anytime someone in my family was in trouble and needed help with money, or help with writing a letter, or help with someone speaking on their behalf, everyone always came to me. And I always helped. A lot of the times helping them would cause me stress, financially or otherwise. But I would do it anyway because that was my role. I was the fixer. This time, I was asked to help try to find a loan. I tried for a few hours online to find a lender but was unsuccessful due to the lack of credit. I had the bright idea of getting credit cards with my name and a family member’s name to establish their credit and improve mine. I know that wasn’t exactly what was asked, but I thought I was helping. But I wasn’t. It became too much of a burden when I was no longer working to make payments and trying to deal with my daughter’s bullying situation. And while what I did was no secret, I had to pay for my poor judgement.

I was lucky. Once the facts came out, I wasn’t charged with identity theft, but I had to pay court costs and finish paying off credit card payments and then everything would be dismissed. I just hate it that now when my name is searched online, there will be a mug shot associated with it. I was concerned because I worked around thousands of dollars every day and I worked around credit-card information every day. I was afraid this would cost me my job because no one really cares about the specifics of a charge; just being charged with a crime could ruin a person’s life. But fortunately, it didn’t ruin mine.

The detective advised that I get a lawyer and fight the charge. That was just what I did. The felony charge was dropped and I received twenty-four hours of community service and twelve months of unsupervised probation. Once all monies had been paid in full, the charges would be dismissed altogether. While the whole situation was scary for me, the bright side of it all is I no longer allow anyone to take advantage of me. I no longer do any favors for anyone. I was so glad to have Andrew during this time; he assured me that I would be OK and he was right. I was OK. I was open with my boss at the clinic and told her everything; she told me that my job was not in jeopardy. I was so grateful for that.

Things began to return to normal for me. Even though the legal trouble had caused a divide in my family, it was a blessing in disguise. I was forced to focus on my life and my children’s lives. And for months, no one asked me for money or any favors…which was the truest blessing.

My little family had things still to look forward to. In August, my mom and the twins and I were ready to set sail on the Carnival Breeze, courtesy of the producers of The View, who had graciously gifted us with the trip when the twins appeared on the show in December of 2013. None of us had ever been on a cruise so I knew this would be an experience. We spent the night in a hotel in Miami. Miami is a beautiful city with a lot of beautiful people. I felt out of place there. I was so uncomfortable, but I knew I would only be there for the night and tomorrow we would be getting on the ship.

The next morning we eagerly left the hotel and grabbed a cab to the port of call. The boarding process was a nightmare, but inside the ship was amazing. It was like a floating hotel. My children were excited about all of the age-appropriate activities that they had and they couldn’t wait to attend Camp Carnival. The first night aboard the ship, Camp Carnival offered an orientation with the parents and the kids attending Camp Carnival. Trying to locate where the orientation was wouldn’t be an easy feat. On the way there, I became separated from the twins and lost them for fifteen minutes. We had only been on board for three hours before this happened so I thought the worst. What if they got off board? What if they fell overboard? I began to hyperventilate and one of the camp counselors helped me. She alerted security and suggested that I call my cabin to ask my mom to be on the lookout. Much to my relief, when I called the cabin, Ryan answered. They had decided to head back to the cabin when they lost me. I was so glad that they had the sense to not only find their way back to our deck, but to remember our cabin number.

I felt like the worst mother ever. Our cruise was not going according to plan. I decided to email Andrew about my experience. He always made me feel better; maybe this time would be no different.

My first day on the cruise yesterday proved to be quite an eventful one. There are like a million people here, the ship is huge. Well, there is this thing called Camp Carnival that the children can go to so that they can play with other children their age, etc. So, parent orientation was yesterday at 5:15pm. I was walking with the twins all over the ship trying to locate where we had to go. Another family was walking just a bit ahead of us looking for the same place. Well, Ryan and Amber got a little ahead of me but were still within eye sight. They turned a corner and I lost sight of them for at least 6 seconds. When I turned the corner, I couldn’t find them. There were 3 different corridors and I ran back and forth between the 3 of twins. I yelled their names... no answer. I lost my babies. Suddenly everything started to spin and there was a loud buzzing noise in my ears and I couldn’t breathe. I kept calling their names but I could hardly get the words out of my mouth. I find the Camp Carnival place and look in there, no twins. I talk to a lady who ends up being one of the counselors and she is telling me to calm down...which just made me even more hysterical and I’m yelling (well, not really yelling because I don’t yell) at her to please find my children. So she tells me to go to guest services, well there are already 34 people in line at guest services (I counted) and I waited like 5 minutes, which felt more like 500 minutes. So I find the camp counselor and I’m like look, I’m not standing in line. My kids are missing, we have to find them now! So she said she had some other staff members looking and she has alerted security. So she calls the cabin I am staying in to talk to my mom to see if the kids had returned...well, Ryan answers the phone. They decided to come back to the room when they lost me. Needless to say I nearly died. The end result was I wouldn’t allow them to go anywhere unless I was there for the rest of the day. So...around 11am the following day, I realized that they got this amazing trip for being amazing kids and they were wasting it in the*sigh* I allowed them to attend camp...and I allowed them to go alone. See? I’m learning.

People are staring at me though. A few of them actually said something when they realized that I caught them staring, and it was always because they recognized my family from one of the TV shows, or from Reader’s Digest. Next month will make it nearly a year from when everything happened, I really hope people can just forget about it or at least not recognize us (or at least me, because the twins don’t seem to mind). Fun times. I don’t know how I’m going to make it until next Wednesday. I don’t think I can do this. ––Karen

I remember one time I lost my daughter at the Marbles museum. It was a very popular day and there were hundreds of kids there. I turned my back for 1 second and she was gone. It’s a horrible feeling. I immediately told the staff and they located her in a minute. It seemed like hours though. I feel for you. I think you did all the right things though. You’re a great mom. Your kids are lucky they have someone who cares for them so much. Focus on the positive parts of your trip. You’ll have some. I know you will. ––Andrew

I knew he would find a way to make me feel better about losing my children.

Thank you for saying I am a good mom, sometimes it doesn’t feel like it. I’m determined to have a good time, in fact, I’m going to venture out to a singles gathering they are hosting at one of the bars tonight. I’m going to behave, but have a good time. Thanks for being so awesome, your words really do help. Have a great night. ––Karen

I was so happy that I’d decided to stick with Andrew. He helped to level me out. He called me on my crazy without being condescending. He helped me. He always knew the right thing to say, or at least it seemed so. I wondered, if I had had someone like Andrew when I first began therapy at age eight, would I have gone through everything on my way to him now?

We all made it back to the States in once piece and together. The next few weeks I spent recovering from the awesome time that I had ended up having on the cruise. So much so that the kids wanted to make it an annual event. I hope I am able to do that for them. The cruise was just enough to give the twins a break from school and a break from their lives, lives that had become unnecessarily stressful for them. They missed about two weeks of school to go on the cruise, but not one of them complained about the time away from school.

I still had a hard time adjusting to being back at work and juggling the feelings of fear that still stuck to me. I found myself having mini panic attacks throughout the day and I knew it was directly related to the armed robbery a few years ago. My coworkers had been very patient with me and Vanessa had been so nice about checking on me and talking to me. I think she noticed when I was having a bad day. I worked with counselors and nurses and Vanessa was a counselor and knew me well. She could always detect a shift in my moods. I tried to keep it in check; maybe she was just incredibly observant. I loved Vanessa; she was so nice. I would have loved to be her friend outside of work too, but I worried about how my ways would affect her. Would she think differently of me if she knew the “real” me? What was the “real” me, anyway?

I always tried to understand my diagnosis so that I could get a grasp of what I was dealing with. Back home in NJ, I was diagnosed with Borderline Personality Disorder (BPD), Obsessive Compulsive Disorder, Major Depression, and Generalized Anxiety Disorder. After moving to NC, I was diagnosed with Bipolar Disorder, Panic Disorder, Major Depression, PTSD, and Hypochondria. I studied all of these disorders and many of them fit, but what seemed to fit like a glove was Borderline Personality Disorder (BPD). That was disheartening because that seemed to be the most-difficult-to-treat disorder. After a few Internet searches, I needed to email Andrew with my findings.

I’ve been trying to understand myself. I know you said labels are a way for insurance companies to limit the amount of services people receive, but I am always so confused. I just feel different and I’ve been trying to make sense of who I am. Why I am, why I feel the way I do and how to stop some of the behaviors. I don’t think I can stop the maladaptive behaviors as long as I don’t understand why I am doing them. I’ve read “I Hate You, Don’t Leave Me.” And let me tell you, I was scared, angry, and frustrated because I had this bright idea to highlight areas that applied to me after reading some things that sounded so much like me. It was definitely eye opening. Right now, I am reading a book called “Am I Bad? Recovering from Abuse.” Reading helps. It hurts, but it helps. It’s easier for me to understand when I read. Speaking of reading, I’ve been on YouTube looking up EMDR, I did a few of the self-administered ones (which was more like meditation) and I ended up finding a letter, I don’t know the origin but it was written by a person who has BPD, to a person who doesn’t have it. I think I do have BPD. I’m not a doctor or anything, but I am about 90% sure I think that’s what’s wrong with me. I don’t think I am bipolar at all. Maybe that’s why medication isn’t working for me, I’m being treated incorrectly. It’s just a theory, but deep down I think I’m right. I dunno. Anyway, I wanted to show you the letter I saw. I highlighted parts that describe me perfectly. It describes how I am in all the relationships I’ve ever had (friendships, family, etc) and I even recognize some of the things I do to you in this letter. I am so sorry. I’m so frustrating, I don’t know how you deal with me. I know it’s your job, but it seems that I’m more trouble than I’m worth. Anyway, I wanted to share this with you. So you can understand how I feel. You don’t have to write me back. I’m OK. I just needed to share this. (Again, not my words, but definitely my feelings...oh, and on Thursday, can you help me figure out a way to tell my doctor that I don’t think I’m bipolar? I’m tired of taking medicine that isn’t helping me.)

“You wanted to know the worst about me, the things I told no one and hid below the surface. How do I explain it? How do I explain who I am when I am not even sure of it myself? How do I put into words the worst parts of me that I have run from for so long? I will tell you my secrets, I will tell you everything. Maybe it will help me. Maybe you will hate me for it or maybe you will understand. I don’t know, but I am sick of running. So here it is, I will give you what you want.

“I hate you. That is not true, but sometimes I think it is. I will not answer the phone when you call, even though I want to talk to you. I will not call you, even though it is all I want to do. I will not reach out to you, even though every part of me wants to. I will be mad at you, I will want to hurt you, I will drive you away because I am afraid to let you closer. I need your constant attention, your reassurances, but I will greet them with cold indifference. I will be jealous of the attention you give others, and I will get mad at you for ignoring me. I will feel close to you and care for you one day, only to be mad and want you out of my life the next.

“I am an emotional amnesiac, maybe I always have been. I take each event, each day, each conversation as a separate event, always looking for signs that you might hurt me. When I feel neglected, I will get mad and forget that the day before you told me how much you cared. I am an inconsistent mess. There is a part of me who is happy and confident and another part that is insecure and needy. These days, I never know which one it will be. Every time I think I am in control, that I know you care and I feel comfortable with our relationship, the fear and doubt will come back. Maybe with time it will go away completely, but doubt it. All it will take is another close relationship, another new friend, another day and it will be back.

“You ask what you can do and I do not know what to say. The needy part of me wants your constant attention, it needs your words and thoughts, your presence. But I know that is not the answer, I must accept the limitations on our relationship. The scared part of me wants you out of my life because it would be easier. The hateful part of me wants to hurt you because it thinks you have hurt me. All I can ask you to do is to understand, to not give up. I will ignore you at times, I may be rude to you, I may try to hurt you. I may hide from you and wait for you to reach out to me, so I know you will care. It is not fair to do these things, but I will. I cannot ask you to put up with this, it is not fair and no matter how I act, I care too much to put you through this. But you asked, and this is all I have to tell you.

“I do not like this. I do not like that I am needy and clinging. I do not like that I hurt people. I do not like that I am rude and sarcastic to those around me. I do not like this part of myself. For years, I have ignored this and pretended it was me, but I have realized that is wrong. This is not me, it is a false identity created to protect me from the world. This was not an easy realization, and perhaps I haven’t fully accepted it yet. But I have found my path, I have realized I can change and I can accept this side of me and keep it from becoming who I am. It will not be easy and it will not be quick, but I have faith that I can do it. Perhaps one day I will see me as the person you see behind my defenses, and perhaps one day I will let others see that person as well.

“This is for you, but you are many people. You are the people close to me now. You are the people I want to be close to even though I have kept you away. You are the friends I have pushed away in the past, the friends I never forgave and never let back in my life, the friends I never had the chance to tell this to. You are the people I will meet in the future, the people I will care about until once again I push them out of my life. You are the part of me that is still trying to understand who I am. You are all of these people and many more.”

Well, that’s it. Thanks for reading. ––Karen

The letter does seem to be an accurate account of BPD life experience. Internal Family Systems theory proposes that there are “parts” that make up a personality. I have copied and pasted an explanation of this theory for you. I selected a few paragraphs that I thought would make this less psychobabble speak. If you want though you can read the full explanation here

I share this with you because I think it may strike a chord. With all your research I think you’re designing a road map. The map Marsha would call “the way out of hell.”

“Most people try to keep parts functional and safe. These parts attempt to maintain control of their inner and outer environments by, for example, keeping them from getting too close or dependent on others, criticizing their appearance or performance to make them look or act better, and focusing on taking care of others’ rather than their own needs. These parts seemed to be in protective, managerial roles and therefore are called managers.

“When a person has been hurt, humiliated, frightened, or shamed in the past, he or she will have parts that carry the emotions, memories, and sensations from those experiences. Managers often want to keep these feelings out of consciousness and, consequently, try to keep vulnerable, needy parts locked in inner closets. These incarcerated parts are known as exiles.

“The third and final group of parts jumps into action whenever one of the exiles is upset to the point that it may flood the person with its extreme feelings or make the person vulnerable to being hurt again. When that is the case, this third group tries to douse the inner flames of feeling as quickly as possible, which earns them the name firefighters. They tend to be highly impulsive and strive to find stimulation that will override or dissociate from the exile’s feelings. Bingeing on drugs, alcohol, food, sex, or work are common firefighter activities.

“One other key aspect of the IFS Model also differentiates it from other models. This is the belief that, in addition to these parts, everyone is at their core a Self––containing many crucial leadership qualities such as perspective, confidence, compassion, and acceptance (these are your values, the self that your friends tell you are but you deny). Working with hundreds of clients for more than two decades, some of whom were severely abused and show severe symptoms, has convinced me that everyone has this healthy and healing Self despite the fact that many people initially have very little access to it. When working with an individual, the goal of IFS is to differentiate this Self from the parts, thereby releasing its resources. When the individual is in the state of Self, we can work together to help the parts out of their extreme roles.

“The IFS Model…views a person as containing an ecology of relatively discrete minds, each of which has valuable qualities and each of which is designed to––and wants to––play a valuable role within. These parts are forced out of their valuable roles, however, by life experiences that can reorganize the system in unhealthy ways. A good analogy is an alcoholic family in which the children are forced into protective and stereotypic roles by the extreme dynamics of their family. While one finds similar sibling roles across alcoholic families (e.g., the scapegoat, mascot, lost child), one does not conclude that those roles represent the essence of those children. Instead, each child is unique and, once released from his or her role by intervention, can find interests and talents separate from the demands of the chaotic family. The same process seems to hold true for internal families––parts are forced into extreme roles by external circumstances and, once it seems safe, they gladly transform into valuable family members.

“What circumstances force these parts into extreme and sometimes destructive roles? Trauma is one factor, and the effects of childhood sexual abuse on internal families has been discussed at length (Goulding and Schwartz, 1995). But more often, it is a person’s family of origin values and interaction patterns that create internal polarizations which escalate over time and are played out in other relationships.”

I would like to combine EMDR with Internal Family Systems. I think this would allow you see the “parts” as “parts” and not as “self.” Parts take on common roles and common inner relationships. These inner roles and relationships are not static and could be changed if one intervened carefully and respectfully. EMDR would be one way to intervene and certainly create some room for you to identify “parts” if you are desensitized to the beliefs you have around them.

I’m not sure what to tell you about the bipolar disorder. I would like to know what you mean when you say “it’s not helping you.” The medication is supposed to help you stabilize so that your mood swings are lessened. That’s how you know it’s working or “helping.” The therapy helps you become less reactive to an emotional state. On the other hand it would be helpful to your doctor to let them know your trauma history. You don’t have to go into detail, other than letting them know that it is extensive. They may adjust your medication to something else. I don’t know what though. ––Andrew”

I loved it when Andrew introduced new information for me to research. It was always useful information. After learning about Internal Family Systems, I could see exactly which parts of me were managers, firefighters, and my exiles. My exiles were comfortable around Andrew because they showed themselves more often. Never in my life had I told anyone the things I’ve told Andrew. I have two best friends that I trust with my life and not even they know as much as Andrew knows. I even told him about things that I thought I had long forgotten about. I worried that telling him these things might affect him negatively and I certainly didn’t want to do that, but he felt safe to talk to.

I loved Andrew; there was no doubt about that. I wanted Andrew to be in my life forever. He owned such a large part of me, through all of my trauma and all of the things I’ve shared with him. I remember sending him one of my many trauma narratives about an experience I’d gone through during a high-school field trip that would make the movie Mean Girls seem tame. After writing it, I told Andrew that the therapeutic relationship is frustrating because a client shares all of this sensitive information and the therapist helps them figure shit out. It’s meant to be short term, and to end, but how do you do that? How can you just lay everything out there, get stronger, get sutures on all of your emotional wounds, and then send them on their way. That seems so...cold. Andrew responded in a way that he always does, a way that I could understand and a way that fostered rational on my part.

Thank you for writing this. It contributes to your trauma narratives. Once you have told the story it is externalized from you. You can distance yourself from it. It doesn’t have to define you anymore. You are not the same person you are today that you were then. That’s the beauty of narrative therapy. It allows you to continue to define the ever evolving “self” story. These trauma narratives are “parts” of you that have been exiled, however by writing the narrative they are acknowledged again. I’m sure your “firefighters” have a heightened awareness while writing them. That’s normal. The “exiles” are hurting and wanting to find a place in you. This is one way to help them feel that.

I like this line a lot. It really defines your therapeutic process. “How can you just lay everything out there, get stronger, get sutures on all of your emotional wounds, and then send them on their way?” Therapy is meant to help you go on with your life and be independent of the therapist. I won’t pretend that I am not impacted by the things you write. I wouldn’t be human if I wasn’t. However I do want you to feel stronger and to heal. ––Andrew

Wait, did he say he was impacted by the things I say? Does that mean that I upset him? I wondered if I should ask him to explain what he meant. Of course, I didn’t. Instead I let it bother me. Should I stop telling him things about my life? Do I upset him? I hoped not. Because I would never want to do anything to make Andrew leave me. I didn’t know what I would do if I didn’t have him in my life. And for the time being, I prayed I would never have to find that out, at least not now. I needed him too much. I realized right then that my biggest fear in my life was having to go through life without Andrew. I didn’t know exactly when it happened, and I didn’t even understand why; what I did know is somewhere along the way, I had fallen truly, madly, and deeply in love with Andrew.

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