The Psych Writer: Exploring Borderline Personality Disorder

I had an idea for introducing the personality disorders after I went through some of the others, but I also take requests, as I said in one of my previous posts. Via Facebook, a request came in for me to write about Borderline Personality Disorder. So I’ll be moving into the Personality Disorders a little earlier than I expected.

That having been said, personality disorders are what we consider “bigger” in therapy. Personality disorders are deeply ingrained into the personality of the client. They are invasive, pervasive, and ever-present.

I live in Georgia. Here in Georgia we have an invasive plant called kudzu. It’s everywhere. It grows all over the place and it can’t just be cut down or even burned (burning is illegal anyway because duh, we’re in a drought most of the time and the place would go up in flames faster than Michael Jackson’s hair in that Pepsi commercial). It has to be uprooted from the ground by its root crown.

That’s exactly what personality disorders are–they’re the kudzu of our personalities. They strangle the existing plant and take over completely. They become the plant itself.

So when we’re dealing with a personality disorder, it takes a long time to get to that root crown and eliminate it so that the person can be less miserable and learn to function better so that the people around them can have improved relationships with them. With several of the personality disorders, close relatives and friends grow weary of the “antics.” It makes it difficult to sustain and maintain relationships.

Personality disorders can also interfere with work relationships and productivity, as well as the general day-to-day functioning of the patient. While the same can be said for any disorder in the DSM-5, with a personality disorder, it is much  more treatment resistant, prone to severe relapse, and is lifelong.

A patient has a personality disorder for life. They are never cured. But they can manage it, find relief, improve their relationships, and even help themselves hold down steady employment. They can work towards stability if they work hard enough. It takes a demanding amount of work.

Borderline Personality Disorder (BPD) falls into “cluster B” of the personality disorders. If you don’t count Personality Change due to Another Medical Condition or Other Specified Personalty Disorder and Unspecified Personality Disorder (which we don’t), you have ten personality disorders in three clusters:

  • Cluster A: This is know as the odd or eccentric cluster. It includes Paranoid Personality Disorder, Schizoid Personalty Disorder, and Schizotypal Personality Disorder.
  • Cluster B: This is the dramatic, emotional, erratic cluster. It includes Antisocial Personality Disorder, Borderline Personality Disorder, Histrionic Personality Disorder, and Narcissistic Personality Disorder.
  • Cluster C: This is the anxious and fearful cluster. It includes Avoidant Personality Disorder, Dependent Personality Disorder, and Obsessive-Compulsive Personality Disorder (which is not the same as OCD).

Borderline is considered to be in the dramatic, emotional, erratic cluster. It is characterized by a lifelong pattern of of instability in interpersonal relationships, self-image and affects, and marked impulse control issues (DSM-5, p. 645).

So what the hell does that mean? That means the patient has little to no stability in their relationships with others (professional and personal), erratic behavior and lack of self-control to the point where self or others are harmed.

According to the DSM-5, the signs and symptoms of BPD are a pervasive pattern (as stated above)–but what makes up these patterns? The DSM-5 reports that for a person to be diagnosed with BPD, they must have five (or more) of the following (which I will give in plain English):

  • Frantic efforts to keep from being abandoned, whether that threat of abandonment is real or imaginary. This does not include suicidal behavior or self-mutilation as that is a separate criterion.
  • Repeated unstable and intense relationships that alternate between extremes of idealization and devaluation. Going from “you’re perfect” to “you’re the scum of the earth.”
  • Unstable sense of self. This instability is marked and persistent and goes to extremes. Not only does the love-hate relationship apply to other people, it applies to themselves and their self-image.
  • Recklessness/lack of impulse control in at least two areas of life that will cause them harm, such as unprotected sex with strangers that could result in STIs, overspending, substance abuse, reckless driving, binge eating, etc.). This still doesn’t include suicidal behavior or self-harm.
  • Recurrent suicide attempts, threats, gestures and behavior, or self-mutilation.
  • ‘Affective instability due to a marked reactivity of mood.’ This one’s a bit hard to explain. Imagine the worst overreacting you’ve ever seen. Now imagine it could happen at any time for any reason. You run out of cotton balls and the person has a massive anxiety attack and the anxiety affect lasts for a few hours. It’s a bit like that.
  • Chronic feelings of emptiness. (Exact words from the DSM. Self-explanatory.)
  • Difficulty controlling anger. Intense anger fits. Inappropriate anger to the stimulus. Imagine telling the person you’re out of donuts and they smash a table in response, demand to see your manager, threaten to sue, and threaten to kill you. While that might be funny and unbelievable, yes, it is that extreme.
  • Stress-related paranoia or severe dissociative symptoms that are transient. In other words, it doesn’t last, but the person will abruptly become paranoid, or they’ll dissociate (the world isn’t real, people are inhuman or automatons, etc.).

Now, writing a character with BPD is actually a challenge. Sure, you can go through all nine of the criteria, but I could almost guarantee you that you’ll create a caricature instead of a character. Even with black-and-white perceptions that many people with BPD have, they are still human beings. Avoid making a cookie cutter. You’ll want to add lines of sympathy to that character. He or she didn’t get there on their own. In many cases of BPD, there is not just a genetic component–there is often a history of abuse–sexual, physical, etc.

The person with BPD does not mean to do these things. They cannot help it. That’s why Dialectical Behavior Therapy helps so much. Patients learn from a system of mindfulness and awareness. DBT was developed by Marsha M. Linehan, who has successfully managed the disorder herself. Bear in mind that if you are writing someone with BPD, remember, they cannot help themselves when they do these things. Yes, some of the behaviors are purposefully manipulative, but they are not malingering. Until they get professional help, they are often unaware that these things are not acceptable, because even though people tell them so, they are often focused on assigning blame to others for their reactions.

Always remember, you are still writing a human being, though these are the extremes of the human condition.

If you came here looking for help with BPD, know that it’s out there. Start with this article here and then search for a therapist in your area who specializes in DBT.


Anne is a former supervised therapist and current author. You can read her books, stare at her Twitter, or stalk her on Facebook if you want.

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The Psych Writer on Major Depressive Disorder, Part Three – MDD with Psychotic Features

This is the final installment of The Psych Writer series on Major Depressive Disorder. This week, we turn our focus on MDD with Psychotic Features.

Of course, when writing any disorder, focus on showing rather than telling, and remember, your character is human. Give them more dimensions than their disorder.

What’s tricky about writing MDD with psychotic features is not making it look like schizophrenia or bipolar with psychotic features. You will need to make sure that the depressive features are most prominent, otherwise the reader isn’t going to get it.

Naturally our writings are always open to interpretation by the reader–that’s what makes it such an enriching experience. It’s not the focus on the symptoms that makes the writing interesting, anyway. It’s the expression of the character and their life that makes the reading compelling.

So, we’ve already reviewed what MDD is all about, but what about psychotic features? Psychotic is a word that’s used in lay terms that tends to get confused with other terms (hell, even I’ve confused the terms when I was exhausted at one point). Psychotic is a term for losing touch with external reality.

The patient who is psychotic can experience any of the following, with some examples for illustrative purposes:

  • delusions – believing someone has bugged their home, is being gang stalked, they have a terrible disease, or that they’re the Archduke Ferdinand.
  • hallucinations – seeing, hearing, tasting, or smelling things that aren’t there, such as seeing a person that no one else can see.
  • anxiety – the person may seem anxious and restless.
  • withdrawal from family and friends – sometimes due to the delusions and hallucinations, the patient withdraws from social interactions. This is not just an “oh, I don’t want to go to the mall.” This is more like they don’t answer any of their phone calls and they stop talking to people entirely. Think the most extreme form of withdrawal possible.
  • suicidal ideation and actions – they may attempt to kill themselves or think about it all the time.
  • disorganized speech – this isn’t your average non-sequitur. Disorganized speech is often completely incoherent. There are several types of DS:
    • word salad – seemingly random words put together in a sentence. “My pants raisin toggle the burp slurped in a cat.”
    • derailment – completely unrelated or tenuously related ideas put together as if they were related. “I have to pick up my dry cleaning. There’s a bar in the street that keeps me from walking to the park.”
    • neologisms – words that are made up. “I took my wife to the helgistahooven for a new haircut.”
    • perseveration – a response repeated uncontrollably (this can be verbal or gestural). “Did you pack a pair of socks?” “Socks, socks, socks, socks, socks, socks, socks…”
    • thought blocking – when a person stops talking abruptly in the middle of a sentence without any explanation. “I went to the store and-” *silence*
    • pressured speech – rapid speech that sometimes is incoherent.
  • difficulty concentrating – this is pretty self-explanatory.
  • hypersomnia or insomnia – sleeping too much or not enough.
  • suspicion of others and situations – this is usually due to delusions.

Keep in mind that the person with psychosis is typically unaware of these symptoms and signs. They are often so out of touch with external reality that they have no idea that their delusions or hallucinations aren’t real, and that their behavior has changed to be out of the ordinary.

Here you see there are some things that crossover with depression, such as suicidal thoughts or actions, anxiety, and withdrawal. Knowing this, it’s easy to understand how difficult differential diagnosis can be.

The standard treatment for MDD with psychotic features is antidepressants and antipsychotics. If that doesn’t bring relief, ECT (electroconvulsive therapy) is another common method.

Overall, when writing a character with this disorder, there’s an opportunity to do a little reality bending. Just don’t make it too much of a trope.

Coming up for The Psych Writer, we’ll tackle some of the following subjects (not necessarily in this order):

  • Bipolar Disorder I and II
  • Munchausen Syndrome
  • Munchausen-By-Proxy Syndrome
  • Anxiety Disorders – Generalized Anxiety Disorders, Panic Disorder, PTSD
  • Schizophrenia
  • Autism Spectrum Disorder
  • Personality Disorders: Exploring the three clusters of the ten disorders.

I also take requests. Any disorder you’d like me to explore? Contact me via Facebook.


Anne is a former supervised therapist at the Master’s level who abandoned it all to become a writer. Visit her shiny Author Page to learn more about her and read some of her more macabre thoughts on paper (or eBook).

The Psych Writer on Major Depressive Disorder, Part Two – Treatment Resistant Depression

Welcome to part two of my series on Major Depressive Disorder (MDD). If you’re looking for the introduction to what MDD is all about, you can find that here.

Last week in part one, I wrote about writing a character with MDD, after detailing the symptoms for the disorder (link in the first paragraph). This week, I’m going to discuss Treatment Resistant Depression (TRD), which I still like to pronounce as ‘turd,” because it really is a turd. When you’re writing a character and would like them to have TRD, it’s important to understand what it is.

So rather than go on with a laundry list of how your character may be written, I’ll go through what TRD is and how it is treated. Then you can decide how your character will fit into it or not. Remember, you’re writing your character as a human being, so it’s okay if they deviate a bit. Humans are not their disorder, so neither are your characters.

TRD is defined as MDD that has not responded to a minimum of two antidepressants. Although some literature says only one, in most professional settings, two antidepressants are tried before determining whether  the depression is treatment resistant.

The difficulty lies in determining the threshold for TRD. There is complete remission and partial remission in symptoms, and there is also reduction in severity of depression. So determining what’s enough for the patient is what determines whether depression is treatment-resistant or not. Personally, I prefer elimination of symptoms, and if any are left, then that’s not good enough, so it’s time to try something else or add something to the treatment. But some people are okay with partial remission. It’s sometimes enough to have some relief over no relief, so best practice is to support the patient’s decision if they have good decision making skills.

When a person has TRD, there are things that they can try to get help. Usually treating TRD begins with an increase of dosage or switching medications. If that doesn’t help, then an add-on is usually used. For example, if the SSRI isn’t working, a combination of an SSRI and an NRI may be used.

Sometimes playing around with medications doesn’t help, though, and sometimes it does exactly what it’s supposed to do. But if it doesn’t work and the patient isn’t already in counseling, they can try a combination of medication and psychotherapy.

Other treatment avenues are Electroconvulsive therapy (ECT), Transcranial magnetic stimulation (TMS), and Vagus nerve stimulation (VNS). Most people cringe when they hear “ECT,” but that’s because they associate it with what they’ve seen in the movies and in old videos when the treatment was actually horrible. Now, the patient is given a sedative and most sleep through it. I’ve watched it done (on video rather than in vivo) and the experience was underwhelming. Of course, there are risks with ECT, including short-term memory loss, but for some patients it beats the hell out of MDD/TRD.

Now, finally, the numbers. This is something you may want to consider when creating a character. Around 10% to 30% of people have TRD, and that number varies on the spectrum of TRD (whether it’s full or partial remission, reduction in severity, etc.). So when you’re creating this character and you want to give them TRD, consider Special Snowflake Syndrome (SSS).While it’s recently been co-opted as a political inflammatory term, I refuse to use it in that manner. SSS means that your character has become a little too precious. If you give them TRD, make sure that they don’t come out corny and cliched, and actually make their suffering real rather than something they manage to brush off whenever it’s inconvenient to your plot.

If you came here looking for help with depression, please seek the help of a licensed professional in your area. Depression is a horrible, soul-sucking disorder that takes your life piece-by-piece. Don’t let it take control over you. Call for help. It’s out there.


There is little more horrific than what lies in our own imaginations. If you love reading about nightmare worlds and strange happenings, check out my author page. You can also follow me on Twitter or Facebook.

The Psych Writer on Major Depressive Disorder, Part One

Disclaimer: This is not a substitute for medical advice and is for educational purposes only. If you read this and any of the below sounds like you, seek the help of a licensed professional in your area.

Depression is a big topic. There are different types of depressive disorders, but for the purposes of this post, I’m going to focus on Major Depressive Disorder (MDD), which affects about 6.7% of the US population. That’s around 15 million adults.

Last week, we reviewed an introduction to MDD, and I still didn’t even get into all of it. So I’ll do that here, briefly. Because of the many sufferers of MDD, there get to be a whole slew of levels of severity and specifiers. While you’re writing about these characters who have these disorders, don’t forget they are a person and they are not their pathology.

Nothing is worse than a character whose only interesting thing about them is their disorder. Remember Forgetful Jones from Sesame Street? Even he had more than one dimension. He was a cowboy. So if a cowboy Muppet with amnestic disorder can be more than just a one-dimensional character, Depressive Jones can, too.

When you decide to write from a place where your character has MDD, decide what type they have. This can be mild, moderate, or severe. They can have psychotic features (delusions, hallucinations, etc.). They can have partial or full remission as well. (Partial remission is having some of the symptoms but not meeting the full criteria for MDD for a period of less than two months. Full remission is an absence of symptoms for more than two months.)

MDD also can come with certain specifiers, such as with anxious distress or with catatonia, but there are too many specifiers to go into without scaring you away from the subject forever. I could likely write a book on each of the specifiers. So, in the interest of time and space constraints (which I will now call space-time constraints to either irritate or amuse mathematicians and physicists), I won’t list them all here. You may wish to skip over certain specifiers, but with psychotic features you can often cross it over with supernatural fiction. This should be handled carefully, though, because otherwise you risk it becoming a trope.

Another important thing to remember is that MDD distorts a person’s perceptions. I used to tell patients that their brains were trolling them. This troll brain is part of the illness. It is best expressed through Beck’s cognitive triad. The person with depression has a negative view of themselves, of the future, and of the world. They often don’t believe they’ll ever get better, this is the way it is, and that there is no one or nothing that can help them. This triad does not necessarily apply to all people with depression all of the time, but there tends to be more leaning towards negative and pessimism during the course of a depressive episode.

When writing from a therapist’s point of view, your character would see the person as ill. They would note things such as poor attention to personal hygiene, being tearful, and a depressed affect (they look “sad” or “down”). It’s an ethical therapist’s job to help a patient process their thoughts and reframe things that happen to them–to teach them how to rethink things. They also do things such as medication education and other interventions. Treatment often consists of Cognitive Behavioral Therapy (CBT).

An unethical therapist would do things such as foster dependency, and interventions that keep the patient depressed and vulnerable to manipulate them into doing things the patient would not normally do. People with depression can be quite vulnerable, and so open to suggestion in order to find relief, a therapist without ethics could possibly ruin the patient’s life further.

I’m not sure if it’s as interesting to write about a therapist treating someone with depression as it is to write about someone who has depression, but even then, it’s important to give your characters full dimensions.

No matter what, though, write your character as a person first, and their condition second. Otherwise, you risk making a flat character that’s nothing more than a stereotype.

If you came here looking for help with depression, please seek the help of a licensed professional in your area. Depression is a horrible, soul-sucking disorder that takes your life piece-by-piece. Don’t let it take control over you. Call for help. It’s out there.


There is little more horrific than what lies in our own imaginations. If you love reading about nightmare worlds and strange happenings, check out my author page. You can also follow me on Twitter or Facebook.

The Psych Writer: Introducing Depression

This is part of a series of The Psych Writer. I tend to write about pretty heavy topics because they’re mainly about mental illness, and though there are many things we can laugh and joke about to alleviate pain, these topics can be painful for some. So I ask you to stay with me and be tough. Put on your writer’s cap and use one of my favorite defense mechanisms–intellectualize with me.

And now, for a disclaimer: None of this is a substitute for professional medical advice. This is for the sole purpose of writing a character with realistic tones. Of course, there’s always poetic license. If you have Major Depressive Disorder (MDD), note your individual experience may vary. If you see yourself in anything I’m describing, consult with a licensed clinician in your area for help.

This is only an introduction. MDD is a complex mood disorder with several possible complications and offshoots, so in order to keep your eyes from falling out of your head (disclaimer: not responsible for deleterious effects), I am going to have to break it up into parts other than this introduction.

So for now, let’s just get to know what MDD is all about. MDD has a lengthy symptom list. The DSM-5 lists MDD as a mood disorder. I’m going to attempt to put it all into plain English here for you, using the copy I have at home.

Here are the criteria for diagnosing Major Depressive disorder:

  • The symptoms must be present daily or nearly every day for a minimum of two weeks before a diagnosis can be made. That means it’s persistent and pervasive.
  • The symptoms must be a change from how the person functioned previously.
  • Five or more of the symptoms must be present during that two-week minimum period. On top of that, the person must have either a depressed mood (feelings of emptiness, sadness, irritability) or loss of interest and pleasure (aka anhedonia). They can have both, but at least one of these must be consistently present.
  • You’re not allowed to include symptoms that can belong to other medical conditions. In other words, they want you to make sure it’s not something else before treatment. Other physical conditions to rule out include:
    • Central nervous system diseases (e.g., Parkinson disease, dementia, multiple sclerosis, neoplastic lesions)
    • Endocrine disorders (e.g., hyperthyroidism, hypothyroidism)
    • Drug-related conditions (e.g., cocaine abuse, side effects of some CNS depressants)
    • Infectious disease (e.g., mononucleosis)
    • Sleep-related disorders
    • Adjustment Disorders
    • Anemia
    • Chronic Fatigue Syndrome
    • Dissociative Disorders
    • Hypochondriasis
    • Hypoglycemia
    • Hypopituitarism (Panhypopituitarism)

    Other psychological conditions to rule out include:

    • Dysthymia
    • Bipolar Disorder
    • Anxiety Disorders (e.g, PTSD, OCD, GAD)
    • Eating Disorders
    • Personality Disorders
    • Schizoaffective Disorder
    • Schizophrenia
    • Somatic Symptom Disorders

      ET CETERA

Okay, so now, the clinician gets into the symptoms. Symptoms of MDD (remember, there is a minimum of five with depressed mood and/or anhedonia being one of them) include:

  • Depressed mood most of the day, nearly every day for at least two weeks. The person can report this themselves (“I feel sad,” “I feel empty,” or “I feel hopeless), or it can be observed by others (“Patient appears tearful.”). For kids and teenagers, there is often a sharp increase in irritability, although irritability is sometimes seen in adults with depression, too. It’s just more often seen in the young ones.
  • Noticeably losing interest and/or pleasure in all or almost all activities that the person enjoyed before. This can be self-reported or by observation from someone else.
  • Significant weight loss when not dieting or weight gain–within one month, losing or gaining more than 5% of the person’s starting weight–or, an increase or decrease in appetite nearly every day (e.g., the person who used to eat their three square can barely choke down a bowl of pudding every day, or a person who used to eat lightly now eats constantly. In kids, this will be seen as failure to make their expected weight gain.
  • Not sleeping (insomnia) or sleeping too much (hypersomnia) almost every day.
  • Moving around too much (fidgeting) or not moving around enough (lethargy) nearly every day. This criterion is known as psychomotor agitation or psychomotor retardation. It also cannot be self-report alone–this must be observable by others.
  • Lack of energy nearly every day (fatigue). Can be self-reported or observed.
  • Feeling worthless or guilty inappropriately, sometimes to the point of being delusional. This isn’t just basic self-reproach or feeling guilt about an illness. It’s a magnified feeling.
  • Difficulty concentrating or making decisions nearly every day. This can be self-reported or observed.
  • Thoughts of death repeatedly–not just fear of death, suicidal thoughts without a plan, with a plan, or an attempt to commit suicide. This also includes repeated suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

And finally, the criteria for these symptoms has to fit as below:

  • The symptoms cause significant distress or inability to function in social situations, on the job, or anywhere a person needs to function.
  • The episode isn’t because of any of the conditions listed previously or because of drugs.
  • The depression isn’t better explained by another psychological condition as listed above.
  • The depression didn’t come with any mania or hypomania. Clinicians can’t count this exclusion if the mania/hypomania is due to a drug/substance or because of a medical condition.

Did you think that MDD was easy to diagnose? As you can see from above, it’s not always clear-cut. That’s why it’s important to pay attention to symptoms.

Keep all this in mind as we venture into the depths of writing MDD, and again, if you need help, contact a licensed clinician in your area for help.


I am a former supervised therapist with experience in the mental health field since I began graduate schooling in 2003. Now, I write about the things in my head.

The Editor’s Corner – The Rough Draft

As you know, last week we just finished up a section on grief in The Psych Writer Series. So this week I wanted to take a break and head to The Editor’s Corner. After all, we’re writers, not psychologists. (For those of you enjoying TPW, we’ll get back to it soon!)

I have a little online writing group and as a freelance editor, I give writing tips and tricks to the youngsters on how to improve their writing (they are ages 13-20). But I don’t care to be all high-and-mighty. I write, too.

And my rough drafts are hellacious.

Everyone’s are. But I put them up in the group, anyway.

There is a reason that I post my rough drafts for their critique. I want to show them that even an editor who picks apart everything about a novel from start to finish to help them make a better piece of writing also has crappy rough drafts. We all have our quirks and problems in our first draft.

This is why I present them a rough draft, so they can see that.

Why?

Because the first time a person gets their manuscript back with line-by-line changes and more “red ink” on it than black, it’s effing discouraging and makes people want to throw their work out the window and into a bonfire.

But I assure them: if you get something back that marked up, it means you have potential. An editor will not waste time on a work if they don’t think it can grow.

So if they or you ever ask me for my professional feedback and you get it, even if some of it’s difficult to take, know that me spending time on your work means something. It means I think it has potential, and that’s the highest compliment an editor can pay to a writer.

In a letter to 19-year-old Arnold Samuelson, Ernest Hemingway once wrote the following:

“Don’t get discouraged because there’s a lot of mechanical work to writing. There is, and you can’t get out of it. I rewrote the first part of A Farewell to Arms at least fifty times. You’ve got to work it over. The first draft of anything is sh*t. When you first start to write you get all the kick and the reader gets none, but after you learn to work it’s your object to convey everything to the reader so that he remembers it not as a story he had read but something that happened to himself.”

This is what an editor helps people do. We don’t function as writers in that moment. What we do is massage the work into a shape that will leave the reader euphoric, devastated, or otherwise moved. They will incorporate your story into the tapestry of their lives.

This is why I share my rough drafts with my group. To show them that the work is always, without exception, in need of more refinement.

So when you share a work with a professional and it’s a rough draft, expect a lot of feedback. A lot of it. That doesn’t mean it’s bad or it’s crap. In fact, it’s the opposite.

Happy writing!


I am Anne Hogue-Boucher. I write stuff and then I edit it, and then edit it some more. I also get it edited. If you’d like to read some of my work, pick up a copy of Exit 1042. There’s more on the way. You can also follow me on Twitter and Facebook.

The Psych Writer: Grief – Phase Seven: Acceptance

This is the final installment of the grief section in The Psych Writer series. Last week, we took a look at The Depression Phase. But now we can take a nice, deep breath and look at how far we’ve come. All the way to acceptance.

These phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized. There is also fluidity in acceptance. It can fluctuate, just like the other phases.

Oh, acceptance, this phase is so lovely, right? Happy bluebirds sing all around you as you realize you fully accept that x loss has happened and sunbeams arch from your head in a golden halo of enlightenment.

NO.

Acceptance isn’t pretty. It’s not always peaceful. It’s not often a loving, gentle tutor that allows us to smile once again. No. It’s part of the process, and sometimes, perhaps most of the time, it’s ugly before it is fine. The experience varies from person to person.

What acceptance is can be anything from a bitter resignation to one’s fate, to a calm recognition of this is how the way things are, and everything in between. This is the moment where a person says, “my mother is dead. Nothing can change that,” or “I lost my job and there’s no going back.”

Acceptance is the first step to putting one foot in front of the other and rebuilding life without whatever was lost.

Acceptance from the Patient’s POV
The patient feels the loss, though often less acutely than in the other stages. The grief has been replaced with the ability to function without the target of their loss. There may be lingering feelings of sadness, anger, and those feelings may resurge from time to time, but there is a sense in the person that they need to move forward. Acceptance of a non-lethal event, such as job loss or divorce, a spark of interest in other activities may arise. The person may have found a new love interest, or a new job may have them ready to move on from the old one.

Acceptance from the Therapist’s POV
While this is often a good sign that the patient is ready to make significant leaps into moving forward, it is important to check in with them to see how they feel about their newly found acceptance. Is there resignation? Optimism? Pessimism? Fear of moving forward? It will be up to the therapist to help the patient work through those retentive feelings so that the patient can move toward healthy and more helpful feelings.

What this Means for You, The Writer
Getting to acceptance might be a good starting point for your character, and however they get there will be far more interesting than the feelings themselves. Does your character need revenge in order to accept something that was taken from them? Will it help? Will they regret what they’ve done, or will they accept it and move on to better things? Starting a character in the acceptance phase might be interesting if you can flip the acceptance on its ear. What comes next after they’ve accepted their fate? These are all questions you may wish to answer for your character.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Breathe easy, we’ve gotten through this together. Now go write.


Now that we’ve done this in-depth examination of grief, let’s move onto some other topics. I take requests (you can ask via Facebook or Twitter). Next week I’ll do some fluffy topics or post a picture of my cat. Maybe. Or I might drag you further into the abyss. Who knows with me? If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on grief and loss, grab a copy of Exit 1042.

The Psych Writer: Grief – Phase Five: Anger

Last week, we explored the guilt phase of grief as part of The Psych Writer series. Thanks for sticking with me thus far, as we’re almost finished with grief, and it’s a difficult topic to face. But after this, there are only two more left in the series, so hang in with me.

So after guilt, the anger phase often follows. Keep in mind the codicil that you can pretty much repeat with me now: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

Now back to anger. The person who is experiencing the anger phase may lash out in a variety of ways. That will depend on the person, the source of loss, and their current circumstances. They get angry with a person for dying, they get angry with the doctors or medical team for “not doing enough” or making a mistake (whether there was a mistake or not doesn’t matter), or they get angry with people for tangential reasons.

While the anger is a natural reaction and completely expected, it is vital that the person doesn’t get stuck in this phase, and it’s probably one of the most addictive phases to get into. You may already know this, but emotions are handled by the amygdala in the brain, and judgment is handled by the prefrontal cortex, and the left prefrontal cortex can shut down emotions. (This is basic information for the sake of brevity: if you want to read more, about anger, check out this article.) When a person is angry, there are a number of hormones released, including adrenaline and noradrenaline. Because those are “pump you up” hormones to get the body ready for a fight, anger can be addictive. It’s like runner’s high without all the knee blowout from running.

Anger from the Patient’s POV
The patient is pissed off royally. How dare X happen? How could grandma do that to you? How dare she die at a time like this?! How dare Phyllis divorce you?! Who does she think she is? Those fucking doctors don’t know anything! They couldn’t save Uncle Phillip and they’re all just money-grubbing bastards. What were they thinking?

There is a touch of the indignant to this type of anger. Remember, the focus of the anger can be anywhere, even at themselves. Grief is necessarily selfish, so the anger is most likely due to the fact that this person has been left alone, holding the bag as they say. There are underlying feelings that are feeding this phase.

Anger from the Therapist’s POV
As the therapist, it is your job to dig with the patient and find out which feelings are feeding the beast. Sometimes it’s fear. Fear of being alone. Fear of loss. Fear of mortality. Sometimes it’s feelings of helplessness. They were abandoned. They lost their sense of control. Or all of the above, plus ones you can’t fathom at the moment.

All of these feelings, and more, are normal and expected. When someone dies, and the patient is angry, it’s important to let them explore those feelings in a safe environment.

Here, you monitor for homicidal ideation even more (although you always monitor for suicidal as well, homicidal should not be forgotten) than before, because people who are angry may not be able to switch on the prefrontal cortex’s ability to stop them from doing something that could ruin even more lives.

Other things you have to watch for is increased substance abuse and self-harm.

What this Means for You, the Writer
This is the perfect opportunity to get your character set up for starting their revenge against whomever caused their loss. It can also be a good opportunity to write about their anger turned inward, and how they fell into a pit of depression, struggled with addiction, or committed acts of self-harm.

If you’re writing an unethical therapist, keeping the patient in this phase can help them orchestrate a murder, create chaos, or other unsavory ends via unsavory means.

Remember, it’s not the grief itself that’s interesting, it’s how the character faces it, doesn’t face it, or makes matters worse that is interesting to the reader.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Good luck, and get writing.


Just two more to go and then we’ll move on to other mental health topics. You’re almost at the end of the grief series, can you believe it? If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on grief and loss, grab a copy of Exit 1042.

The Psych Writer: Grief – Phase Four: Guilt

I want to take a moment to thank my blog followers for sticking with me through these heavy topics. We’re more than halfway through now, and soon, I’ll be moving on to how to write other aspects of mental illness accurately. While it doesn’t mean you can’t take liberties and poetic license, I’ve seen writers bumble through having no idea what they’re writing about. (One of the most woeful examples I can recall is calling a person on the Autism Spectrum a “psychopath.”) The stories are still popular, but for people with the disorders they’re maligning, and the therapists who treat them, it’s cringe-worthy and ruins the story.

Last week, we explored the phase of bargaining in The Psych Writer series. This week, we’ll look at the next one: Guilt.

All together now, say it with me: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

Nearly everyone on earth has experienced guilt and knows how it feels. When it happens in the guilt phase of grief, it manifests in a variety of ways. Here are some of the most common statements I’ve heard from patients in this phase:

“I wish I had spent more time with X before s/he died.”

“I should have been there to take away his car keys.”

“The last thing I said was ‘I wish you were dead,’ and now look what happened!”

“This is all my fault. I had to sign the papers to pull the plug. I killed my X.”

“If I had just noticed sooner, I could have urged them to go to the hospital earlier.”

See a common thread here? The guilt doesn’t typically surround the deceased or the object of loss, rather what the person perceives or feels about their own actions. This is often where the person feels a tremendous burden, a wish to go back in time. Regret. Remorse. As if there was one thing they could have said/not said, done/not done and it would magically change everything.

It won’t.

Guilt from the Patient’s POV
The person feeling guilt has turned inward, usually after bargaining and getting nowhere. Unsuccessful in finding an outward solution, s/he turns inward. There must be something she could have done to change the outcome, right? He will play the scenario over and over in his mind. She will ruminate on what the one thing is she should have changed to prevent “this event” (death, loss, etc.) from happening.

Guilt from the Therapist’s POV
As the therapist, your job is to remind the patient (gently) that loss is not something a person can prevent (unless they actually murdered a person). If there is some reasoning that the person could have prevented it, then it’s your job to bring the patient’s attention back to the present. What is done cannot be undone, as the saying goes. There are no time machines and even if there were, the action the patient believes might fix something may not fix it or even make it worse.

Understand that guilt is selfish, and it’s 100% okay to be selfish in this case. This is also a necessary part of grief as a person recognizes that s/he too is mortal, and not capable of stopping all death from happening.

People are self-centered in the guilt stage, and it becomes about what happened to them or what they could have done to stop the loss. Self-centered attitudes are not necessarily a bad thing as they ensure human survival, and when it comes to guilt, the focus on self is a necessary part of it. If you don’t care for the terms “self-centered” or “selfish,” think of it as “focusing inward.”

What this Means for You, The Writer
This is going to depend on quite a few factors when  you write a character’s guilt over a situation. Did they cause the loss? Do they feel remorse? Are they capable of remorse? Are they traumatized? What level is their involvement in the loss?

As you answer these questions, keep in mind that the character will be focused inward. Keep it to what they believe they “should have” or “could have” done to prevent the loss from happening.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Good luck, and get writing.


All right, just three more of these to go, and then we can get into other wild topics. Hang tough, dear readers! If you’re in need of some lighthearted diversions, check out my Facebook and Twitter. Or for some entertaining fiction that touches on this subject, grab a copy of Exit 1042.

 

The Psych Writer: Grief – Phase Two: Denial

This is an ongoing series called The Psych Writer. Last week, we explored the first phase or stage of grief: shock and disbelief. This week, we’ll take a closer look at phase two: denial.

This stage used to be lumped into the first stage of shock and disbelief, which makes sense, but over time, therapists have discovered that denial takes on a life of its own.

Now, the standard caveat that you will be able to repeat with me by the end of the grief series: these phases are organized for the benefit of the clinician. They are not set in stone and the patient will likely not feel these things in order, or one at a time. They might, but they might not. Grief is individualized.

This phase is usually the “second phase” because of its proximity to shock and disbelief. It seems easy to fall into denial. Keeping in mind not everyone experiences this phase (see the note above), some people find their shock and disbelief is extended. For some, it becomes more elaborate.

For example, little Tommy was four years old when his mother died suddenly. Unable to accept or cope with the loss of his mother, Tommy begins to believe a story that she’s gone on a trip and will be “back soon.”

Another example: Greta is a 55-year-old who has been diagnosed with a terminal illness. When her husband asks her about it, she says she doesn’t know anything and doesn’t want to know anything about it. She doesn’t want to lose sleep over “worrying about it.”

Denial from the Patient’s POV
This phase is a more elaborate, amplified version of shock and disbelief. The person experiencing denial may appear quite strong to family and friends. They hold their heads high, or say things such as, “I have to keep on going.” They appear to have accepted their fate. Or they act more like Greta, and say things such as “I can’t think about this right now.”

The person in denial often has internal dialog of the wandering mind. They cannot concentrate, or are forgetful surrounding the loss. The person may find himself setting an extra place at the dinner table. She may reach for the phone to call the loved on to tell them some bit of good news. They may leave the person’s room untouched and not sell or get rid of all items (keeping heirlooms and keepsakes do not count), and get livid if you move them or disturb them.

In the extreme, rooms become shrines to the lost one, or the person turns to substance abuse to aid in suppression of pain.

Denial from the Therapist’s POV
Boy, have you got your work cut out for you. As a good therapist (remember to do the opposite if you’re writing a crappy one), it’s your job to serve as a point of reality for the patient. Your reminders for the patient that the loved one is gone or the job will not suddenly return need to be consistent. Be with the patient in his/her denial and empathize without sympathizing (the difference being that this is about the patient and their unique experience, not about you and your own grief).

Here’s an example of how a session might go, and how the therapist would guide the patient into reality:

Patient: I reached for the phone to tell Grandpa the good news about my promotion.
Therapist: What happened?
Patient: I didn’t call. I put down the phone and made coffee.
Therapist: So you didn’t complete the call, and distracted yourself with something else, then?
Patient: I guess I did. I just can’t accept that he’s gone.
Therapist: How do you feel about him being gone, and that you can’t call him with good news anymore?

The therapist is extracting information to find out how the patient is processing the loss and where they are in their grief. How deep is this denial? Do they get tearful in their response? Do they get angry? Confused? Delusional?

Fictionalize it any way you like, of course. What would happen if Grandpa had answered?

What this Means for You, the Writer
If you are writing someone in the phase of denial, you’ll be the one to decide how extreme it is or if there are any paranormal elements. Consider how long the phase will last (the more extreme cases of denial last longer than six weeks and sometimes for years), and the elaborate lengths your character will go do to keep their denial going.

If you came here looking for psychological assistance, please contact your local crisis line. Dial 2-1-1 in the US for the United Way, or contact the Samaritans in the UK. For a list of international crisis lines, click here.

Remember that when you write this phase, it’s important to think of it as a more elaborate trick of the mind to protect your character from pain. If you are writing from the therapists point of view, remember your goals are of a facilitator and you are there to cushion the blow of brutal reality for your patient. You are the bridge back to healthy grief processing, and it is up to you to provide tools for the patient to get beyond this stage so he or she can begin functioning once again. Additionally, remember that you are not to foster dependency on you as the therapist (unless you’re writing a bad or unethical one). You are there with the tools for your patient. If you’re portraying an unethical therapist, be sure to exploit this phase by assisting in expanding patient denial.

Be well and get writing.


Well that was yet another heavy topic, I know, and there will be more to come soon, so brace yourselves. For some lighthearted things, check out myFacebook and Twitter. Or for some entertaining fiction, grab a copy of Exit 1042.