DBT thoughts again……and self-harm thoughts

Long time readers of this blog know I have complicated feelings on DBT. These feelings have evolved continue to evolve.

Where I am at now is that I think DBT has a lot to offer but that it is not perfect. Part of me feels robbed that I was kicked out of DBT as a high schooler. I think at that time I could have benefited from the skills taught there. But since I was too anxious to complete coaching calls and didn’t want to stop self harming I wasn’t allowed access to the parts of DBT that could help me. Further complicating the matter is that the DBT I got wasn’t 100% adherent but still by calling it DBT it made me never want to try DBT again. And to be fair even in really DBT I’d have run into the same issues, though I do think a better therapist could have handled it better.

I have a big problem with the idea that non-suicidal self injury is considered a therapy interfering behavior. I feel like there are cases where it can be therapy interfering, but unilaterally across the board saying that is it always therapy interfering feels black and white in a way that in inconsistent with the philosophy of DBT. I’ve done best in treatments where clinicians pay very little attention to my non-suicidal self-injury. I guess on some level that make DBT a bad fit for me because DBT is a behavioral therapy and self-injury is a behavior.

DBT is coming up a lot for me of late. I got an email forwarded to me a couple weeks ago authored by my former DBT therapist advertising a job. It’s tough seeing him in a high level job when the way he handled things with me caused me harm.

I’m currently in a training for DBT. It’s ……. It’s ….. an experience. I can see how so many clinician’s full force jump in and drink the DBT cool-aid. There are aspects about it that are amazing and the person leading the training is a very skilled clinician. But there are places where some things get expressed and I’m like hmm I don’t feel great about that even though you presented it in a way to make it sound great. It’s not always things I can put my finger on to articulate where it feels off.

Being in this training is bringing up a lot of feelings. Honestly of stronger intensity than I would have expected. My mood on average is so much more level now a days than back when I began this blog. But sometimes I get a rush of emotions and it reminds me ‘oh yes I used to feel like this everyday.’ Some of these things it kind of amazes me how strong it can be given the amount of time passed. I still really feel anger towards that DBT therapist. I also feel angry at a system that was focused on getting me to stop self harming at the expense of the chance to learn skills that might have helped me reduce self harming as a side effect.

It’s taken years. A lot of years. But in the past several months I have gotten to a place where I am actually really looking to make changes with my self-harm. This is a desire for change that is coming from me with no one else putting pressure on me for it. I have self-harmed for more than half of my life without trying to quit. It’s strange to be in a place where I am actually trying.

It’s harder than I expected.

Let’s back track a little first though.

Why now?

I’ve felt for years that for self-harm that is in moderation and not presenting a serious danger to self that telling someone to not self-harm is driven mostly by moralistic beliefs about it being wrong to hurt yourself. Obviously I know better than to communicate this idea in my professional life. But I really do this there is at least a kernel of truth here. Especially if a patient is not wanting to stop. I think folks treating self harm could benefit a lot form borrowing harm reduction ideas from substance use disorder interventions.

So why stop now? I have lots of scars so at this point stopping isn’t going to make my legs ever look normal.

Reasons to stop self-harm:

  1. I have been telling myself for the past year that since I was probably going to get DBT training if I do DBT therapy I need to be making a real effort to stop for myself. DBT wants clinicians to be genuine and I can’t do that if in the back of my mind I’m thinking about how I am still self-harming but holding my clients to higher standards.
  2. It not unusual for me to skip a month if things are going well but I got a string of a couple months and now and maybe at 4-ish months (I didn’t track the last date I did it so not 100% sure it could be longer) so I have some momentum.
  3. I have moved somewhere warm and am wearing shorts a lot. Normally I wear long pants most days but here that’s just not realistic. I’m okay if scars are slightly visible because if seen I can say they are old. But I’m not going to feel comfortable showing fresh cuts.
  4. Joiner’s interpersonal model of suicide argues that acquired capacity is is factor that is needed to die by suicide. Non-suicidal self-injury is one way that acquired capacity increases. Basically self-harm causes you to become habituated to the idea of harming yourself putting you are greater risk over time of death by suicide. There’s a little more to the model than that but I won’t go into it here.                           I think this is important because from my perspective this is the only non-moralistic argument against NSSI that applies globally to anyone engaging in NSSI. Basically, even though it is non-suicidal it puts you are greater death by suicide when you have another time in your life where you are thinking of acting on thoughts of suicide. It’s an unintentional side effect that could increase risk of death when a suicide attempt is made.

 

So this is where I am. I’m at a place where the reasons to quit are at least a teensy bit stronger than the reasons to continue it. I’m letting myself be okay with not being perfect with it. I’m trying not to do it, but also realize that I might self-harm that that that is okay if it happens.

It’s much harder than expected. I thought it would be easier because my self-harm frequency does vary a lot. Going a month without is not unusual nor is doing it several times in one week. But right now is the longest time I’ve ever tried not to do it. In the past I’ve made myself pause it for things like women’s health visits etc.  You have to realize I’m a person who self-harmed with razor blades I snuck in when I was hospitalized and self-harmed without getting caught even on 1 to 1 observations during 3 different admissions. If I’ve wanted to do it I’ve found a way but I have also been able to not do it when needed like the above example of women’s health visits where fresh cuts would maybe been seen (though I’m good at hiding them too with the paper gown, it’s more stressful).

I’ve had evenings where I felt like I was crawling out of my skin in tension. Physical tension is the biggest cue for me to self-harm. I’ve been trying to exercise as a strategy, but ended up injuring myself from pushing too hard.

I’m handling this mostly on my own. I’m not seeing my new therapist (#30) often because of a mix of financial constraints and time constraints.

There is something amazing and specific about where I live that has brought me an immeasurable amount of joy and that is helping me cope. I wish I could share the specific thing here, but it would make my location too identifiable. But trust me if you knew the thing, it would be very clear why it is helping me. I go to this place at least once a week and it feels like a reset switch on any stress I’ve been feeling. I feel so lucky to have access to this place and frankly it is one of the best things that has ever happened to me.

But it’s tough. I’m in a new place. In a new job. And I’m working on making a big change without much support. I have tons of book knowledge about things to help me but it’s not always the easiest to apply to yourself.

I can’t help but wonder the different trajectory I’d have been on about this if DBT had been more flexible with me 13+ years ago. I’m stubborn so maybe it wouldn’t have mattered. It’s certainly not constructive going through these what-ifs but they are popping up as I go through this DBT training.

 

Will I make it through?

I feel lost.

I don’t have any words written for my dissertation proposal yet.

I have to propose it this fall.

I’m so burnt out and exhausted

I’m spending 35+ hours a week on things I have to do but that are not related to my dissertation. Like practicum and teaching and managing research assistants.

 

On the weekends I’m exhausted

I cant focus to move forward

I’m scared I’m going to be kicked out of the program if I don’t so progress by getting this proposed this fall

I have to propose this fall to apply to internship

The list of internship sites is overwhelming

The idea of having to self-promote for interviews and applications is terrifying given how lousy I feel about my accomplishments in grad school

I’m not sure I can do this

My advisor is well intentioned but overloaded with managing some departmental drama and family problems.

I usually like teaching but feel so resentful of it right now for the time it takes away from my ability to work on my dissertation

These feelings are real but I think they are amplified by being on the placebo section of birth control right now

I’m still a lesbian

But I’ve been dealing with awful nausea and one sided pelvic pain for 50% of days linked with my cycle. I’m tying BC to manage it. It seems to me working and I got the green light today to not have to have periods at all anymore.

Stress is breaking my body

I hate the weight I’ve gained in grad school

Today I went from the place of just being tense anxious to looking up suicide methods.

Then I got anxious about risks of it going wrong and opted for a shower, some self harm and a klonopin instead of suicide

I have not activated the mammalian dive reflex yet but it probably is coming later tonight

My cat is useless when I am this distressed

He knows I will hug him tighter that he wants when I am this upset so he is avoiding me

I can’t die because of the cat. He needs me. He’s scared of everyone but me.

I can’t die because I have to teach Wednesday and they need me.

I can’t die because I have patients scheduled this week

When I go to therapy Wednesday I’ll probably feel completely different and have trouble talking about how I felt today.

There will be too much distance from the emotions.

For me feeling suicidal is having intrusive images of methods popping into my head over and over

I’m less impulsive than I was when I was younger.

Instead of going from thoughts to actions I’m trapped in the immobilization of imagery that I am too scared to act on.

For those misreading my intentions here I’ll be explicit and say that I am not at imminent risk of suicide.

I am just flooded with ideation

When I was a teenager the ideation was pretty much daily.

As I’ve gotten older it is less often

But sometimes I am ambushed

I don’t think I ate enough today. 3 muffins and some hummas and crackers probably isn’t enough and probably is making me feel worse

Picking something from the freezer to put in the microwave feels overwhelming

How can I dissertate if I can’t select a frozen meal?

What will I do if I get kicked out without a PhD?

I cant go there.

I need to make the stakes salient to motivate myself

But if it is too salient I am immobilized.

Can anyone recommend something light and fun on Netflix?

I plan to eat better tomorrow

I really put that above sentence there to display being future oriented so no one calls the cops on me

Telling that may have negated the purpose.

But I am future oriented.

Promise

I hate graduate school

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Don’t get a PhD. But I’m 5 years in so i have to see it through.

Diagnoses

In my very first post on this blog 9 years ago I listed different diagnoses I have been given. I was thinking it might be interesting to go through those now given that I have some expertise at this point in diagnosing where I can critically evaluate them. The diagnoses below are all ones I have been given in the past.

Dysthymic Disorder: This one is hard for me. I have a really hard time judging for myself whether I have this or not. I flip flop all the time about whether I think this diagnosis describes me well. It’s really hard for me to objectively take a step back and see if I meet that persistent depressed mood criterion. I can certainly tell when I’ve dipped down into an MDD episode but it’s hard for me to self evaluate if my baseline is really depressed. I certainly have chronically low energy and sleep a lot. But I also accomplish a ton of stuff and keep really busy. But my baseline is very self critical. Jury is out on this one.

Major Depression: There is zero question that I have had many major depressive episodes.

Bipolar type 2: I absolutely do not have Bipolar type 2. People who tried to give me this diagnosis looked at the apparent conflict between my depressive symptoms and my productivity and assumed that there must be a hypomanic component but I never have anything close to elevated mood for that could meet the duration and I sleep a ton all the time. I think there’s also an element of people mistaking my fast talking for hypomania when I just always talk really fast. There’s an anxious part to my rate of speaking but I’ve also tested at 99th percentile processing speed. I think there’s an aspect of me just being able to think very fast. Also I am very socially isolated. Sometimes when I have a chance to speak after not for a long time a lot of stuff comes out because I have not talked for awhile.

Bipolar type 3: An inpatient doc tried to give me this diagnosis once because I had a bad reaction to Ritalin. This diagnosis does not exist so I clearly don’t have it.

Social Anxiety: I have anxiety about a lot of things. Sometimes some of it is about social things but I don’t believe I have ever really had social anxiety. It’s more than some of my generalized anxiety bleeds into social domains. But the symptoms are better accounted for by my Generalized Anxiety Disorder.

Generalized Anxiety Disorder: Hell yes. This is my main underlying problem. Everything stems from my GAD. When I am depressed it’s usually because I ran myself into the ground from being super anxious. Sometimes I have a few good days where I think maybe I don’t have GAD anymore and then some speedbump happens and I realize I clearly still have GAD.

Panic Disorder: I have had panic attacks but I have never had panic disorder. Panic disorder requires fear about having panic attacks. For me it was always that I was anxious about something else and happened to have a panic attack.

OCD: I have a tendency to by obsessional but I think it is really stretching to say I’ve ever had OCD. That obsession compulsion loop does not describe me well generally and when it does it is better explained by other disorders.

Trichotillomania: I absolutely met for this in the past but no longer meet criteria for it. I still pull but the severity is so low that it’s not causing any problems for me. When i get stressed my pulling can increase but I’m not in the clinically significant category anymore.

Tourettes: Yes I meet criteria but I do feel like my symptom presentation is a bit odd since it developed more in adolescence than childhood. Ive had this tendency to get caught on repeating phrases though as a self soothing thing for my whole life so I think that I had an element of this going on as a kid but my parents perhaps didn’t realize that the verbal loops I was getting in were not under my control. I’d say things like “I like my cat” a bunch of times and my parents would respond “Yes we get it you like your cat”. But I wasn’t really trying to communicate things. It was more of a loop I was caught in. I still have tics and they get worse when I’m stressed. It’s only certain kinds of stress though. Social rumination is a major trigger for my tics. I feel nervous wearing headphones in public because I worry I will have verbal tics and not realize I am doing it.

ADHD (inattentive type): I have a pretty well documented pile of neuropsychological testing that says I have ADHD. I think perhaps though I actually have the combined type no the predominantly inattentive type. I’ve gone through all my records from childhood and they all talk about impulsivity symptoms. My most recent assessment found that I did terribly on measures of impulsivity on the Conners CPT.  Right now impulsivity symptoms are the most impairing part of my ADHD. For example I have an extraordinarily hard time inhibiting urged to blurt things out when a thought comes to mind which make some people REALLY mad when it means I interrupt them. I try so hard to manage that but I basically have two modes either fully suppressing any talking or talking where I’m likely to end up unintentionally interrupting.

Sensory integration Disorder: This is more an OT diagnosis and is not in the DSM so I don’t feel qualified to comment.

Auditory Processing Disorder: This is more an audiologist diagnosis so again don’t feel qualified.

Borderline Personality Disorder: Here’s the thing. I can see why people applied a borderline diagnosis to me. I still really don’t think I have ever 100% met criteria for it. I think you always had to stretch some of the criteria in strange ways to make me meet. As of right now I think it’s even clearer that at this  point in time I don’t meet criteria. Borderline PD is often conceptualized as being on this emotional rollercoaster. Certainly I was like that in the past. Now I’m more stably anxious. Under extreme stress I will start to look “borderline” ish because I become very emotionally reactive, am prone to impulsive self destruction, get very distrustful of others, etc. But the thing is I don’t look like that on a typical day or even in the typical week. In the past I had a lot more daily mood instability but I am less reactive now. Every now and then I get ambushed with periods of being on an emotional yoyo but it’s far from being my baseline. Even at my worst people were most likely to give me a borderline diagnosis when I was in acute distress. I don’t think that’s a good way to diagnose personality disorders. Do I have a personality disorder? Probably, but I think I’m more in the cluster A and C camps than B.

Mood Disorder NOS: This is not longer in the DSM but was basically a catchall for weird mood stuff that didn’t fit elsewhere. I actually think a lot of that weirdness can be explained by PMDD

PMDD: I fought this for a long time but I think I’ve come around to it.  The way I see it, PMDD is an amplifier of my existing symptoms. It explains a lot about why I often have short lived depressive episodes that are intense but don’t hit the 2 week criteria needed for MDD. It’s hard to really get across how giant of a mood shift I can have from this. Even when I know that PMDD is at fault because I can look at my period tracker it does little to help in the moment because the emotions feel like just as important signals as they do at other times. It is a source of endless frustration that there is so little research on treating PMDD.

Things I wish I knew before I decided to do a Ph.D. in Clinical Psychology

  • Going in this field makes it harder to get mental health treatment for yourself. You can’t get treatment at the place you work and you need to avoid getting treatment at places you might want to work in the future.
    • When you get treatment it can add a weird dynamic that not all therapists are equipped to handle. It’s hard for my therapist to get the right balance of pointing out a way to apply a useful skill to my situation and irritating me from telling me something I know well from my own clinical work.
    • Graduate school was the worst thing I could have done for my mental health.
  • The stakes are so high for me to not get to the point of needing a psych hospitalization. In those situations so many different people are involved in you care and that means losing control over who has my information.
  • Most people are doing “me-search” but within field stigma against mental illness among people in the field is extremely high. Frankly I think there is more pressure to hide mental illness in this field than in almost any other career.
    • Some mild anxiety or depression is okay. But things like my self-injury would turn some serious heads.
    • There are some high profile people who “come out” about their personal mental health struggles but until you are a top tier famous researcher you have to hide mental illness or risk being discriminated against.
  • Some supervisors  conduct clinical supervision in ways that is dangerously close to therapy. Avoid Avoid Avoid.
  • A PhD takes a looooong time. I know so many people in other careers who have paid off the student loans while mine are still sitting in deferment. I am over this situation of not being in a “real” job. I want to settle down but there are years of additional tasks ahead of me before that.
  • So much of your fate is in your advisors hands and they have zero consequences when they let you down
  • Graduate school is not like school. At the beginning yes you take classes but later it becomes an apprenticeship.
  • In late graduate school you’re functionally holding a job but you don’t get the rights that you would have in a normal job. In fact your university probably will block you from getting the employee benefits they give to their staff.
    • In a normal job if you are treated poorly you can quit and probably find something in the same field. In graduate school transferring is very rare. I am unhappy with my program but my choices are to leave and abandon this field or stick it out.
    • My program feels they even have the right to control our ability to volunteer in activities unrelated to our professional work
  • The longer I am in this program the less of an idea I have about what I want to do with my life

 

I am lost and floundering. I don’t know how I will present my accomplishments positively for internship applications when I am so angry over the ways my program let me down in both my clinical and research training. Reality did not match the advertising.

 

I just so desperately want a job that does not have a time limit on it. Every year my funding is assigned for the year. Every year a new practicum to learn the ropes of. Whenever I get my footing the year is over and I start over. It’s a endless cycle of CV updates and new computer logins.

I have to do internship and a postdoc.  And even after postdoc I’m not guaranteed job stability if I go an academic route.

I could be 40 by the time I have security in the position I hold.

I want a real job

I do not recommend getting a Ph.D.

 

Healthy by graduate school standards

I’ve been in a strange position where people have repeatedly described me as calm, handling things well, good with stress. Not ways I am typically described.

I’m in the midst of some objectively bad circumstances. What makes this situation unusual is that other people are going through it with me. I’m so used to the majority of my suffering coming from mental illness. That’s an isolating struggles. It is bizarre to have a struggle that with social support embedded in it.

People around me in this mess are experiencing their first run ins with clinically significant anxiety and depression. I’m in strange situation where years of dealing with internal stressors that felt worst; somehow have me coping more effectively in the face of an actual objective undeniably shitty situation. I guess of coping with buckets of anxiety and depression that were disproportionate to the situation got me some benefit for handling my present difficulties. I’m still secretly cutting of course, but that is my baseline level of functioning.

Don’t get me wrong. I am miserable. But within normal range and at most adjustment disorder miserable. Not trying to find the fastest way to kill myself miserable.

I’m so aware of my past propensity to quickly escalate to suicide attempts that even being many steps removed I panicked asked my psychiatrist for seroquel prn just in case I need to knock myself out to keep myself safe. I’ve lost some major protective factors in my life. I’m in this strange place of having built so much insight into what makes me suicidal, that losing protective factors makes me anxious even if I am not having suicidal ideation.

But I’m not suicidal. I’m grieving in a way. Not from death, but due to an unexpected and uncontrollable major life change.

When I first started graduate school I viewed the negative comments and despair represented in phd comics as something of hyperbole. I’m deep enough in that that comic is my truth now. I started of thinking grad school was just a matter of systematically plugging way at things and that I would make it through. Now I’m treading water and have a vague idea of where land is. I am working towards finding land but I don’t know if it is the right way or if I will make it. I think I will, but these doubts about finishing are new. I didn’t view failing to get the phd as a possible risk before.

Somehow I have landed in a space where my misery is within the realm of normative graduate school emotions.  I find myself wondering if I still meet criteria for GAD at times. Then I’ll be ambushed by something stressful and decide yep, still there.  But at least in how I am outwardly presenting to others somehow it appears I have my shit together. I guess years of mental health difficulties have actually boosted my coping skills. At least making me look normal compared to a bunch of neurotic graduate students undergoing a major stressor.