Monthly Archives: July 2010

Imagining Self-Injury and Therapy

I think about self-injury a lot. Most days I don’t self-injure, but most days I think about self-injuring.

In the earlier days of my self-injury the thought would pop into my head and in most cases I would do it as soon as I could following the idea.

I didn’t care about getting blood on my clothes and often wore dark pants that would hide the blood stains.

I wanted to self-injure and then it was off to the nearest bathroom. That’s an exaggeration. I still thought of self-injury more than I acted on it, but I acted on it much more quickly when I did. Certainly external events would sometimes prevent me from doing it, but I’d often find ways, even if it meant secretly scratching myself with a safety-pin under my clothing.

That was high school. Things shifted in college.

It’s obviously more comfortable to self-injure in my bathroom than in a public one. In high school waiting until I got home meant waiting until the end of the day. In college, waiting until I got home often meant waiting however long it would take me travel there. Sometimes that means waiting until a class is over, but rarely the long waits I would have in high school.

I began opting to wait a bit to have the better self-injury experience at home rather than the scared “I hope I don’t get caught” one in a public bathroom. I don’t always do this. I still punch trees, sign posts and walls while walking places, but those days are more extreme than most.

This waiting has stretched out more and more. When before it was waiting 3 hours for a class to end, now I’ll wait the whole work day. Almost all of my self-injury now occurs at night. Self-injury at night is routine, but in the day time is a sign of trouble.

The freedom is crucial. It’s not that anyone is telling me I can’t self-injure then. I can do it if I want to, but often opt to instead wait for the preferred environment.

I picture the self-injury in my head. Imagining the cuts on my body. Sometimes I move a finger briskly across the location I will cut. I think of watching the blood drip down my leg.

And these images in my head are soothing. I plan, “I’ll self-injure when I get home”. Knowing that option and plan is there helps.

I fully intend in the moment to self-injure when I arrive home. But often by the time I arrive at home, my mind is on to other things. Sometimes I self-injure and others I don’t. The intention is the same when the initial thought arrives, but the intervening experiences vary, leading to different outcomes.

I want to be sure to differentiate what I am talking about from therapy techniques where a therapist authoritatively tells a client that they should stop self injuring by trying to wait X amount of time and then revisit the idea.
This is a process that has evolved on its own rather than being artificially forced upon me.

I am not waiting as a means of ultimately avoiding self-injury. As I have said, I don’t think self-injury in moderation is objectionable.
But do I prefer to bleed through a pair of pajama bottoms rather than a nice pair of pants? Yes.
Do I like looking down at my leg throughout the day to be sure blood isn’t visible to people? Not really.

In the moment, I believe with a high degree of certainty that I will self-injure when I arrive at home.
It just turns out that I am not very good at predicting this.

I recently had an occasion where I was concerned I might need to change clothing in front of another person. I wasn’t sure and it turned out not to be the case, but I was very worried about it at the time.
If no fresh cuts are visible I can angle my body so that scars might not be seen.
I had to avoid self-injuring for a few days after I learned of this event. I go weeks without self-injuring fairly regularly. I thought a few days would be nothing.

Once I told myself I couldn’t self-injure my stress skyrocketed. I couldn’t visualize the self-injury. It only worked when I believed in the moment that I would do it for real when I was home. The images were nothing without the hope of reality.

I’d not been fully aware how often the thoughts were in my head. As soon as you try not to do something it becomes so much worse.

The thoughts themselves are soothing. I need the possibility to be open.
I can’t force any of this. It only works if the thoughts are spontaneous.

I was able to avoid self-injuring, but it was not an enjoyable few days.

I’ve found a similar phenomenon occurs with my therapy.
When I am in therapy I have frequent conversations in my head with my therapist. All the conversations are ones I imagine I could have with the therapist. Often they are difficult topics I’m struggling to bring up and I replay the scene over and over looking for the right way to present information.
My actual therapy sessions only vaguely resemble their imagined versions. Some topics from my visualizations do get brought up in my real therapy, but most do not.
The pretend therapy in my head is a useful tool for sorting out thoughts and often by the time I get to therapy I don’t need to talk about that issue any longer.

When I am not in therapy this process doesn’t work. I have to be able to think the conversation could take place. Without it my brain becomes a cluttered mess.

When in therapy that doesn’t seem to help much in session, the pretend therapist in my head that I gain access to can be more valuable than the session itself.

Without therapy I sometimes shift to imagined blogging, which is not as good as imagined therapy, but serves a similar function.

CBT therapist

I’m not going to apologize for my lack of posting, because I hate reading those.

After firing therapist number 23, I thought I might take a break from therapy for a bit. I was very angry at him, but leaving was a huge relief and immediately had a positive impact on my mood. The relief lasted a bit, but soon, without another outlet, some grumpyness began to ooze into my professional life.

I really like psychodynamic theories. The therapist who I have liked the most was psychodynamically oriented, while the one who kicked me out of school was into CBT.

I keep seeking out these psychodynamic therapists in an effort to replicate the therapy I had with this other therapist (S.M.). I want this idealized perfect therapy that I read about in text books. I want one where there are insightful interpretations and the new relationship disproves the assumptions from my old object relations.

My best and worst ideas are impulses that come to me while trying to sleep or taking a shower. I lept out of bed to the computer. I needed something completely different.
I searched on the ABCT therapist directory. I would find a CBT therapist.
This was harder than I expected.
Despite living in an area with a relatively high population of therapists, the list was short. Many of the names were names of researchers working at one particular research center. I didn’t want to participate in a study. I’d feel too guilty when I didn’t get better.
I narrowed the list to two choices and went to sleep.

I made a call to one therapist in the morning.

After the call I began rationalizing my impulsive, poorly thought out decision.

“This isn’t real therapy”, I thought. “This is rebound therapy”.
I don’t believe CBT has the ability to ultimately fix my problems, but I thought maybe I should give it another shot
temporarily. After all it is really the B part, behavioral, I object to, the C part, Cognitive, is not so bad. If I could find a person using the right balance of minimal B and mostly C, maybe it could work.

I figured it could be short term and might shove me out of my therapy rut.

Whenever I disagreed with my previous therapist’s interpretations he would argue that maybe the process he was speaking of was unconscious. It was infuriating, when he would pull things out of seemingly nowhere and say this. How can you argue with the unconscious?
At least with CBT I could dodge that.

I made an appointment and began to feel guilty.

I have so much anger towards the CBT therapist who got me kicked out of my school much of which has generalized to the theoretical perspective as a whole. This poor woman would have to be subjected to this. She had no way of knowing what she was getting into. She’d done nothing wrong yet, I’d not even met her, but I was feeling intense rage and fear towards her.

I felt awful about what I would put this poor woman through and decided I needed a peace-offering to begin with.

Where do CBT and I have common ground? We both like data. I keep track of a number of variables in my life.
I decided to print out an excel sheet of the past several months of certain variables, complete with averages at the bottom of each column.
As it turned out, I never showed her the spreadsheet, because the timing was never right.

I built her up in my head as this monster I needed to defend myself against. When I arrived at the first appointment to discover she had only one head and no visible fangs it was a relief. Almost anything she could have done would have been better than my expectations.

Much of the anger dissipated once I entered the waiting room for the first appointment and behind it I was terrified.

She won some points for acknowledging how traumatic the whole getting kicked out of school mess was.

I decided to keep meeting with her.

I never told her where I go to school or where I work. It started to feel silly after awhile, but it was a nice little extra level of safety. She couldn’t use that information to hurt me if she didn’t possess it.

She’s a psychologist, so she can’t prescribe. In the first week of August my Klonopin was going to expire. That date acted as a deadline for when I needed to transition therapy to a psychiatrist or at least find a psychopharmacologist.

Through a misunderstanding, she thought I wanted to end at the end of June. I’d been thinking more like the end of July, but decided to leave it at June.

I went to her looking for CBT and received supportive therapy, not CBT.
That’s not useless, but also not what I’d been looking for.
For all of ABCT’s posturing about empirically supported treatments and manualized therapies, I didn’t see much of that. I shouldn’t really be that surprised that outside of a research setting CBT can mean anything really. Both CBT and Psychodynamic ideas have problems with inconsistencies in their implementation. Finding that specific treatment you want out in the world is not so simple.

I was even willing to fill out worksheets. There was not a single one. I have trouble believing it’s real CBT without a worksheet or two.

She did admit that it wasn’t really CBT.

Maybe getting something other than CBT from a CBT practitioner was all I could really handle. If nothing else it was some exposure therapy to just show up.

I had such a problem during the spring semester in one of my classes. My intellectual feelings about CBT differ from my emotional feelings. Speaking in class I need to be so careful to only speak from my frontal cortex rather than from my amygdala. Too often I’ve allowed bit of emotion to bleed into my words.

Professionally I need to be able to separate the two. More and more I am encountering situations that push my limits with exposure to CBT outside of my own personal therapy.

Villainizing CBT can be too easy when working with psychodynamically oriented therapists. There is a long history of animosity between the two groups. They tend to collude with me in this issue. The difference is that they are objecting to it theoretically (although emotions are certainly there, but they are an effect rather than a cause), while I am objecting to it emotionally and finding intellectual reasons to rationalize that emotional reaction.

I do feel I got some benefit from the therapy, even though it was clear the therapist felt she’d failed me somehow. Most sessions were me spending an hour going through my massive to do list. I was so busy and exhausted that directing therapy towards a goal was way outside of my present abilities.

Just being there with a CBT therapist, the content wasn’t important. What was important was the conflict free relationship with a CBT practitioner. This helped me work through some of the negative transference I’d been experiencing toward her before the first appointment. Really in this way the “CBT” therapy did more for my object relations than a lot of psychodynamic therapy has done.

I’m still messed up, but this feels like a teensy step in a good direction.

I feel embarrassed about going to see a CBT therapist. I called S.M. a couple of times while I was seeing her. I lied saying I wasn’t in therapy. I asked him for a referral for the new therapist I went to see after this CBT therapist. I also did not tell the new therapist who I saw on Thursday. I lied and said I’d been out of therapy entirely for the past couple of months.