Updated thoughts on DBT

It appears my post about getting DBT notes has gotten some attention recently. This made me realize I’m long overdue for updating here about my current thoughts on DBT.

Here’s a link to an earlier post about my thoughts on DBT: Do I need to rethink my feelings about DBT?

There is a part of me that feels I was robbed of a “true” DBT experience. I know now that strict adherence to DBT protocols would not have allowed for me to do individual therapy for DBT while waiting for an opening in the skills group.  I never got to join the group before being kicked out.  From what I’ve learned in coursework about DBT I think I would have really benefited from the interpersonal effectiveness modules at that time in my life.

I think that the therapist I was working with could have done a lot more to work with me regarding my anxiety around phone calls. I do still feel that it seems backwards to kick me out for self-injuring and being too anxious to make coaching calls.  I don’t believe that low severity NSSI should be classified as “therapy interfering behavior”. I still find this rule to be very backwards. However, I do think that it could have been possible to sell me on this part of the treatment if it had been explained the right way. The way I experienced it, I was just ambushed one day with an ultimatum to do the calls or quit. I think if the role the calls play in the model of treatment had been explained to me clearly  I might have been able to buy into them more.

My non-DBT therapist at that time was doing a lot to unintentionally reinforce my self harm. When I didn’t self harm  after feeling upset she would ask in excruciating detail why I had not self harmed. This led me to self harm more since I never had a good answer for why I hadn’t done it. If I self harmed when upset I didn’t have to generate a reason why I didn’t do it. I didn’t have the language at that time to articulate this. But I think a lot of problems around the coaching calls besides the phone anxiety related me to at some level understanding that in many cases talking about my self harm in therapy was making it occur more often.

The “DBT” I encountered in hospital and partial hospital settings was DBT in it’s worst form. It was done in a way that didn’t strictly adhere to the protocol (It was just handouts) and was run by people with minimal training in the therapy. This didn’t help my opinion of DBT. I think my DBT experiences drive home how much damage can be done when people deviate from a manualized brand name treatment but still label it with the brand name. It was a long time before I realized that I didn’t ever get DBT in the way Linehan intended. If I had realized this maybe I might have made different choices about trying DBT again.

I still object to the way DBT can be pushed aggressively and I think the rules around NSSI and coaching calls are too strict. But I have warmed up to the benefits a lot of the skills can offer.

I’ve warmed up to Linehan as a person. I love watching her call out people on bullshit at conferences. She is a wonderful public speaker. I love her presentations about the iatrogenic impacts of hospitalization. Despite her data against hospitalization being being correlational, I think she makes a really good point in this area about the lack of evidence in favor of hospitalization.  That said, I’ve not warmed up to her so much that I’d ever want to work closely with her in a professional context.

I don’t think I’ve warmed up to DBT enough to do DBT as a clinician. I certainly use some DBT handouts with clients, but that’s different from doing DBT and I don’t represent what I do as DBT. I don’t think I could buy into all the parts of the treatment sincerely enough to do it. I also think that with DBT if I were to strictly follow the protocol it would be wrong for me to continue my own self harm while treating it as a “therapy interfering behavior” for my clients. I believe I could stop self harming if I were in this situation. But I’m not sure I want to. For me, the benefits of self-harm still feel greater than the negative consequences.

My feelings towards DBT are more positive than they were in the past, but I maintain some criticisms of the treatment design.



Every year is filled with new exposures

Every year moving forward in my career brings new challenges related to the intersection on my professional life and my experiences on the patient side of the mental health system.

This brings me sitting in an employee bathroom at a Psych hospital looking at the cuts on my legs. I think about the hypocrisy that my clients would be placed on one to one observation over this behavior while I have the freedom to cut or not cut as a choose. I have the keys to the doors and come and go as I please.

I have anxiety about whether I am doing too good a job of validating patient frustrations about being in hospitals. If I validate too well does it dislodge my mask of someone who is psychologically healthy?

I am glad I wrote so much down in this blog. As I read through old posts sometimes I scare myself realizing how I have forgotten some details. I think documenting what I have felt is good to make sure I don’t lose perspective. I wanted to join this field partially to be able to fix things from the inside. But if I lose what I felt when outside the field I can’t properly advocate for situations relevant to past me.

My first day at the hospital, hearing the doors shut behind me was very anxiety provoking. I feel more confident having used the key many times. But when a key is finicky and gets stuck I feel trapped in the moments while I wiggle it into position.

I grapple with the tension between the type of therapy I have gravitated towards preferring to implement (CBT) and the type of therapy I like for myself. I find supportive and psychodynamic approaches helpful. Yet when I do supportive therapy for clients I feel guilt over not teaching concrete skills. When therapists through skills at me I am a master of trash talking any emotion regulation skill that I don’t feel like using for myself. I went from hating CBT based on personal experiences to considering it a solid first line treatment.

I am going to a conference where I might run into the therapist who kicked me out of my undergrad school. I don’t know if I am terrified or just looking forward to getting over the inevitable first meeting.I am bound to run into him at some point. We have lots of mutual colleagues. I kind of just want to pull off the bandaid and get this interaction (or awkward hallway eye contact) over with. I have been playing disaster scenarios in my mind for 9 years about running into him. Sometimes in them I’m snarky, others I’m panicky, others I run away. None of my anxious imaginary situations are as simple as a handshake and pretending to have never met him before. I doubt he would recognise me. I look very different. Worry is about worst case situations. If I can get the event over with I can finally stop this worry.

Working at a college counseling center softened some of my tendency to view them as villains. However I did leave still with the feeling that they are deeply flawed organizations. The flaws though are less about them trying to shove students out of school. I have had the good experience of seeing the center strongly defend student confidentiality from nosy administrators. I still worry though what might lurk in a corner that I didn’t see.






Why did I do this to myself?

In a post I made previously https://psychologytales.com/2015/03/10/anxiety-and-the-way-it-sneaks-up-on-you/ I talked about the possibility of doing my practicum at a college counseling center.

I ended up deciding to do the practicum at the college counseling center.

I’m having a rough time. Due to some scheduling issues on my part and my therapist’s part I’ve been seeing my therapist (Still working with #29!) less often than I normally would. This week is the week I will start having weekly sessions consistently again. However, I can say with a lot of confidence that not having therapy during the first 3 weeks of my practicum was an awful idea. I’ve had only 3 sessions in the past 2 months.

I knew going to this practicum would be hard. I don’t think I factored in enough though that on top of the emotional angle that makes this difficult because of all the things it is activating about the Involuntary leave saga it’s also just challenging independent of that. So I have the expected challenges on top of me trying to deal with all the anxiety associated with being in that setting.

I am terrified that lurking behind all of the very friendly warm kind people there that there is a back door discriminatory bureaucratic system that forces people deemed too at-risk to withdraw involuntarily.

I have done my research and can’t find any trace that they are doing this to people there. In fact the things I find in my research suggest that they are advocating often in the direction of things that protect the students who are clients there in ways that my school did not protect me.

But there are things that make me jumpy. I see infrastructure in the system to allow communication with hospitals about students and mechanisms to communicate with school officials. Everything I see seems above board.

It’s hard to confirm the absence of things. I can look under every rock but then miss something lurking behind a tree. There’s no way I can know for sure this does not happen there.

It’s not a thing people advertise. I’m afraid I’ll somehow be ambushed by it only by seeing it happen to a client of mine. I worry I’d be as ambushed by it as the client.

In all my interactions with people there is an undercurrent of thoughts in the back of my mind saying “I can’t trust you. You might be just like the therapist who kicked me out of school”

Dear W.P.

See: http://www.businessweek.com/pdfs/princeton-mental-health-complaint.pdf


See: http://www.bloomberg.com/bw/articles/2014-12-01/princeton-students-say-theyre-afraid-to-seek-help-after-suicidal-freshman-was-expelled

Dear W.P. (aka. The student suing Princeton following a forced medical leave),

Best of luck with your case. I relate a lot to things written in your lawsuit. I especially relate to the idea of living in constant anxiety trying to comply with the readmission requirements. I also can relate a lot to the issue of the campus counseling center betraying confidentiality and contacting non-health professional school officials. It was terrifying to realize how imperfect confidentiality is.

About the gap in your academic record. I was really worried about that, but no one has ever noticed or questioned it.

I hope you win and can help make some changes in the policies at Princeton.

I imagine the lawsuit is a stressful route. I beat myself up periodically for not taking the lawsuit route. The OCR complaint seemed better since it was less aggressive and I wasn’t to stay at the school. But I wonder if I had pursued the lawsuit route if I could have had more of an impact. I hope it works out for you.

Anxiety and the way it sneaks up on you

As anyone who had read anything on this blog knows, I’m an anxious person. There’s not a day that can go by without me feeling anxious. The things is though that most days at this point although my average daily level of anxiety certainly remains in the clinical range the intensity is something that is very manageable.

This lulls me into a false sense of security. I can forget what it feels like when it spikes back up.

Then all of a sudden it will appear unexpectedly. It’s been 8 years since the involuntary leave saga happened. It’s bizarre that cues related to this event can activate panic so intense after so much time has passed. I had a point where anxiety relating to this was generalizing to anything tangentially related to the event. I have made a lot of progress though. There are things that were formerly consistently able to evoke anxiety that now are not anxiety provoking at all.

But there are still things than can make me anxious with thoughts about this event.

Today I was ambushed by anxiety.

Graduate school likes to create situations where students are presented with options but gently and clearly informed that there is one choice they should make. This seems to be the case with practicum selection for next year.  I reviewed the options with my current practicum supervisor and was clearly told which practicum I should apply to. I was told this information in a way that makes me think that if I deviate from this direction that I will likely not get a good recommendation for other options that I pursue for this next year. The bit about the recommendation is likely me making a slightly paranoid leap based on the information. However, I do know it is clear that I do not have the support from my supervisor for pursuing the other option which I had greater interest in.

The problem? The location is a college counseling center.

I had no idea the idea of working at a location like that would make me so anxious until I was presented with a situation that suggests it may be my only option.

My mind leaps to worries about what if I end up in the role of a cog in a big bureaucratic machine and am forced to choose between my job and doing to another student the same thing that was done to me. I have no way of knowing if this school does involuntary leaves. It’s not a thing schools like to advertise.

This is the largest burst of anxiety that I have experienced for awhile.

Then I had a bizarre moment of doing therapy on myself. I have not been doing therapy with clients for long. This is the biggest spike in anxiety I have had since getting into more of a rhythm of doing CBT with clients.

So internal therapist me said: Ok so you are worried that at this practicum you might do to someone else, a thing that was very damaging for you to experience. What would happen if this occurred?

Anxious Me: If I do that to someone, I’ll probably kill myself

Internal Therapist Me: So you’re worried that if this happened you would not be able to cope.

Anxious Me: Yes. Maybe I wouldn’t kill myself, but I would be very dysregulated and probably do something impulsive like maybe an overdose that is unsuccessful like I used to do all the time in high school.

Internal Therapist Me: So is it a 100% chance that this would happen?

Anxious Me: Ok well I guess there is a possibility that it might have other outcomes. Maybe by the time this happened I would be in a better place. But I’m worried about what I would do. Would I secretly let the student know their legal options?

Internal Therapist: Switching this issue to the question of whether you’d advise the student about legal options is a way you are using worry to avoid the catastrophe and the anxiety associated with it. You fear causing the same trauma to happen to someone else or that a similar event will happen again to you and that you will not be able to cope if it occurs. The worry here is not about the little details. The details allow you to cognitively avoid the real feared situation but they maintain the worry.

As I am writing this out for this blog I am thinking……………..

Anxious Me: But I’m still anxious. It’s probably because I’m a lousy therapist and being a lousy therapist is why my supervisor does not want me to apply for the other practicum location.

Internal Therapist: Do you see how this thought might relate to the same core belief? You are saying that you are not a good enough therapist and also that you would not be able to cope. What core belief is this?

Anxious Me: That I’m inadequate.

Internal Therapist Me: Do you have any evidence that does not support the belief?

Anxious Me: I got into this graduate program. I regularly do things that make me anxious rather than avoiding them. I have more publications early in graduate school than many people have when they graduate. But….we know that I have a big history of not coping well at times and having quickly escalating suicidally.

Internal Therapist Me: It’s true that you have had a lot of times where you had trouble coping, but some of the more serious situations were awhile ago. Are there things that have changed that make you better at coping now?

Anxious Me: Yes I’m in a much better place than I have been in the past. I tend to be able to wait longer before acting on destructive impulses. Even though I still self-harm, I am able to limit it only to the evening which generally means that by the time is it the evening often I no longer want to do it.

Internal Therapist Me: So we can’t be certain that if the feared situation occurs that you would be unable to cope.

Anxious Me: Yea maybe I would cope. But it does not matter. If it happened it would be so terrible. I just really don’t want it to happen. Or if it is going to happen I want to know and I want all of the details so I can prepare.

Internal Therapist Me: I can’t promise you that it would not happen. No one can predict the future with complete certainty. Worrying is not preparation. This is a maladaptive belief about worry. It tricks you into thinking you are preparing, but really there is nothing you can do right now impact the possibility that this even might occur.

Anxious Me: I know that intellectually but convincing myself emotionally of it is not an easy task.

Internal Therapist Me: Maybe you need to try some imaginal exposures to the catastrophe?

Anxious Me: No. exposures for worry are dumb and I’m not convinced they work.

Internal Therapist Me: Have you tried them?

Anxious Me: No. But I don’t want to.

Internal Therapist Me: Then how do you know it won’t work?

Anxious Me: Ok I don’t really know for certain but I still don’t want to do it.

Internal Therapist Me: Does thinking about doing them make you anxious?

Anxious Me: Of course. That’s kind of the point of exposures. It’s not an exposure if it’s not anxiety provoking.

Internal Therapist Me: Do you think that it is worth trying then?

Anxious Me: Maybe. But back off on this issue or I’ll pretend fire you and then have to deliberate on whether I can add myself to my list of fired therapists. 

Internal Therapist Me: Ok if not the worry exposures what else might you be able to try?

Anxious Me: I could choose to specifically pursue this practicum. My clinical supervisor isn’t the only influence over where I get placed and my advisor will support me wherever i would like to work. So I really do have a choice in this situation. Now that I know how much it makes me anxious, on some level it feels like i should do the practicum just so I can’t have anything in the back of my head making me think that going elsewhere is an avoidance behavior. If I go there it will chip at another angle of how the worry related to this event spread into a lot of different places.


Ok that’s enough of that. I need ice cream.

The thing about grad school

  • The thing about grad school is that you get stretched so thin that you can’t do your best at anything.
  • The thing about grad school is you are too tired too appreciate how amazing it is to be paid to learn.
  • The thing about grad school is that every day is a question of picking which people to let down today.
  • The thing about grad school is that you don’t have the power to arrange your schedule in the most effective way
  • The thing about grad school is that you can’t read google calendar on the weekly view because there are too many things each day.
  • The thing about grad school is you know you are not operating at your full potential when you make mistakes from being over burdened
  • The thing about grad school is that everyone wants the tasks they assign to you to be your number 1 priority, but it is impossible to have 5+ different number 1 priorities.
  • The thing about grad school is you are too busy to pause to think about aspects of your work you enjoy.
  • The thing about grad school is everyone says they will not give you a task until they think you are able to do it, but somehow you always end up working beyond your skill level.
  • The thing about grad school is you can still get student discounts while also being an instructor of students.
  • The thing about grad school is you care too much about all of the things you under-preform at.
  • The thing about grad school is watching what happens when a bunch of high achieving perfectionists get pushed to their limits
  • The thing about grad school is everyone tells you grades don’t matter but keeping the funding is dependent on your GPA.
  • The thing about grad school is you start to get academic spam mail for bogus conferences.
  • The thing about grad school is you become an author on a paper you don’t even like.
  • The thing about grad school is you identify useful skills you could have acquired in undergrad if only you had known. And now you have no time to learn them.
  • The thing about grad school is you don’t have time to employ the good study skills that helped get you into grad school.
  • The thing about grad school is to survive you have to be more accepting of your mistakes.
  • The thing about grad school is not being able to enjoy things that past-you would have been so excited to do.
  • The thing about grad school is that every day is a roller-coaster of inching towards productivity and failures.
  • The thing about grad school is wondering whether you are coping worse than others.
  • The thing about grad school is wanting to sleep for a year.
  • The thing about grad school is lack of privacy for emotional breakdowns in the lab.
  • The thing about grad school is it’s hard to find a tutor to help when the class content you don’t understand is so specialized.
  • The thing about grad school is you feel invested in helping your undergraduate students and sacrifice sleep to schedule more office hour meetings.
  • The thing about grad school is moving to a new place and only knowing people in your cohort.
  • The thing about grad school is doing the math estimates of when would be best to have a baby.
  • The thing about grad school is fear of letting down your psychotherapy clients
  • The thing about grad school is wanting to stay despite the problems.

Edit March 11th, 2015: Where was this post linked that is causing me to get so much traffic to this page? WordPress says somewhere on Facebook but won’t tell me the exact link. Where are you coming from?

Anything else?

“Have you ever been hospitalized over night for anything?”, the allergist asked. I paused and told him about my appendectomy. “What about for anything else?” he asked. And I responded “No.”

I hate lying. But I didn’t want to open that unrelated can of worms about my three past psychiatric hospitalizations. I am forthcoming about the big picture existence of my mood and anxiety symptoms and any medications I am on. Any doctor I see knows I have anxiety issues, but it’s hard to trust everyone with specifics. With the rise of electronic medical records I get anxious about disclosing more information to be documented in a record system I have less control over. The anxiety a little question like this causes is one of the many ripple effects of my Involuntary Leave Saga. I need to control access to my information in order to keep myself from being vulnerable to misuse by fumbling but maybe well-meaning health care providers.

I have had a rough few weeks. My therapist (still number #29 Mr. sarcastic anonymous commenter) has vanished for the past 3 weeks. He is sick. The absence was unplanned. I have no idea what is wrong or even for certain if he will return next week. I can generate possible worst case situations of what happened faster than I can type them. I was in a downward mood slope before he got sick and have continued to be below my baseline. I am worried about him and feel simultaneously guilty for the truck-load of problems I have been collecting to dump onto him. How can I go in and unleash all that when his past 3 weeks have clearly been much worse?