An adventure to Second-Closest-City and Therapist #26

Last week S.M. contacted me with a name of a potential therapist. The one we’d spoken about before for the consultation wasn’t available. I googled this person and was very uncomfortable about meeting with her because she’s a member of a small organization that a large number of people I work with are also part of. The connection to my work was way too close.
I articulated this to S.M. and he was insistent that I needed compromise somewhere with my confidentiality concerns. He wants me to meet with someone even if I am worried about their association with my work and then work through those concerns in the therapy. There’s just no way I could feel comfortable enough to even begin therapy with someone so closely associated.

I believe I made the right decision here and feel further reinforced with this by the fact that at my work this week, the organization that that therapist is a part of came up in a meeting. We are inviting this group to an event in the near future. The organization already contains 1 past therapist from several years ago before I began this job. Had I agreed to meet with this new therapist I might have been dodging 2 past therapists at the same event. Hopefully that one therapist won’t attend this event.

S.M. told me that he’d run out of resources and that he would call this therapist if I wanted to meet with her, but otherwise I needed to find a therapist on my own.
I feel horrible. I feel guilty for bothering him so many times about referrals. He’s really gone above and beyond with finding me therapists in the past so it’s not fair to feel angry at him. But I am a bit angry. I was holding myself together with the hope that he’d find me a therapist and it fell apart.
Part of me wanted to call him apologizing for bothering him so much, but I didn’t because I realized the apology would be a little passive aggressive.

I found one last local place to try to call. They didn’t have availability until January. I can’t wait that long. I had a panic attack while on the phone. I was such a mess, that the secretary put me on hold, saying that she’d try to find someone I could talk to right then on the phone. At some point the call was dropped. I tried calling back, but they had closed for the day.

Per the suggestion of some folks here, I decided to expand my search radius. I discovered that Second-Closest-City is easier to get to than I’d realized. It’s actually easier and faster to get to this further away city than to a lot of the suburbs surrounding my city. This city is far enough away that people are not all affiliated with where I work.

I made a lot of phone calls. Nothing was working. I can’t count how many panic attacks I had. I skipped out on a lot of obligations, because I was too upset to leave my apartment.

I was working on my next suicide method and kept calling my Dad crying. He took over the search for me. I hate having my Dad do these things for me. He’s very busy and I am really trying to pretend to be an adult. But I was falling apart trying to manage it myself.

My Dad found someone for me to meet with who was able to see me a few days from then.

On the day of the appointment I traveled to Second-Closest-City. I’ve traveled through Second-Closest-City many times, but I can only think of one time when I was maybe 12 that I actually visited it.
I was very prepared for my trip. I put together a whole packet of maps and train schedules. I decided I would walk, but spent 20 minutes getting lost and progressively more anxious. It’s scary coming to a new City and not even knowing where the main streets are. I asked a stranger if she knew where I could get a cab and she gave me the number of a cab company.
I waited for 10 minutes, no cab arrived. The time of my appointment was rapidly approaching, and I was worried about waiting for a cab that might not ever show up. I backtracked to a more populated part I’d walked through earlier and found a cab.

I really don’t like taking cabs. It goes against the whole don’t get in a car with strangers idea. I know a number of people who’ve been held up by cab drivers and some who cab drivers attempted to rape. I’m a very tiny person, I wouldn’t be able to do much to protect myself.
Also in a strange city sometimes it can be hard to distinguish legitimate cabs from illegitimate ones. This one was particularly shady, but I was desperate. It had a meter which added some legitimacy to it, but it was very run down and the driver gave me the creeps.
I safely made it to the building where the therapist is located. I had traveled 2 hours from the door of my apartment to the door of his office to discover that he has a buzzer at his door.

He directed me to a waiting room, which wasn’t really a waiting room. It’s clearly a room he usually uses for group therapy sessions. The chairs were all arranged in a circle. At first I thought he was going to conduct the individual session in there! There would have been a lot of empty chairs available for the empty chair technique.
The actual office was more typical, although it was meticulously organized. My first impression of him is that he dresses more like a lawyer than a therapist.

He commented on my outfit and asked if I was still dressed for Halloween. I let him know I dress like this year round. A tactless early comment, but I let it slide.

The first session went well enough that I returned again for a second appointment.

The second appointment went less well. My trip to Second-Closest-City was nice. I conveniently was able to take the same train as a friend who commutes daily to Second-Closest-City. This friend is someone who doesn’t know any specifics about my crazy, but I am comfortable enough with that I shared my reason for going to Second-Closest-City with him. I have a lot of trouble justifying social interaction in my schedule. If nothing else this trip can force me to communicate with another human for a bit.
My friend and I shared a cab, because the weather was bad and he was traveling in the same direction.

I arrived at the office with 3 minutes to spare. A big change from my usual 20 minutes early, where I avoid going into the office until at least 10 minutes of.

He was dressed less like a lawyer this time, but I have a serious comment for you folks: Do not wear brown shoes with a black suit. Fashion disasters make me sad.

I brought my collection of neuropsychological testing to the appointment. The therapist had seemed a little uncomfortable about writing my Ritalin prescription and asked if it could wait until this 2nd session. I figured I should bring the testing so he’d know I wasn’t inventing the ADHD diagnosis myself. I’m really worried that my decision to go so far away might be misinterpreted as something drug seeking.
I’ve given many of my therapists copies of my testing. Some are more interested in others. Based on his questioning from the first appointment, (He asked a lot of neurological and general medical history type questions) I thought he’d want to see them.
I don’t have a good way to make copies. I could theoretically do it at school or work, but I don’t feel comfortable copying my personal private information there. So I brought the originals and asked if he was able to make copies.

He said he could make copies there and proceeded to do so. For the next 15 minutes. The copier was misbehaving. He unstapled and restapled all my reports. Papers were put everywhere. I have to check through all my reports now to make sure no pages or entire reports are missing.

It felt very disrespectful of my time. Yes the therapy session is only scheduled for 50 minutes, but I have to carve out 5 hours in my day when including travel time. If I’m waking up at 5:30 in the morning to begin my day so I can fit this in, then I’d like to get the full 50 minutes.

I get that he might want to avoid having tasks for patients outside of the billable hour, but despite his similarities in fashion choices to a lawyer, therapists billable hours don’t usually work the same way. Their fee should partially factor in doing some tasks outside of the session. This is why the hours are 50 minutes rather than 60. Every other therapist who I’ve given reports to has made copies and given the originals back to me the next session, rather that using session time.
It’s possible that he just didn’t realize how much trouble he’d have with the printer, so it took longer than expected. But I found a similar trend in the 5+ minutes spent discussing billing. He mentioned that I’d not brought a check the first session. I hadn’t realized he wanted me to. I thought he was going to bill my Dad. I asked if he could just send my Dad the bill. He wasn’t very into this idea. he really wanted to sort it out right there.
It turns out he takes credit card. I paid with my American express card. American express has a reputation for charging a lot in fees to vendors. I hope he got charged a lot in fees for being too lazy to send my Dad a bill. I get that maybe a lot of patients don’t pay bills promptly, but my Dad is very reliable about these things. I’m not sure if my credit limit can handle getting too many of these charges. I usually just use it to buy food.

It makes me really anxious to see the sticker price of sessions. When I submit it to my insurance company for reimbursement the cost will go down to 15-20 dollars per session, but to see $500 for the two sessions on my receipt makes my heart rate speed up.

This left less than 30 minutes of therapy time.
We had a very uncomfortable interaction where he asked me if I wanted him to help me. He wanted me to say “I want you to help me” rather than me just answering his question with a “Yes”. I didn’t cooperate.
This and a couple of things made him feel more like a bad “self help guru” than a psychiatrist. He listed the 5 things he felt were important in a psychotherapy session and the 3 types of communication he believes exist. It felt trite and cheap and tacky.

The session was very directed towards talking about my childhood. I certainly do believe that my childhood had a role in the types of problems I have today, but he doesn’t even know yet what most of my problems today are. It’s too easy for this type of therapy to turn into time where I just say horrible things about my parents. And my parents (especially my Mom) definitely messed up in some places, but they were well intentioned. I did not appreciate his efforts to make me express anger about my Dad for a situation where my Dad really had no good options. He’s paying the bill! and basically is a good guy aside from his inability to be emotionally supportive.
I mentioned that I am not going home on Thanksgiving and the therapist reacted much too enthusiastically about this. He hardly knows my situation and reacted as if I was cutting ties from an abusive family situation. My family is dysfunctional in many ways, but not abusive. My reasons for staying here are more academic than emotional.

I much prefer information about growing up to come out organically in relation to information I share about the present. I am suffering here in the present. Yes the past influences that, but the present matters too. Dwelling on every detail of my childhood is not conducive to changing how to feel today. Really, it just makes me more miserable.
Is it unfair for me to seek out a psychodynamic therapist and criticize him for wanting to talk about my childhood too much? I don’t think so. I think a therapy can be dynamically informed while having a present focus.

I mentioned how I’m not fond of the pure free association type of therapy and I prefer when it’s more interactive. He said that he agreed and said that he’d once been in therapy with a classical Freudian-type and had hated that style. I am kind of uncomfortable with that self-disclosure, even though I realize it’s very typical for analytically oriented therapists to have had their own therapy at some point. It felt like over sharing.

When working on the billing, he asked what ICD code I wanted. I’ve been asked in the past what diagnosis others have used for the bill, because they want to be sure I get reimbursed, but never flat out asked which code I wanted. I opted for Major depression, recurrent, moderate, because I’ve had that used a lot in the past.

I’ve been trying to do work on the train, so I don’t feel the time is wasted, but unfortunately I’ve been so tired, that I’ve not been very productive. Maybe as it becomes more routine it will be easier.

I’ve been having a lot of reactions to the idea of going to Second-Closest-City for therapy. When I was calling places looking for a therapist, they’d ask where I coming from and I’d tell them and as soon as they wondered why I’d come so far, I’d start crying. I’d hardly be able to speak.
I feels like it’s some kind of punishment for being so crazy. I’m so messed up I can’t even find a therapist in a city filled with therapists. 3 of my former therapists are within a 5 block radius of my home.
I’m mostly keeping these trips private, people would think it’d strange for me to go to this Second-Closest-City for a couple of hours only. I feel like I’m going on these secret adventures that I can’t tell anyone about.

Some of my professors commute from Second-Closest-City to my city. I have a slight fear that because I am taking such an early train that I might run into them at the train station in Second-Closest-City. I’m not sure how I would explain seeing them there, then seeing them in class later that day. It’s close enough for a commute, but far enough that people don’t usually just stop in for the morning.

There are some upsides though. If I were to be hospitalized, I’d be hospitalized there and my confidentiality would be safer than it could be in any hospitals around here.
I also feel like in this other city, I am suddenly free from a lot of my worries about privacy. I’m in this city where hardly anyone knows me. It’s liberating.

I have some serious doubts that #26 is going to work out. I’ll give it one more appointment to see if things improve, but otherwise I’ll move on. If nothing else I’ve learned that Second-Closest-City is a viable option for finding therapy.

cbt equivalent of object relations- Searches Answered #1

Every now and then in my stats I see that someone showed up here using an interesting search term looking for something that isn’t answered directly in my blog.

Today “cbt equivalent of object relations” popped up.

I like this question, because I think the idea that CBT is not the opposite of Psychodynamic therapy is important. Often with differing theories people are using different words for similar concepts

I think first what’s important to establish is what is meant by object relations. Object relations theory as a whole gets into a lot of things. But I am guessing this person was interested in object relations as in the idea that early ways of relating to people are repeated in future relationships.

My knowledge of cognitive behavioral ideas are more limited so excuse any over simplification.

One way of looking at this with CBT is the idea of schema (http://en.wikipedia.org/wiki/Schema_(psychology) ) both involve a mental set defined early in life.
Or also possibly you could say that a person’s interactions with their caregivers can lead to stimulus generalization (http://psychology.about.com/od/sindex/g/stimgen.htm) where they interpret others as reacting like their parents even if they are not.

Even if there may be some overlap, CBT has nothing on Object Relations Theory when it comes to evocative imagery.

And on that note, I will leave you with two Harry Guntrip Quotes:
“A patient who fantasized standing with a vacuum cleaner (herself, empty and hungry), and everyone who came near she sucked into it. At a more normal and ordinary conscious level this is expressed by a patient thus: ‘I’m afraid I couldn’t make moderate demands on people so I don’t make any demands at all.”

“love made hungry is the schizoid problem and it rouses the terrible fear that one’s love has become so devouring and incorporative that love itself has become destructive”

I relate strongly to the second quote.

Also if you are interested in things that make different types of therapies similar you might be interested in reading about Common Factors.

The more you need help the less willing people are to provide it + the intersection of work and treatment

A few weeks ago I decided to give CBT another shot. How is it fair for me to fully reject it as a treatment option for myself, when my experience with it has been so poorly applied?
I picked out a local prestigious research center and gave them a call.

I felt that maybe the failures with my previous efforts to get “real CBT” were because I was looking for treatment in the community rather than from researchers. Maybe this “empirically supported treatment” only exists in the magical world of academia. The treatment outside might share the same name, but maybe it is something different.

In the past I’ve avoided treatment research studies (even though I’ve participated in many other types of studies) because I worried about the guilt I’d feel when I didn’t get better. I don’t want to ruin their study.

I don’t talk about my work here much, both to maintain my anonymity and due to confidentiality rules. I love what I am doing and I am making amazing professional connections. It is doing wonderful things for my developing career, but not so good things for my ability to find treatment. I am very concerned about keeping my crazy separate from my professional life. Most of the people I work with are therapists.
As my therapist list grows longer and longer and my work social network also expands I’m running into increasing problems of overlap between the two. I know that both therapists number 23 and 25 in particular had some form of connection to people whom I work with. I’m sure others have had connections I don’t know about.

S.M has tried to assure me that some amount of this problem is very typical for folks working in the mental health field and that clinicians should be able to handle it tactfully. The problem is that most people only have one therapist they are awkwardly avoiding in their professional life. I have 25 and counting.
If I knew for sure, ‘ok this therapist is the last one I will ever have to see, because this therapist will be a good fit’ then I might be less concerned about the therapist possibly knowing a coworker or attending some of the same conferences as me. The problem is that in all likelihood therapist number 26 won’t be able to help me any more than the other 24 (S.M is excluded as I only left him because he’s located far away). As I see more and more therapists I cut off more and more career options. I wish I could wipe my identifying bits of information out of a therapists head after I fire them.
The ideal therapist for me would be completely professionally isolated, the problem is that someone that isolated is not likely a very good clinician.

It may seem like I got a bit off topic in the above paragraph from my thesis sentence, but here’s where it connects. Something that made this Prestigious Research Center (henceforth known as PRC because psychologists love acronyms almost as much as Unitarian Universalists) a wonderful choice for my treatment is that I have zero desire to work there. We have differing theoretical interests and this is a place that would be particularly hostile for a person with my perspective to work. I could go there as a patient and not feel like I am blocking off a future job opprotunity.

I played telephone tag for a week with PRC and finally got in touch with a fellow who conducted a phone screening interview. I prefaced the interview by letting him know that I realize I’m not the ideal person for their research, due to my large amount of treatment experience and number of co-morbid diagnoses. He said this was fine, because the research clinicians also see patients there outside of the studies.
I thought this was great. I could get the research clinician without the guilt of sabotaging their study.
He said that sometimes they do have to refer people out with certain kinds of problems that they don’t work with e.g. substance abuse. As substance abuse is not a problem of mine, I wasn’t concerned.

I became even more attached to PRC when he told me that all of their patients go through a thorough assessment prior to therapy (things like personality measures, structured clinical interview etc) with an accompanying report.
I have a large stack of neuropsychological testing, but never any formal assessment, independent of the treatment, about the rest of my crazy. If nothing else I was excited about the idea of a beautiful organized report with charts and standard deviations. I adore data. Even if this therapy didn’t work out at least I’d have a report (albeit one biased towards militant CBT research) to show future clinicians.

The phone interview lasted an hour and a half. I was told I’d get a call back from the main desk to book an appointment for the assessment. Instead the fellow from the phone interview called me back to say they were unable to work with me. He’d talked to his supervisor who told him they had a policy of not working with anyone who has had more than 2 hospitalizations in the past 5 years (I’ve had 3). Then he offered me a referral to Other Prestigious Research Center.
The problem? Other Prestigious Research Center is where I work. Not in the specific part he referred me to, but very closely affiliated with it. This isn’t just a matter of me being obsessed with boundaries where I avoid people even loosely associated with my work. This is closely related enough that it would be unbelievably inappropriate for me to look for treatment at this particular location.
I was so taken by surprise that I actually told him why I couldn’t use that referral. An unusual self-revelation for me.
He got back to me the next day with more referrals except this time for people in private practice. When I googled them it turns out they both worked at the same Other Prestigious Research Center that I have to avoid.

So my plan of getting CBT was foiled again. I called S.M. asking for a referral. I feel so awful coming back to him over and over. He has a hard time making these referrals because he doesn’t know many people in my area.

For the past couple of years he’s been trying to get me to see a “senior analyst” for a consultation. Someone too busy (or mostly retired) to take on any new patients, but who could be a fresh set of eyes for my problems and would know clinicians in my area well enough to select a strong match.
I’d been turning him down, because I didn’t want to add an extra person who knows my problems to the world unless they were someone I was planning to meet with long term. I finally agreed to give this a shot.
He told me a name and I googled her to establish sufficient separation from work. She is loosely connected but far enough apart that I can tolerate it. S.M told me he would give her a call and see if she could see me for a consultation.

It been a couple of weeks. I’m not sure what’s going on. I guess she’s not answering his call? S.M. keeps telling me he expects to hear back soon, but it hasn’t happened.
Meanwhile I’m waiting, feeling like I can’t try to pursue other options (as if I even have any) until this sorts itself out.
I’ll go to work next week where I’m surrounded by therapists, while I am still unable to find a therapist for myself.

Galvactivator

I stumbled across the website today for the Galvactivator. It’s a glove that’s a skin conductance sensor with a light built into it that lights up at higher levels of conductivity. Made by some folks at MIT.

Website is here: http://www.media.mit.edu/galvactivator/index2.html *
As you may know anxiety/emotional arousal is one of a number of things associated with higher levels skin conductivity. Here's a plot of data from their website, showing changes in skin conductivity.
I could see something like this having useful applications for therapy.

One of the major reasons therapy hasn’t worked out for me has been that I didn’t feel like the therapist understood me. We’re very out of sync. These therapists can’t all be so out of sync with all their clients. Something I’m bringing to the table must make it more difficult. Aside from the obvious problem of my attachment issues, I think it’s possible that my facial expressions are also harder to read than average.

I’m very practiced at hiding reactions. It’s not that I don’t show facial expressions, of course I do, but there’s a lot that’s hidden too. It’s not at all unusual for me to get a sudden panic about something while in class or a meeting. My heart rate will go out of control, but no one notices, because my face doesn’t show it (at least not that I’m aware). A lot of this unintentionally carries over to my therapy. I’m sure it complicates things if they’re working from fewer visual clues.
S.M (the one therapist who gets me, but sadly does not work in the area) has a particularly large chair in his office. He’s commented to me how he can tell when I’m getting upset by how far down I’ve slid down the chair. Sometimes I nearly fall out. Therapy is a cycle of sliding down the chair and then realizing I’m going to fall out and sitting up again.

Something like this could be an interesting tool in therapy, because it would be an added piece of visual information about a client’s emotional state. It does get suspiciously close to the fantasy of wanting mind reading I was once accused of by a therapist, but is safer, because it would still be up to the wearer to choose to share the content/cause of the emotions.

What do you think?

It’s too bad they’re not for sale. The faq says someone is looking into making them for sale though, so maybe they’ll be available eventually. I would definitely buy one.

—

*It’s a shame the website uses frames, really I expect better webcoding from MIT. It’s not 1998 anymore. Also in-line CSS and tables used for layout. Eww. Why? Maybe the website is old?

It would have been nice to end on a multiple of 5

I’ve seen more therapists than I have years that I’ve been alive. I started therapy when I was 14.

How am I? Oh well I’m emotionally dysregulated. How are you?

I’ve gone and fired therapist number 25 before I even had a chance to write an entry in here about the start of therapy with him. I met with him for 2 and 1/2 months or so.

Only a handful of sessions in I started to feel really attached to him. It terrified me, because that doesn’t usually happen and was and felt way out of proportion to how little he knew me.

That idealization was crushed shortly after. Because I felt over-attached, I rushed into some tough topics.

I think an important role of a therapist is to keep an eye on the patients level of affect and ensure that it is neither too low or too high. The optimal rage is different for everyone every day. Too low and the therapy is too superficial, but too high and it will be too overwhelming to be therapeutic. The optimal level varies based on how much time remains in the session. As the session nears its end the therapist needs to find the way to bring the affect to a level the patient can manage outside of the container of the therapeutic relationship.

I realize this can often be a difficult task, but he did about as poorly with this as possible. The session ended abruptly, leaving me in a vulnerable emotional state. This left me feeling wary about the therapy, realizing that he and I were very out of sync. I picture this session as a chart where x is time and y is affect. We both started at low affect and his line was straight across with no slope, while mine got higher and higher.

We did talk about this after, but I think he took the wrong message from it. I wanted him to be more aware of when things were escalating too far, while he took this to mean he shouldn’t press certain topics at all.

A couple of weeks ago I wasn’t feeling great. I won’t get into the reasons right now, because retrospectively I’m embarrassed about how trivial they were.
I cut in the bathroom of his building before my appointment. I felt extremely out of control. I bled through my pants leg. I spent the session with my purse held over the blood spot so he wouldn’t see.
Obviously he can’t read my mind (Although once a therapist accused me of wanting him to do that, probably with some justification) but I really resented him for not noticing something. I always keep my purse on the floor rather than holding it. Clearly I wasn’t meeting with Sherlock Holmes for therapy.
He was so focused on convincing me that I shouldn’t feel how I felt, that he didn’t get around to understanding how I felt.
He asked me if I was going to be okay over the weekend and I very unconvincingly said ‘Yes’. He didn’t question it.

That weekend I was not feeling well. I had some oxycodone left over from a medical problem I had over the summer (This is a topic for another post) I took that, some klonopin and some seroquel too.
Unfortunately I only slept for 13 hours as opposed to forever.

This is the first time I’ve ever misused prescription medications like this. I felt incredibly guilty about it. I’ve always only used over the counter medications for overdoses. I feel like doing this is betraying a level of trust between me and the perscribing doctor.

I rationalized this somewhat by not going over the daily limit for the klonopin, and only doing so with the oxycodone, because I care more about the trust between me and my psychiatrist than me and random doctor from the hospital who will never know about this.

With a lot of reluctance, I told therapist number 25 about this, but it took me two sessions to fully get out. At the time when I told him about this I wasn’t feeling suicidal any more. I came early though to that session to plan out my escape routes in case he tried to hospitalize me and I needed to bolt. I tossed a hat and sunglasses and change of clothing in my bag as well.

I brought up the idea during that session that my period may be relevant to some of my more serious mood problems. I’ve brought this up before with therapists. I never really can feel sure. Is it confirmation bias? I don’t have a good way to keep track of if my mood changes around my period. I don’t buy into those mood monthly calendars. All self report measures of mood are highly subjective and because I wouldn’t be blinded to when I have my period I question their validity.

I mentioned feeling conflicted about this due to my identity as a feminist. I don’t really have a fleshed out coherent argument about my feelings with this, just an uncomfortable feeling. Somehow I think that if I say the words feminism and menstruation enough my feelings will be clear to everyone.
The feelings have something to do with the society wanting to view women as overemotional on their periods, the medicalization of a normal process and the validity of PMDD as a diagnosis, but again I’m not good at expressing myself here. I can see both sides of an argument about PMDD.
He seemed confused about why feminism would be relevant to a discussion of PMDD. I can handle disagreement, especially since both sides of the argument are dueling it out in my brain. But I was shocked that he wouldn’t even be aware of the possible relevance of feminism to an issue involving menstruation. He seemed very perplexed and I was horrified.

He did apologize the following session without prompting, but still it was unsettling.

Then to make things even more exciting and wonderful (note the sarcasm) The therapist who kicked me out of school (I need a shorter way to refer to him) was on a major news network promoting his book.
Every bit of publicity feels like he is taunting me.

I sent him 3 angry tweets from my twitter account. This twitter account is public and associated with my real identity (not my real name, but the username I mostly use an also people I know in real like follow me there). Probably not my most brilliant idea ever, but I’m leaving them up. If any person searches for his @replies they will know that at least one person out there is very unhappy with him. They’re vague enough that if a person didn’t know the background they would know I was angry with him, but the reasons would be unclear.
This means he now has access to most of my social networking pages. That’s fine though as I put my best foot forward on those, unlike in this blog.

When I went to therapy to talk about this I was very let down. Awhile ago I made a comment about how klonopin makes me stupid, which it does. The stupidity occurs in varying degrees, but to have any relief from anxiety thoughts rushing around, some of the good smart thoughts are slowed down as well. Sometimes thoughts can even be of both types.
I commented on how I had to stop what I’d been working on (Probably for the better as is it was slightly destructive) when the klonopin kicked in, because I wasn’t able to think well enough. He decided to take this time to argue with me about wither I am on the correct dosage. I have had the dosage fiddled with to the point of adjusting it by increments of 1/4 of the smallest pill size. This is the right dose. I’ve been taking it at this dose for a couple of years. I’m not messing with it. He was convinced that there is some ideal dose where I won’t be anxious or stupid. I don’t believe this is possible, because the two are so intertwined and the impact of the same klonopin dose varies depending on the day.
The comments felt accusatory too. Like he thought I was abusing it, although I have never ever gone over my prescribed limit. In the context of previously telling him about my oxycodone and klonopin adventures I was very sensitive to this sort of comment, because I feel so guilty about it.

He was taking a super ego guilt inducing role. My super ego is super at making me feel guilty already thankyouverymuch.

I told him about something I had thought of doing, but did not do and he took his guilt induction much too far. I can’t write about the details here, but basically he took a thought of mine and turned it into a worst case scenario. I tried to protest, but he kept making it worse and worse. The things he was saying were already fears in my head. I didn’t need him to give them credibility.
I have far worse thoughts in my head that I haven’t told anyone. If he reacts with such a judgmental extreme to something less horrible then there’s no way he can handle the worst of me.

I felt like he was treating me like he thought I was a sociopath. He was playing this role of a conscious for me as if I had none.
If he had even a basic personality conceptualization of me he was working from to base his comments he’d have realized that I am already very skilled at guilt.

I stopped talking. I stared out the window for a bit.
Then, I pulled out my Nintendo DS and resumed the game I’d been playing in the waiting room. Really juvenile, but I don’t care.
My brother called while I was ignoring the therapist. I refused the call, but then he called again and I took it, upping my rudeness level by +10. He just had a quick answer to a question I’d had about the game I was playing.

After about 20 minutes of ignoring the therapist although with the occasional yes or no answer to a question I said “I think I should just leave”. And I did. He asked if I wanted to make another appointment and I said “No”.
There wasn’t anything he could say at the point that could have made me comfortable continuing therapy with him.
I hate myself already, I don’t need a therapist thinking I am awful as well.

I rushed out of the building, worried that I was going to be followed or stopped by security. Psychiatry departments are never placed near an easy exit and I think we all know this is not an accident.

I arrived home and decided to take some ibuprofen. I think the reason I am still alive after all these years is that I am awful at swallowing pills. If I were better at I’d have succeed years ago. I had liquid gel filled capsule type ibuprofen. I decided that if I dumped the liquid out and drank it that might work.
Turns out this is the worst idea ever. I tried opening one up, but it didn’t work well, so I decided to just put it in my mouth and bite it. It was extremely acidic. I ran to the sink to rinse my mouth out to stop the pain. My mouth and throat felt sore after, like I’d been vomiting.
With that method ruined, I gave up to the time being.

It’s a few days later and I’m okayish now. I’m not being very productive with school work. I’ve mostly been sleeping and eating ice cream. I don’t know what I’m going to do about the lack of a therapist situation. I hate starting over again and again.

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.

DBT Summary Letter

This is a follow up to my post “A roadbump while looking for records”. You should read that first.

I googled the office address of the DBT therapist that I got off of his website. I found the therapist who moved into his office after him. I figured it was a long shot, but called her anyway.

She got back to me promptly and was very kind and apologetic, she said that she didn’t know how to contact him.
But then the next day I got a voicemail message from the DBT therapist. Apparently she had found a way to get in contact with him. He didn’t leave a number in the message, but said he would call again to try to reach me later.

I waited a bit over 2 weeks without a call back from him. I had no phone number to call him at. I called back the therapist who had moved into his old office and left her a message. Shortly after, I got a call from the DBT therapist. I wasn’t able to get him to agree to send full records (not a surprise) but he agreed to send a summary letter.

Finally I got a letter from him in the mail. No return address listed. I think he must not be practicing right now, because I never got a contact phone number for him and the letter doesn’t even have an office address as a heading or footer. Also, after speaking with him he took down the entire website with his outdated contact information.

I scanned the letter and put it up here. Edited out some identifying bits.

The envelope was post marked April 9th. So it took over a month from when I started at the end of February trying to contact him to when I got the letter in the mail.

This was probably the most work I have gone through to get any records and the least fulfilling.

It reads mostly like a textbook explanation of DBT. So little of the content of the letter feels specific to me.
I got a kick out of the bit where he wrote “We discovered several vital functions and reinforcing properties of her self harm..” as if I hadn’t already had an understanding of these before meeting him.

I realize 12 sessions is not a huge number of sessions, but I don’t think it is an insignificant number either. I get the feeling reading the letter and based on our no-pleasantries-exchanged-phone-conversation that he didn’t remember me and struggled to write the letter based on a few scribbles in a notepad.

I was most interested in how he would describe terminating the treatment.
He kept telling me that I needed to call him if I was going to cut. If I couldn’t agree to call him then he told me we couldn’t meet any more.

Phone anxiety aside (This has gotten better over the years, but never completely gone), I didn’t want to do this because it is hard for me to judge if I am going to cut in a situation or not. I don’t really know if I’m going to cut until I’ve done it. I think about cutting a lot. Only a very small percentage of the time do I act on it. If I called him and then did not cut after the phone call (even though the purpose of speaking to him was to help me avoid cutting) I would have felt guilty for making the phone call. If I didn’t cut then, I would have bothered him for no reason. I’d have worried I had called him during a time when I wasn’t going to cut anyways. I probably would have half-heartedly made a small injury to ease my guilt.
His request for me to phone him would actually increase my self injury rather than decrease it. And I’m fine with my self-injury in general (I was pressured into going to the DBT and was very ambivalent about it) but that doesn’t mean I want to intentionally enter into a situation that will needlessly increase it.
I’m not sure how well I articulated that to him. I’m better at expressing some of these things now, because my meta-cognition has further developed.

Whatever the reason, he doesn’t appear to have understood my objection to the phone calls. Still I had often wondered if he realized he messed up when he told me ‘phone calls or no therapy’. I imagine he thought the ultimatum would get me to fall in line with his rules, but it backfired and I left.
His letter reads as if it were more of a mutual agreement, instead of a “do this or leave” command.
—

Would people be interested in more posts like this where I post some of my records with comments? I have a few other topics I want to talk about here first, but if people are interested, I can also do more like this one later.

Therapy: Monday April 11

I wrote this the other day, I was going to write more, going day by day through my week last week, but didn’t finish. This is the roughest period of finals I’ve had yet. So much to do.
It was a very emotionally intense week. I fired my therapist that Thursday. I suppose I can go more into that later, but I’ll just throw up here what I’ve written so far. Sorry that this is sloppier than what I normally post.

Monday April 11:
I was very angry in the waiting room. I wanted to go in and scream at him. Instead, I walked into his office and could hardly speak.

When I could speak I asked to play chess. I was able to say “check “numerous times and “checkmate” when I won.

My vocabulary then branched out from exclusively chess related speech.

I couldn’t bring myself to tell him outright about the suicidal thoughts I’d been dealing with the past several months
About how I was spending time looking up how I might buy cyanide.
Or how earlier that day I’d bought an assortment of pain killers, which by the time I left to go to therapy I had decided not to take, but were (and still are) sitting in my room.

Instead I stared at the wall and listed reasons why I couldn’t kill myself.
Reasons like, “I’m too busy to kill myself”.
Seems like a strange reason, but somehow the idea of waiting until break to kill myself makes sense in my head. Like it’s this thing I want, but first let me finish this huge amount of work I need to do.
And reasons like “I can’t kill myself because I have my period”.
I have had my period during all of my hospitalizations. If I’m going to kill myself I need to be sure it’s not PMS.

There was a moment where I got scared. A response of his made me think he was thinking about hospitalization. I had to backpedal, but needed to do so in a way that would not seem like obvious backpedaling.

In keeping with my format of listing reasons not to kill myself I explained that I wasn’t going to kill myself because If I were to kill myself I’d want to be sure it would work, but given all the times I have unsuccessfully tried to kill myself I am clearly not terribly good at it and so it’s not worth even bothering.

I told him about how my professor has assigned homework to read an entry from the blog that has endorsed the therapist who kicked me out of school’s blog. This put my entire class two mouse clicks away from that therapist’s blog.

I talked about how, I’d called my former therapist (S.M. the one who I actually liked) to talk when I found out about this assignment.

He kept saying how it seemed like thing were going so well in my life and wondering if maybe I was actually upset because I was feeling more connected to him. No matter how many times I have told him I don’t feel more connected to him or even connected at all he doesn’t buy it.

Beside that point things are not going so well. I realize that realistically the things I am beating myself up about are small and I am being too hard on myself, but the feelings are still there. That I’m doing an awful job of everything and destroying the little bit of credibility I worked hard for at my internship. But validating those feelings would require him to have some ability to understand what I’m going through, instead he just has to argue with me.

I talked about my frustrations with this therapy and how it’s so much worse when I’m having a rough time to also not have therapy that I feel is working.

He, being the master of saying the wrong thing, brought up the possibility of me leaving and offered a referral.
As much as it is a subject I have thought a lot about it was not something I could think or speak about in such a period of acute stress.

The appointment was coming to an end. “See you Thursday at 9:30?”, He asked.
Panicked at the thought of waiting that long while I was so emotionally unstable, I meekly asked if he has any availability for Tuesday.
He did. So I made another appointment for tuesday..

A roadbump while looking for records

Last week I was speaking in therapy about the therapy I had been in during high school, this included my experience with DBT.
It inspired me to google my DBT therapist. I found his website. He’s moved to a new location very far from where I met with him.
I looked at the list of articles he’s written. There was one on psychodynamic therapy. That threw me off. Nothing about the time I met with him would have led me to guess that. It somehow made me vilify him less, because now the possibility exists that we might have some similar theoretical views.
It’s strange though because everything else on his page is about DBT and CBT, all but this one out of place psychodynamic article.

I decided to read the psychodynamic article.
Looking at the abstract I realize, “I think I’ve read something else that cited something similar”.
I continued reading, “No. I’ve definitely read something else that cited this exact study.”
It only took looking up two recently-ish read articles to find the one I was thinking of.

I’d had this other article folded open on my desk for weeks to the page he’s cited on and not had a clue.
I had that particular page open, because I’d highlighted some interesting quotes. I’d been thinking of writing about it here. I feel the quotes address the key problems I had in DBT.
The highlighted quotes had nothing to do with his contribution to the article, but what a strange coincidence that he would be on the same page.

I decided I want to contact him for my records. The idea is in my head. I’m stubborn and don’t want to let go of the idea once it is there.

As I’ve mentioned before, I am collecting my psych records bit by bit. It started as a effort to get closure with the therapist who kicked me out of school and then spread to all my other treatments as well.

Private practice records are harder to obtain, so I have fewer of those, but gathering as many as I can is a project I pick up from time to time.

I called the number on his website. It was disconnected. Maybe I dialed wrong, I tried again and again and again. Definitely disconnected.

Double checked the website, looks like it may not have been updated since 2008.

I checked the whois info, but it was set to private via a third party.

After some debate, I decided to send an email. Less than ideal for this situation, but I included my phone number and address so he could contact me.
I don’t have anyway of knowing if he still actively checks this email address. It is associated with his domain name and if he’s not updated the website enough to fix his phone number, I have doubts that he would also check the email.

The next day I received two phone calls from a “withheld” number. They didn’t leave a message and I was unable to answer at the time. I wondered if it was him. I’ve been waiting since then to see if this “withheld” number will call again, but they haven’t. I’ve been kicking myself mentally for not excusing myself to answer the phone.

I decided to pursue other options, while waiting.

I looked up his lisence. It’s active and was renewed in Jan 2010, so I know he didn’t just decide to stop practicing.

I called a former employer to ask if they knew a way to contact him. They didn’t.

I called his state license organization to see if they could help. They had information, but couldn’t disclose it due to privacy reasons. Understandable.

I called ABCT(his website said he’s a member). They said that for $54 I could join and gain access to their member database which maybe had the information I was looking for, but couldn’t guarantee.

I realized I could look in the APA member database for him. I ran a search. He showed up, but I received a notice saying “This Member has opted not to publish information in the directory”.

I’ve google searched his name and location in every imaginable combination, including yellow page searches. I only find his old office and the new number that is disconnected.

I googled for obituaries to make sure he’s not dead. Nothing came up, so I assume he is alive.

I’m tempted to send him another email asking if the “withheld” number was him and if so apologizing for not answering and then listing times I am more available to answer the phone. But I don’t feel confident enough that it was him. I have a guess of someone else it might be. If it was him why wouldn’t he send me an email saying he’d tried to reach me by phone unsuccessfully?

It’s funny. A reason I left was because he wanted me to call him whenever I was going to cut. I objected. He said he couldn’t meet with me if I couldn’t agree to that. Now here I am trying to find a way to phone him.

Besides sending him another email, I am out of ideas.
It’s a strange situation. I have a right to my records, but what is one to do when the person holding the records is unreachable?