Do I need to rethink my feelings about DBT?

I don’t usually post links to other articles here. That’s generally not my style. And judging from the content of this one, it’s probably going to get posted many other places.
I just have to share some of my reactions somewhere.

Here is the article
You may need to make a free NYT account to be able to read it.
tldr version: Marsha Linehan reveals her personal history of self-injury

DBT was not helpful for me. With other therapy types that have not helped I never really felt anger towards the big names that created it. I don’t have strong feelings towards Aaron Beck as a person even though there are some complex emotions going on for me about CBT. Things have been different with Linehan though.

Her name has been all over my experience of the therapy. When I was in DBT I worked in her workbook, which I pursed a copy of. In hospitals when DBT was shoved down my throat I used xeroxes of the same workbook.

After I quit DBT my (non DBT) therapist pressured me to take home DVDs of Linehan’s to watch. If I refused to continue the DBT therapy, she thought maybe the DVDs would help. They just made me angrier. I have pages of typed notes picking apart every detail of those DVDs. Some of them were obnoxious and irrelevant such as my criticisms of the lighting quality. Mostly I just felt that Linehan just didn’t get it. Combined with later viewings of youtube clips of her and videos of her I saw in school, I’ve developed a view of her as cold, mean and out of touch. The cultish language of DBT did nothing either to endear her towards me either. That she could possibly have a personal history of these problems was not something that ever would have occurred to me.

A lot of my anger towards this therapy, that was repeatedly forced upon me, became directed at her. She created this overhyped therapy that no one will believe is ineffective for me.

This article really turns a lot of my feelings upsidedown. I guess she’s not quite as out of touch as I thought. Some of these comments she made that seemed cruel make me think more now that she’s using humor as a way to deal with some fo these things.

I am not going to become a hardcore DBT advocate, but it does make me feel its worth a little more examination. Not so much as a treatment for myself (I’ve long ago ruled out the possibility of it being effective for me and strongly believe anyone who treats any therapy as a panacea is delusional), but in terms of general professional knowledge it could be useful. I still have theoretical objections and think DBT is backwards (behaviors should not be the first issue address with in a therapy, IMHO), but this gives it a little more credibility.

This news is certainly going to take over my therapy session today.

I’m still processing my thoughts about this. I don’t usually like to post here without digesting thoughts more, but I wanted to share while it was still fresh news. Feel free to add your thoughts on the matter.

Edit:
I walked into therapy and said “Hey, did you read the NYT today?”
S.M. replied “I haven’t finished reading it yet, but I bet you want to talk about the Linehan article”
He’s got me figured out.

 

Edit Aug 14, 2018: I see I was linked on metafilter and am getting a lot of traffic from there. Be sure to see my newer post on this topicĀ https://psychologytales.com/2016/10/08/updated-thoughts-on-dbt/

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.

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.

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.

Escape and Keeping things seperate

When I tell people why I switched schools/majors I try to put a happy spin on it. ‘It was purely for academics’, I’ll say.
The reality is that after I returned from my involuntary leave, I did not feel welcome.

I was placed in freshman dorms again and harassed by roommates who’d heard rumors about me and dug through my prescriptions, running google searches. They google diagnosed me with schizophrenia and decided I was out to murder them in their sleep. If they were really so scared of me why did they yell at me so much?

I was only able to take one class in my major, because the prerequisites I needed were not offered that semester. My semester off left me a year behind. I hardly saw the classmates I’d known when I was there before. They’d moved on without me.
I avoided large sections of the campus. I couldn’t go near any of the offices involved in forcing me out. I hid when I spotted people involved.
It was not a welcome return.
I just wanted to pick up where I left off like nothing had ever happened, but it was impossible.

I felt so on edge and unwanted. I needed to escape.
I couldn’t transfer and stay the same major. I couldn’t justify that to myself.
I was enjoying my Intro Psych class and reading a lot of psychology books. I’d thought before it wasn’t an option, but as I learned more I reconsidered.
I told my therapist I was leaving to get an MBA. I refused to talk over my decision in therapy. I didn’t tell him I was switching to psychology. I felt uncomfortable telling a therapist I was going into his field. I justified this lie by telling myself I could get an MBA after I got the psychology degree, but didn’t really believe it.

I hate to make it sound like I don’t love what I’m doing now that I am a psychology major. In retrospect I realize now that I have much more enthusiasm for this than I had for my previous major, but the decision will always be tainted because it was made to escape one thing rather than pursue another.

So I escaped to a new school. Except the escape didn’t work. Changing location wasn’t enough. I can’t escape the fear of it happening again.

No matter how well I do academically I am still at risk of it happening again. My last school didn’t care that I was a good student, this one won’t either. The fear is in my head guiding every action I make.

I see a person who looks like the therapist who kicked me out. I know it’s not him, but what if it were him? What if he showed up at my new school? I run through scenarios of what I would do. I get lost in my thoughts.
It’s like I have two images layered on top of each other. One is reality and one is my fear scenario. The opacity is being adjusted up and down. I see one then I see the other. Volume alternates between the scenes. I can forget that I’m only in my thoughts.
I react as if it is happening. Fisted clenched, heart pounding, tears welling up in my eyes.
It goes until something jolts me back into the real world.

I’ve tried all sorts of reactions in my head. Sometimes I scream at him, sometimes I glare angrily, make sarcastic comments. I sometimes try explaining to someone how much he hurt me and that he needs to leave. Or maybe I quietly make an exit and other times the exit is dramatic.

I also go through scenarios where my new school tries to kick me out. Sure I’m better prepared this time because I know my legal rights, but I’d still have to fight for it. The new school becomes tainted because then they also don’t want me there. All my effort to hide things and I end up in the same situation as the old school.

There’s never a good resolution. In every imaginary situation I dig myself into a deeper mess.
I think part of it is my brain trying to find a way to deal with it. If I had a good solution, should the situation arise, maybe I wouldn’t need to fear it so much.

Another part of it that I realized recently is that part of me wants a confrontation with the therapist who kicked me out. I sent him a much too nice email awhile ago which he ignored. I want to him to see my rage. The damage that his own fear caused me.
Even in my head seeking him out for this is unacceptable. But if he invaded my territory, then I’ve every right to defend it. I could show him my anger without as much guilt.

My favorite professor has a number of things in common with the therapist who kicked me out. I’ve been through many scary stories in my head where it turns out they are friends. The rational part of me had been able to say that this was unrealistic. They have similar research interests and theoretical perspectives, but so do a lot of people who don’t know each other.
This semester has been rough. I have a class with that professor and have learned more about him. Like how he enjoys going to conferences of a organization that once named the therapist who kicked me out as their therapist of the month.
My professor recently mentioned reading a blog and recommended it to me and a few others. It was a blog I’m familiar with. This blog has repeatedly endorsed the blog belonging to the therapist who kicked me out. The therapist’s blog is one of 13 links in a recommended blogs section. That therapist’s blog has a word in it’s title that is my professor’s primary area of research interest. If he were scanning that list of blogs this one would stick out.
It is fairly likely based on this information that my professor has read/reads the blog belonging to that therapist.

This potential merging of parts of my life is terrifying.
A whole new set of fear scenarios has been launched. Even something that might seem as small as my professor mentioning the therapist’s blog is scary. How would I react to it? Am I able to hide my reaction?
What if my anger towards the blog isn’t concealed? What if he puts things together, realizing that that therapist worked at my old school?
It’s possible that the reason that therapist no longer works at my old school is at least in part due to my legal action. What if he talked to people about it, without saying my name? What if he talked to my professor about it. What if then my professor put two and two together and realized it was me who the therapist kicked out?

It’s impossible to escape fully as long as I still live in fear of being kicked out of my new school. Even once I graduate I won’t be safe. It’s not just about being kicked out of school. It’s about stigma.
There’s nothing I can do to keep myself safe from the stigma other than hiding everything. It requires large amounts of mental energy. I have to be several steps ahead of everyone. I can’t say something that would elicit a question that might lead to showing too much.
And ironically the problem causing me the most distress is the anxiety surrounding escaping stigma. If I didn’t have this worry I’d have better mental health, certainly not perfect, but better. Trying to hide my crazy is making me crazier.

Non-Suicidal Self Injury in the DSM 5

As you likely already know, a draft of the DSM 5 came out Wednesday.
There’s a lot of interesting stuff to look through, but the part I had the biggest reaction to was the addition of Non-Suicidal Self Injury. Funny that this is what interested me, because in general research on self-injury bores me.

My initial reaction was entirely positive, but after some more thought I realized some potential problems. So, here’s a list of pros and cons.

Pros:
Too often people who self injure get stuck with the borderline personality disorder diagnosis who don’t meet the criteria only because they self injure. In the paper explaining the rationale for this addition (It’s a quick read. I recommend skimming through it if you’re at all interested) the authors mention that self injury occurs in many different disorders.

The specific wording in the title differentiates self injury from a suicide attempt. Hopefully this can help to cut down on some of the overreaction from practitioners about self injury.

Cons:
Does self injury really belong as its own disorder? Are there people who self injure on multiple occasions without any other diagnosis? Is there research on this? Seems strange to add a disorder that might only rarely be seen in isolation, increasing problems of co-morbidity.
But I understand that the way the DSM is set up, it has to be its own disorder or nothing at all. Possibly the benefits outweigh the negatives of added co-morbidity.
In the article (page 10-11) the authors justify self-injury as a separate phenomena by mentioning a longitudinal study showing that self injury decreased independent of other symptoms. This study was done only on patients with borderline diagnoses, not sure it is fair to generalize this to other patients especially because this new disorder plays a role to separate self injury away from only borderline personality disorder.

My largest problem is with section B: “The behavior and its consequences cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.
This seems like a benign thing to add. Similar qualifiers are in every disorder.

Here’s the problem: The way it is written right now, I don’t meet the criteria for this disorder. I don’t have impairment or distress from the self injury, but I have a lot of that from the feelings leading up to the self injury.

Seems silly. No one would try to argue with me that what I do is self injury. I’ve even participated in a number of studies researching non-suicidal self injury. Those studies could easily be used to support inclusion of this diagnosis, wouldn’t make sense for their participants to not all qualify.

Instead, I feel section B should be written something like this: “The behavior, its consequences and/or feelings precipitating the behavior cause clinically significant distress or impairment in interpersonal, academic, or other important areas of functioning.”

The current writing reflects an unfortunate trend to treat self-injury as the problem rather than the reasons for self injury. Certainly many people feel guilt over their self injury, but this is not the case with everyone.
The authors touched upon a similar idea in their section, “Placement in the system: A Mood or a Behavior Disorder?” (Pages 8-9). Much of their argument leads towards placing it in mood disorders, with a side note of similarity towards impulse control disorders, so it seems strange for the mood component to be omitted from the impairment part of the diagnostic criteria.

Partial Hospitalization #1

A partial hospital program is sometimes also called a day program. You spend the day at the hospital, but then go home to sleep.

My first partial hospital program was right after my first hospitalization. I lasted two days there.
This is the program that I mentioned in my post about how they sent me someone else’s records.

The social worker in my hospitalization set up the intake at the partial hospital program for me.
I told her two requirements I had for it:
1. It needed to be an adolescent program
2. I did not want to do DBT

When the social worker informed me it was set up, she told me my requirements had been met.

When I arrived on the first day, I quickly learned neither request had been fulfilled.

I realize now that avoiding DBT in this type of program is likely an impossibility, but I’d have appreciated her being upfront with me about this. To be fair she probably didn’t know the program contained DBT. But the reason for this is probably because she didn’t put any effort to find out.

My request for an adolescent program was reasonable. I was 19. My inpatient hospitalization had been with adolescents (their cut off was age 21).

There was a group of about 6 others in the program. I was by far the youngest. Most were old enough to be my parents.
I was very uncomfortable. I listened to people complain about their children and spouses. I couldn’t relate.

At my intake meeting a ‘No Harm Contract’ was presented.
‘No way’, I said ‘I will self injure if I want to and forcing me to sign that just will force me to lie. I’d rather not need to lie.’
The contract was pushed aside to be reevaluated in the future.
I left that meeting with the understanding that I had in no way suggested I would refrain from self-injuring.

I was very angry and aggressive (verbally, not physically). Largely because I was stuck at this partial hospital program because I’d been kicked out of school and possibly also in a small part because of a bad reaction I was having to Celexa.

I was under the impression that successful completion of this program was necessary to help my return to school. Despite despising the program, I felt I needed to stick it out.

The first day was a Friday. That weekend I returned to the school to move everything out of my dorm room.
Most was removed Saturday. Sunday morning I came to retrieve the last few items and discovered another person sleeping in what had been my bed and a large bong in the bathroom.

Monday I returned to the partial hospital program. The first day I had left my sharp items at home. I wasn’t sure what I was getting into (would my items be searched?) and decided it was in my best interests to leave them at home. Monday, the second day, I came prepared with a swiss army knife in my pocket. This seemed fine based on my experience the first day.

Inpatient hospitalizations are under-structured. Too much time with nothing to do. Partial hospital programs are over-structured. One group after another. Spending the entire day dwelling on problems, because the structure prevents one from going out and doing anything enjoyable.

I was frustrated with the way the people leading the groups spoke down to us, as if the depression meant we were cognitively challenged.

During the lunch break I made a few little tiny cuts on my leg. Very minimal, close to zero blood draw.

In the afternoon I had a daily check-in meeting with a social worker. As a side note I mentioned cutting a little during lunch. I didn’t think it was a big deal to mention. I’d never agreed to the no harm contract.

I was transported into an office with another woman (someone with a higher level of authority). She demanded to see what I’d used. I handed over the knife.
A lecture proceeded in a disgusted tone, wondering how I could have possibly thought it was acceptable to bring a “weapon” (aka a small swiss army knife) into a hospital.

She demanded to see the cuts.
I refused, explaining they were minimal and did not need medical attention.
She argued that because I had done it “on the premises” she had to see them.
I continued to refuse.
“I’d have to take off my pants to show you”, I protested.
She seemed unconcerned.
I was scared and eventually intimidated into giving in.
I tried rolling up the pant leg to show the cuts, but as I’d suspected the leg wouldn’t push up far enough.
I unzipped, pulled down my pants and showed her the cuts.
I felt very violated.

“Well there’s not too much damage this time“, she huffed.

That was it. The last straw. I announced I was leaving the program.

She bombarded me with questions assessing my current suicidal risk, trying to trick me into saying something to allow them to keep me there.
I didn’t fall for it.

My knife was returned and I went home.

I still didn’t have a therapist. While making phone calls to find one, many therapists refused to see me on the basis that I’d not properly completed the partial hospital program. I only was able to get into therapy (although this was my fake therapy, because anything I said was at risk of being reported back to my school) eventually when I left out the bit about the incomplete partial program.