Undersharing With the Oversharers

My therapist knows that I read my records, and will in fact be reading some soon because I requested a batch a couple of weeks ago. So when I came into my appointment last week she went ahead and mentioned to me that the notes made by the DBT group therapist indicate that while I seem to understand the concepts, I am struggling to apply the skills to my life. She commented that she doesn’t see that, because when I share my diary cards with her there are always multiple skills on each day and they usually help at least a little. So what’s different about group?

Well, in group I try to share the one or two best examples of skill use from my week, without getting into detail about the situations that prompted use of those skills. When I went to the appointment where group was explained to me, that therapist (a different one from both my individual and group therapists) said that sharing diary cards in group was just about sharing the skills used and that sharing the life situations should be minimized. I was quite put off when I got into the group and found that people overshared in this regard, and yet undershared in that they rambled on and on with cryptic references to their lives which made me wonder if I was the only one having trouble understanding.

I also noted to my therapist that when these other group members start rambling, they are prompted to keep sharing. They are asked questions about the situations, and then when they seem to be done they are repeatedly asked if they used any other skills that week. When I share my brief example of skills? They thank me and move on. The only time I’ve been prompted to share is the week when I was made uncomfortable by the presence of a different therapist (and the fact that my skill use related to some very negative situations), and I declined to share anything. At this point I was asked, “Didn’t you use any skills?” I said, “Yes, I just have nothing to share.” The group therapist did have the decency to ask me on the break if I was okay, but she was walking with the stranger and I just muttered, “Yeah.” Hint: I was not even remotely okay that day.

I do not tend to be a very angry person, but I felt a flash of anger at learning that I was being perceived negatively for doing what it was both said and implied that I should do. I recalled the shift notes from my first inpatient stay, which repeatedly stated that I kept to myself and did not socialize with other clients. I had no idea that socializing was acceptable, let alone expected. It was a hospital setting! How can it possibly be appropriate to make small talk with other people who are there seeking treatment? I felt both shame that I once again did not understand people’s unspoken expectations, and anger that the expectations were never explained to me. Had someone come up to me at the first sign of me staying secluded and invited me to engage with the other clients, I happily would have tried to do so.

So, back to group and my apparent failure to do what was expected of me. My therapist has been encouraging me, due to my continuing hatred of group, to contact the group therapist and explain to her what is frustrating me so that I don’t end up exploding and saying something I regret. In addition to this new information about my “struggle to apply the skills”, I’ve been increasingly frustrated by how little we are taught in group. My therapist has been giving me worksheets from a book by Moonshine Consulting, which has numerous skills in each of the four categories: Distress Tolerance, Mindfulness, Emotional Regulation, and Interpersonal Effectiveness. These worksheets are very helpful, and I expected group to cover the same material. Instead, they use only handouts from Marsha Linehan’s Skills Training Manual for Treating Borderline Personality Disorder. There were only three total skills in the Interpersonal Effectiveness section we started with! Yet, it took us weeks to actually cover what little material was offered.

This slow pace and lack of content has had me leaving group every week feeling that I’ve just wasted another 2 hours of my life, not to mention the money I paid to attend group. Many of the group members have been in group for years, repeating the same material over and over. This is not my objective. My aim is to get through the skills and get out. So not only do I wish we’d move faster, but now that I see how little we’re being taught I question the point of trying to stick with the group through the entire cycle of skills, when I have an individual therapist who is giving me better material to work with. I went into group with the caveat that I would have to quit if I found a job that conflicted with the scheduled group time. In my first interview, for a part-time job, I actually listed group as a scheduling conflict. They asked, so it seemed plausible they could schedule around it. I didn’t get that job, and now I’m desperately wishing for a job, any job, that will force me to leave group so that I don’t have to look bad by quitting.

I did finally e-mail the group therapist today, pushed over the edge by the notion that I’m being unfairly judged. I tried to keep all my comments polite and focused on my emotions and perceptions and not on laying blame, but I’m not sure how well I succeeded. I’m still working on assertiveness, and I’m sure I frequently miss the mark. However, I feel much better now that I’ve put my thoughts out there for her to read. Either she’ll have something helpful to say, or she’ll encourage me to go ahead and leave the group, and either of those has to be better than the current situation.

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ANSAs to My Questions

When I wrote the post Medical Records, I was waiting on a third batch of records to arrive.  I’ve had that batch for quite some time, but never managed to write about what I learned from reading it.  On my first read-through, I laughed hysterically.  For example, at the line “Smiled inappropriately several times during the interview when talking about suicide and substance abuse.”  Gee, you think maybe because I was nervous?!  I’ve been seeing my current therapist since May and she’s still waiting for the day when I’m comfortable enough to hold a conversation without being sarcastic and cracking jokes.

There’s also a note of “laughed when asked to sign a safety contract”.  By this point, I’ve lost track of how many I actually signed, and how many times I laughed and said signing was pointless.  Initially this was because the contract relies upon a willingness to pick up a phone and call for help if having suicidal or self-injurious thoughts.  I knew I would never, ever pick up the phone.  Eventually I did call once, on a lunch break from work, to discuss the fact that I had a strong urge to cut myself.  Did that 5-minute call help?  Actually, yes.  Am I at all confident in my ability to call again?  No, especially considering my failure to call somewhere between nagging suicidal thoughts and the overdose that occurred days later.

Another example of the hilarity was a 3-page Emergency Services Assessment that managed to note not once, not twice, but thrice that I had walked in with a number of suicide methods written on my arm.  This was actually more of an intellectual exercise (or, as the inpatient psych APRN noted, “an academic thought”) than anything else, but the on-call therapist (who I wanted to talk to about feeling stuck with my current therapist) fixated a bit on the content of my “self-decoration”.

I’m also a bit enamored of the phrase “Risk for not taking medications as prescribed.”  I’ve never quite been sure if that is a risk they consider specific to me, or simply a product of statistics about my diagnosis.  At the time this particular report was written, I had a couple of instances of taking leftover pills that were no longer prescribed, but had not yet experienced the 5-day stretch of willfully skipping my medication.  So perhaps they were leaning more toward statistics at this point, although my own stupid behavior would account for this risk assessment in the future.

The most informative portion of these records was an update to my Adult Needs and Strengths Assessment (ANSA).  This assessment has to be updated every 6 months, so this was my second time having it done.  I was curious as to how it turned out, because I was not actually involved with the production of this assessment.  My therapist did it herself based on information from past sessions, because on the date it was due she was too busy dragging me back to the inpatient unit.

ANSA

My reaction to this assessment was a sudden increase in depression.  Each need on the assessment can be ranked 0 = no problems, 1 = history/mild, 2 = moderate, or 3 = severe.  At the time of my original assessment, there were 5 needs ranked at level 2, and everything else was 0 or 1.  I went into this assessment expecting about the same.  I thought there might be a couple more at level 2, simply because my original assessment was based on 90 minutes with a stranger.

Reality was cruel.  Two needs (Depression and Interpersonal Problems) had leaped up to level 3, and I now have a whopping ten at level 2.  So my full list of needs to be addressed (as prioritized by my therapist):

Suicide Risk
Depression
Self-Injury
Other Self-Harm (Recklessness)
Criminal Behavior
Decision-Making (Judgment)
Medication Involvement
Impulse Control
Interpersonal Problems
Social Functioning
Family Functioning
Recreational

I noted on one of my diary cards that I felt sadness because “ANSA update was depressing.”  In therapy I continued that by saying “All those needs exploded everywhere.”  Before my therapist could even try to reassure me, I commented that I knew it was a matter of them being needs this whole time, just that they hadn’t been recognized yet at the time of the original assessment.  Does this make me feel any better?  Not so much.  It doesn’t change the harsh reality that there is so much to deal with in therapy that I will probably never go more than a week without it.

Medical Records

medical-records

In an online bipolar support group, I recently posed the following questions:

How many of you request copies of your medical records? If you do read them, how do you feel about what you read?

I have requested records three times (and received them twice…still waiting on the third batch).  The first time was in March, immediately out of my first stay in the IPU.  Aside from general curiosity, I wanted some specific information that had not been shared with me: my exact diagnosis and the results of my first-ever blood tests.  I got my answers, and a few moments of humor, and a few other moments of being really annoyed.  For one thing, my appearance when I arrived at the IPU was described as “bizarre”.  I showed up clean, in dressy clothes and full makeup, and just happened to have purple hair.  This is not bizarre.  In fact, it was quite pretty.

I also was annoyed that every time someone did an assessment of my intelligence, they wrote down “average”.  The staff members who have seen me over the long term would definitely laugh at the thought of me being average.

A few months later, in late May, I submitted a request for everything added since that first batch.  The day before they arrived, my therapist told me she had been notified of my request in case she had any concerns.  I would still receive the records either way, but she did tell me she was concerned that as a people-pleaser I may read things as criticism that weren’t intended that way and become upset.  And possibly injure myself in response.  She made me promise that I would talk to her about anything in my records that upset me.

I tried not to be upset by anything.  I knew my reactions were irrational.  However, some things kept nagging at me, so when I next saw her I told her we needed to discuss it.  Most of my concerns were things she couldn’t really address since it was about other people’s notes.  The only thing I was bothered by in her notes was that she refers to me by name instead of as “the client” like my former therapist did, and I got a reasonable explanation as to why that’s done.

Last week I stopped in to submit another request, this time for the past 4 months worth of records.  Aside from being a longer time period, it is also one that was quite eventful, so I’m expecting a very large stack of papers, including:

  • Updated Adult Needs & Strengths Assessment (ANSA)
  • Updated treatment plan
  • 2 inpatient nursing assessments
  • 2 inpatient physicals
  • 2 admission notes to the inpatient unit
  • 2 discharge notes to the inpatient unit
  • 21 inpatient shift notes
  • 7 visits with inpatient psychiatrist/psych APRN
  • 3 visits with regular psych APRN
  • 21+ visits with regular therapist
  • 1 visit with therapist’s supervisor
  • 1 visit with on-call therapist
  • 1 phone call with a different on-call therapist

In fact, I won’t say “including”.  I don’t think I’ve missed anything, so if there are additional pages beyond a few more times seeing my regular therapist between now and when the records are printed, I think someone should take me out back and shoot me.