Plateau

Today in session, I was telling my therapist that I feel like I’m at some sort of therapeutic plateau. I have come so far in terms of stability. I am in a good place – my life is overall quite wonderful. Of course there’s a lot I still struggle with, but that is entirely internal at this point. I have eliminated all sources of truly toxic or harmful external stresses. There is no one left in my life who can, or would, hurt me.

So, naturally, I feel a compulsion to continue to hurt myself.

During last night’s session, I nearly had a flashback. I think the only thing that stopped it was that I felt it coming on and mentioned that fact to my therapist. She told me that she knew it would annoy me, but that she was going to do what she needed to do in order to keep me “in the room” with her. For us, that means she asks a lot of grounding questions and makes a lot of grounding statements.

Why is this annoying? Because it feels like an abandonment. Not necessarily from me, but from the parts that are stuck in trauma time. I want to pull away from the memories and sensations, but unfortunately that means that I leave those traumatized parts stranded in their present-day torture.

Which sucks. But I just can’t do it. I can’t go there.

Scheduling Changes

It’s probably fairly clear from all the time I spend blogging about scheduling issues that my therapist and I often struggle to keep our three weekly sessions. We’ve somehow always managed to figure it out thus far, but it’s tough. We both end up doing a lot of rearranging and making small sacrifices here and there to make it work. Overall, I think it’s worth it, but that doesn’t necessarily make it less challenging.

I’ve been seeing her on Mondays for a very long time. That has probably been the most consistent day in which we’ve had sessions together. Due to my latest clinic schedule, however, she’s had to do a lot of shifting her schedule in order to offer me three “primetime” (i.e. after standard work hours) slots.

Which means no more Mondays. For the next month I will see her on Tuesday, Wednesday, and Friday. Except for a couple of weeks where I either have class or she has a conflict and we have to switch Friday to Thursday. As I mentioned recently, we changed my session to Thursday last week. And then I didn’t have session today because my Mondays were switched to Tuesdays.

I really don’t like that. I’ve gotten into a nice little routine of starting my week with a session after school/clinic. It was bizarre and unsettling to realize that wouldn’t be happening today. One positive is that it opens up my schedule to attend my favorite yoga class again, but I still felt sad and upset about the missing my normal session time.

Using Anorexia to Disengage

Things have been pretty calm in therapy lately, at least from a relational perspective.

That’s not necessarily why I haven’t been writing about it more on here, but I think it might be part of it. Mostly I’m just too under-nourished and distracted by my obsession with food and other related numbers to find the time or energy for blogging.

I don’t know how others experience eating disorders, but I must admit it is the most energy-consuming and demanding thing I have probably ever encountered. There are moments here and there where I feel like I’ll start to shake it off, but then something activates me and bam! I’m right back to the usual nonsense.

It’s tough. Using ED behaviors as both a pretty effective coping mechanism and a tool of self-destruction has become more of a habit than anything else. There are moments when I think about pulling out of the incessant self-deprecation. For example, I’ll think, “Okay, so I’m disgusting. But maybe that’s okay. Maybe I don’t need to obsess and panic about it every literal 3 seconds.” Which, for me, is progress. But then I feel the ED tug on me and I reassure it that even if I am less self-loathing, I won’t give up the disorder.

It is stubborn and strong and a LIAR. Yet I love it. It makes me feel safe and powerful and worthy and capable and accomplished. It is what my therapist has not so lovingly started calling my “greatest frenemy”.

Sickness as Abandonment

All week long my therapist has been sick. Not severely sick, just a head cold. But when I got to my first session of the week, I immediately realized she sounded congested and I asked her about it. She said she has a bit of a cold, but it was nothing major.

Sure.

Except, it totally freaked me out. In the past year and a half, she’s never been noticeably ill before. She’s never cancelled or rescheduled a session for personal reasons at all. So I don’t know if I was worried she would get more sick and then take time off from work or what, but it really upset me.

Then for our second session of the week, she called me an hour before my session and left a voicemail. I was nervous that she’d called to cancel, but she actually just had a client cancel their session, so she wanted to know if I happened to be available to come in earlier.

I was a little irritated with her for unidentified reasons (probably her head cold, to be honest) so I’d considered just not showing up for session at all. I almost stayed on the train when it stopped by her office. But then I told myself that I didn’t have to go to session just because I was in the area, so I got off the train.

F44.81

In an effort to attempt to get some of my therapy paid for by out of network insurance coverage, I asked my therapist to write me up invoices for January and February. We briefly discussed what diagnosis codes she should use. I was overwhelmed by the conversation at the time and ultimately indifferent to the code choices. I just told her to write whatever seemed most appropriate. 

Today she gave me those invoices. Here’s a screenshot showing the codes she chose:

  
90834 is a CPT code just indicating that she sees me for individual psychotherapy. 

F44.81 is an International Classification of Diseases, 10th edition (ICD-10) code. I honestly wasn’t sure what my therapist would put for this. I figured it would be genereric, like “anxiety disorder” or “mood disorder – unspecified”, which is what Zooey always listed on her invoices, and what my psychiatrists frequently use. 

But I looked up the code and here is what it says online:

F44.81 – Dissociative Identity Disorder 

This is a specific ICD-10-CM code that can be used to specify a diagnosis. This is the American ICD-10-CM version of F44.81. Other international ICD-10 versions may differ.

Clinical Information:

• A disorder characterized by the presence of two or more identities with distinct patterns of perception and personality which recurrently take control of the person’s behavior; this is accompanied by a retrospective gap in memory of important personal information that far exceeds ordinary forgetfulness. The changes in identity are not due to substance use or to a general medical condition.
• A dissociative disorder in which the individual adopts two or more distinct personalities. Each personality is a fully integrated and complex unit with memories, behavior patterns and social friendships. Transition from one personality to another is sudden.

Applicable To: Multiple personality disorder. 

ICD-10-CM F44.81 is grouped within Diagnostic Related Group (MS-DRG v32.0): 883 Disorders of personality and impulse control. 

I know this is not news to you (or me), but this is the first time I have ever actually seen this on paper for myself. 
This is real. 

I really have this. I have officially (on paper I can see with my own eyes) been diagnosed with Dissociative Identity Disorder. My therapist believes me. And she believes me with enough conviction to bill my insurance using that specific code. 

Holy shit. I have a lot of feels right now. 

Not My Favorite

The first thing my therapist and I discussed during Friday’s session was the upcoming schedule changes. As I wrote previously, my school and clinic schedule will be shifting (yet again), causing me to change all three of my weekly sessions.

My therapist had originally discussed the option of having sessions on Mondays and Wednesdays, with the choice to do a double session on Wednesdays or two 90 minute sessions. I respected her efforts to maintain our three hours of session per week, but knew that the length of time from Wednesday to Monday would be very challenging for me.

My plan was to bring this up with her and explain my feelings. I didn’t have solution, but I wanted her to understand how this could potentially impact me.

But in a rare act of initiating the conversation, she asked if she could start out session by talking about scheduling. She said she’d gotten a little mixed up when giving me possible times and wanted to clarify. She said the Monday time would work, but that she couldn’t see me until 7pm on Wednesday (no big deal since that actually would work a little better on the days I have my seminar class). She also said there’s a chance she could see me for a third session. She said, “I could see you on Fridays, maybe, but that’s not my favorite.”

Um, what?

Mother, Money, Medication

As I mentioned in my last post, I really wanted to talk to my therapist about both scheduling and money in our last session. We got through the scheduling conversation fairly quickly, which left nearly 45 minutes to tackle the money part.

Oh boy.

My therapist and I have tried to have conversations about money, primarily within the context of how the financial cost of therapy impacts me. It’s a lot of money. A LOT. It is the biggest expense for my wife and I (and that includes rent in NYC). It wasn’t so bad when I started with this therapist because it was just one session per week. But then one became two and a few months later, we settled into three sessions each week.

It’s pretty clear that this frequency works well for me. I don’t mind seeing her so often, but I won’t pretend the cost isn’t a burden for me. My wife insists that my health, including my mental health, is worth the expense. I believe her. But there is still so much intense guilt that comes up for me, especially since I’m still in school and thus not generating income for myself.

I do get a small stipend and all of my education is paid for in grants and scholarships, so at this point all of my therapy expenses have come from my own bank account. I am happy about that, but it also means that I’m literally contributing NOTHING to our other bills – rent, utilities, groceries, cell phones, transportation, etc. And that is very hard for me to swallow.

Scheduling Changes (Again)

My schedule is shifting. Again.

My third (and final!) clinical affiliation starts on the 21st and will last for 8 weeks total, Monday to Friday, 9-5pm at a local hospital.

The whole hospital setting is activating and I have plenty of fears and anxiety about that, but I can’t even go there yet. I just need to feel relatively calm for a week or so before I actively tackle those emotions.

But this also means I will have to shift sessions around again. I told my therapist my schedule as soon as I heard from my clinical director. She was okay with it and said she would start moving things around in her schedule to make room for me.

On Monday, she mentioned it and said we should try to talk about it soon. So for Wednesday’s session, I went in with the intent to talk about two things:

Truth and Transitions

Since I had to go to therapy right after the rather disastrous appointment with my shrink on Monday, I was in a difficult emotional space. I felt intense rejection and a sense that the world was caving in. I think I also felt like I had very little left to lose, since I was now in conflict with both my therapist and psychiatrist, which emboldened me in a much needed way.

So when I got to session, I opened with about as much truth as I could handle. I said,

“I feel like we should just end this: therapy, sessions. Because I feel like you are dangerously close to bailing on me and I can’t tolerate that thought. I can’t be in that space, dealing with all of this fear. I can’t be waiting for that. I can’t be imagining it. I don’t want to think or feel or do anything that has to do with you abandoning me. So I just want to walk away now, before you can really hurt me.”

She first assured me that she has (still) not had any thoughts about bailing on me or ending our treatment, but then she asked if perhaps her comment from last week had left me feeling afraid and concerned that she was at a limit with me?

“Yes, absolutely.”

Rejected

Late last month I saw my shrink. It was one of those days where I woke up drowning in self-loathing. As I wrote about in this post, I showed up to my appointment about ten minutes late and was a sloppy incoherent mess of emotions. I mostly just cried and rambled before leaving in an admittedly abrupt and tantrum-y way. My frustration was not with my shrink, it was with myself and how dysregulated I felt at that time.

She called the next business day and left a voicemail saying she wanted to check in. She also offered a couple of times for our next appointment and said we should talk about “how you want things to proceed from here.” She mentioned that my medication seems to be more or less “squared away” and she’s wondering how this would “work best for me.”

It was a nice enough voicemail but I had a bad feeling about it. I mentioned this whole scenario to my therapist who suggested I schedule a follow-up sooner rather than later and suggested that my shrink was simply trying to open a dialogue about our work together.

Perhaps.