Research indicates that the most successful scenario for treating and coping with mental illness is a combination of medication and therapy. Either one, when used alone, is not nearly as beneficial as when used together. And yet, as complicated as the medication can be (and it can be plenty complicated), it can be simple in comparison to the task of finding the right therapeutic match.
For starters, not all therapies are created equal, but there is not necessarily good information out there for patients and families to use to understand the strengths of various therapies and the differences between approaches. Furthermore, a sound therapeutic model does not guarantee that all of its practitioners are good therapists. Again, there is very little information out there to assist individuals in choosing the therapist that will be their best match, especially since someone who makes a great therapist for one person does not necessarily make a great therapist for a different individual.
And there are some bad therapists out there.
Therapists run the gamut from outstanding to good to adequate to mediocre to downright bad. A bad therapist is worse than simply ineffective; they can be detrimental to the patient's health and harm the reputation of the practice of large. Many people, once they've had a bad therapy experience, will write off therapy altogether and never go near it again: that's how damaging a bad therapist can be. It's a shame, since there are good therapists out there who could be helping those who now view therapy as worthless.
In my day, I've had two bad therapists (like the guy who told me to be kind to myself and eat some ice cream when I called to tell him--totally freaked out--that I'd woken up suicidal the day before), a few good therapists, and Andrea.
Andrea belongs in the class of exceptional therapists and for seven years she's been my invaluable guide. This week, I saw her one last time, as she is leaving the practice where she's worked all these years to explore different horizons. Although I'm sorry to see her go, she leaves me in good hands: my own. While I will take on another therapist in the practice as backup, over the years, Andrea has helped me become so skillful at managing my emotions and troubleshooting problems that I've only needed to check in with her every six months or so.
When we first met in March of 2005, it was a different story. I was in bad shape. The month before, I'd had my fourth psychiatric hospitalization in slightly more than a year's time. I was seeing a psychiatrist, but after the overdose that put me in the hospital, everyone agreed that I needed more extensive therapeutic treatment. That's how I found myself at the DBT Center of Seattle.
DBT, or Dialectical Behavior Therapy, deserves a blog post all its own to fully explain why it is, in my opinion, the best possible therapy out there. The extremely short summary is that it teaches individuals how to cope and respond to difficult emotional situations through the use of a variety of skills. It is a therapy of doing, of moving forward, of changing how you think and therefore how you feel, and it is extremely effective. I was first introduced to DBT at the psych hospital in Chicago and had seen a good therapist at the DBT Center of Seattle when I had been home for a few months between hospitalizations two and three. I was, therefore, not wholly unfamiliar with the general concept or that office in particular, but it was with Andrea that my true Dialectical Behavior Therapy education began.
As I said, I was not doing well when we first met. I remember her asking each week if I could make a contract for safety with her, meaning that I would promise not to hurt myself until I saw her next, and each week I would refuse to make that promise because I didn't want to make a promise that I wasn't sure I could keep. There are four units in DBT–Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness, and Wise Mind–and it should be no surprise that we jumped right into Distress Tolerance, the unit that focuses on surviving and coping with the most painful and extreme emotions.
The first few months were hard. I wasn't really well enough to even absorb a lot of what I was being taught, but between Andrea's gentle, kind, but firm guidance and my weekly DBT skills group, the principles started to take root. Six months into DBT, I was started on lithium, and suddenly, everything clicked. From then on, my progress accelerated tremendously.
When I think back to those early months (not that they are very clear), what I remember most is how helpful Andrea was in helping me confront my severely debilitating social anxiety. Together we made up a list of all the things I was scared to do and ranked them according to Subjective Units of Distress, or SUDs, which is basically, on a scale of 0 to 100, how terrified I was to do them. This list included things like asking for directions, talking on the phone, going into a store even if I didn't intend to buy something, asking a bus driver a question about stops or the route, looking at a map in public, taking the time to find the exact change when purchasing an item, making any kind of request of anyone, and dozens of other seemingly innocuous things that filled me with paralyzing anxiety. Then she had me choose one or two items off the list that I had ranked in the 20 to 30 SUDs range to do each week. It wasn't easy at first. But if I didn't do an item one week, it remained my assignment to do it the next. As items were crossed off the list, they were replaced by ones with higher rankings. Slowly this exposure therapy started to take hold, where years of cajoling and reasoning had failed. As my anxiety lessened, it became easier for me to move about the world without feeling like I was constantly being negatively judged by every single person around me. After I'd gotten the hang of challenging myself, we put the list away, but I remember when we looked at it again perhaps a year or so later. It was astonishing. Things that I had ranked as high as 70 or 80 SUDs now seemed so easy, meriting big fat zeros in terms of subjective distress in my revised view on life. The only thing that remained on the list that I agreed with was singing karaoke: sorry people, not gonna happen! It was amazing to see how far I'd come, and to this day, I still marvel at how wonderful it is to be able to do the kind of everyday things that used to fill me with terror and to be free of that sense of being constantly watched and judged. Without Andrea's advice, encouragement, and underlying firmness, I might still be obsessing over what terrible things other drivers were thinking about me because I had set my windshield wipers to "intermittent" when other drivers (and I was checking the wiper activity of every other car on the road) didn't seem to have theirs on at all. (Seriously, the thought that I might have my windshield wipers on the "wrong" setting used to preoccupy me terribly and any drive in the drizzle/rain/mist--and I live in Seattle, so there was no shortage of drizzly, rainy, misty days--was an exhausting, nerve-wracking, humiliating experience. It was a terrible way to have to live and am so thankful to be free of it.)
It could be argued that I might have done well with any DBT therapist, but I'm sure that without Andrea's attributes, I would not have come nearly as far nearly as fast. She was exactly what I needed in a therapist: friendly and positive without being superficial or exuberant; so clearly patient and kind and nonjudgmental that even I, who was so terrified of being "wrong" somehow, was able to learn to relax and trust her; clear in both her explanations and expectations; and, at the core, where it was needed, absolutely firm. I remember in one early session, during a time when I was still sorting through and dealing with suicidal thoughts, saying something somewhat glib or certainly self-centered about the benefits of suicide and her reply, that suicide really fucks up people's loved ones, shocked me tremendously. That Andrea would say "fuck" in a session was as shocking as, well, my mother saying it, or the queen. And when she said it, I believed her. That was the last time I ever indulged in fantasizing about suicide. From then on, I was wholeheartedly on board in trying to turn my thinking away from self-destruction.
And so I learned how to arrest a spiraling state of emotional intensity in its tracks; to notice when I was engaging in catastrophic thinking and how to make myself stop; how to quiet my mind when my thoughts started racing; how look for the positives in every situation instead of focusing on the negative; how to ask for what I needed and then, once I had accomplished that, how to ask for things I wanted (this was huge because my sense of self-worth was so low at the outset that I didn't believe I deserved to have needs, much less wants, and the worst possible thing would be to inconvenience anyone with something so selfish as asking for what I needed); how to separate the facts of a situation (or emotion) from the judgments and assumptions; and how to effectively respond once the facts of a situation or emotion had been established. With Andrea's helpful tutelage, I was able to leave that cringing, shrinking, petrified, miserable, out-of-control, profoundly unhappy torture chamber that was my life and enter into a positive way of being, where I believe in my worth, in my opinion, my voice, and my happiness.
It's a good thing I had DBT and Andrea at my disposal, since six months after I started taking lithium, I found myself desperately needing the skills I'd been learning. I'd started lithium because I was going off of a drug called Geodon that was causing tardive dyskinesia, or involuntary movements of the mouth and face, a condition that can become permanent if the medication causing it is not stopped. My experience with Geodon will get its own blog post one of these days, but what happened is that after six months of problem-free reductions, with me getting better and better by remarkable leaps and bounds, I slammed head-on into excruciating withdrawal. It was awful. There was agonizing pain, horrible nausea, immense fatigue, bizarre sensory hallucinations, cognitive problems, vision problems, you name it. It went on for years. And not only did the withdrawal symptoms get worse the closer I was to finishing the taper, but they continued for a full year AFTER I was off the medication. I started tapering off Geodon in 2005 and was not wholly free of its effects until 2009. And that's not counting its permanent legacy: hypoglycemia, worsened migraines, and periodic fibromyalgia. I might not have been able to cope with finishing the taper if I hadn't had DBT and Andrea to help me through one health crisis and setback after another. It really might have been unbearable. It's a good thing I was able to endure the withdrawal, though, because emotionally I am so much better completely off of Geodon!
In fact, I was able to do so well, thanks to lithium and Andrea and my year in the DBT skills group, that I was still in the Geodon withdrawal process that I started coming to my weekly therapy appointments without any problems to discuss. I'd become so skillful that I was able to tackle things by myself as they arose. It seemed silly to meet every week simply for me to report on how well I was doing, so we started meeting every other week. But even then I was managing just fine. So Andrea and I started meeting once a month. Before long, even that was excessive! In the last few years, I've been down to two or three check-in appointments a year. A lot of times, they'll just be half hour appointments to touch base. Sometimes, if I have a particular problem that I want assistance with, I'll specifically schedule an appointment to see her, but I no longer need weekly or even monthly guidance. It's hard for me to get downtown to the DBT Center's office now that I've had the chronic migraines to contend with, so we've had most of our appointments over the last two and a half years over the phone, and that's worked just fine.
Lithium, in combination with several other medications, is essential to managing my bipolar II disorder. But if I hadn't had Andrea's gentle but insistent instruction to help me cope during the seven months between the fourth hospitalization and when I started taking lithium, it's probable I would have continued ping-ponging in and out of the psych hospital, almost certain that I would have embarked too far down a road of self-destruction to easily turn back, and possible that I might have ended my life altogether. At the time we met, after years of just barely clinging to a facade of normalcy, I had become unmoored. I knew the frightening thoughts and urges that were flooding my mind were the result of brain chemistry out of balance, but I also didn't know how to stop them, and their warped seductiveness was becoming harder to resist. I was so terrified and also so appalled that I could think such things that it was hard for me to talk about them, but I trusted Andrea, and even before I was able to effectively implement the DBT skills I was learning from her and my group therapy, it gave me hope that I might someday regain control of my mind. It's not a coincidence that I have never needed another psychiatric hospitalization since I started DBT!
And so with Andrea's invaluable help, I was able to grow from a fragile, damaged, terrified husk of a human being into a confident, balanced, happy woman. I went from being so emotionally raw that the slightest thing could send me into a tailspin and so fearful that the mere thought of ordering a pizza over the phone could send me into a panic to the point where I was able, on my days off, to get all dressed up, experiment with a little dramatic makeup, go downtown, take myself out to lunch at a nice restaurant, go to a matinee of a play all by myself, stroll around downtown while enjoying the admiring looks of passersby, check out the latest fashions even if I wasn't planning on buying anything, make a purchase at a drugstore and chat with the cashier while taking the time to find the exact change despite someone waiting behind me in line, and generally have a wonderful time. Even more remarkably, when the onset of the chronic migraines brought an end to those fabulous afternoons and left me unable to work, socialize, or even leave the house because of pain and tremendous light- and noise-sensitivity, I've still been okay. When I am happy, and I frequently am, it is a happiness as legitimate and whole as what I felt on those delightful, confident days spent enjoying the dining, shopping, and entertainment offerings of the city. I owe it all to DBT. Had I not learned how to stop myself from fixating on the negatives and instead see and capitalize on the positives during my climb out of the depths of depression, I would not have handled this disability with nearly so much aplomb!
While I have no doubts about my ability to continue to not only manage my emotions but to thrive, it has been a bit of an emotional process to say goodbye to Andrea. Walking past the Louis Vuitton store on the way to my final appointment yesterday, I recalled how it was one of my earliest assignments in my quest to conquer my social phobia to go in the store and look around for several minutes despite my belief that I was not "good enough" to be in there. It took several weeks for me to work up the courage to open the door and endure the judgmental (I was sure) stares of the security guard and sales associates as I nervously made myself look at every bag and every shoe. It's simply phenomenal how far I've come and while I remain grateful and proud of myself every time I make a phone call or go into a new situation without panicking or ask for help or any other scenario that would have been nearly impossible for me in my anxious days, it's been very moving to really remember down to the visceral level how I used to feel in those wretched days and compare it to how I feel now. I have not seen the last of Andrea; while our professional relationship has ended, DBT guidelines allow for ongoing contact between former therapists and clients if such a thing is agreeable to both parties, and we agree that it would be really nice to get to touch base now and then! I was very glad, though, when we parted, that I was able to tell her that she has made a tremendous difference in this world: she changed--and perhaps even saved--at least one life for the better. She always credits my hard work for my success, but without her approach and personality and patient coaching, I would never have been able to form the bond with her that has, over time, enabled me to succeed.
So thank you, Andrea, from the very bottom of my heart. I love the person who I am now, am no longer afraid of the world and its opinions, and I no longer need to be afraid of myself, three things that, when we met, seven years ago, I never could have even dreamed would be possible. I have been so fortunate to have known you and worked with you and thrived because you. The vastness of my gratitude matches the scope of my former unhappiness, which is, to say, immense. Thank you! Thank you! Thank you!