Tag Archives: Cognitive-Behavioral Therapy

My Experience With Therapy and Counseling #Write31Days

31 Days of Mental Health

Welcome to day 23 in the #Write31Days challenge on mental health. Today, I’ll focus on another question in the 30-day mental illness awareness challenge. For day 23, the topic is your opinion on therapy. I will share my experiences of therapy and my opinion on various approaches. I have decided to include both traditional psychotherapy approaches and non-verbal approaches.

I had my first experience of therapy as a child, when I had four sessions of play therapy. I didn’t like the therapist, didn’t have insight into my problems, and four sessions obviously wasn’t enough to garner any results. In hindsight, my play behavior did show my problems with rigid thinking, emotion regulation and behavioral control. For example, I’d throw out the dollhouse dolls with purple hair because “people don’t have purple hair”. I also preferred to play with toys that allowed me to show anger, such as toy guns. One vivid memory I have is of me trying to overflow the water tray. The therapist did show me why it wouldn’t work, but I tried anyway.

My first experience with verbal therapy was when I was nineteen and attending the rehabilitation center for the blind. Once again, I didn’t like the therapist, who appeared a bit inpatient towards my difficulties adjusting to blindness and misunderstanding of my social ineptitude. She tried to offer practical advice, while I felt I needed to process the rollercoaster ride that my life had become. Of course, time constraints – I had only about twelve sessions -, prevented us from going deeper.

During my first sixteen months in the psychiatric hospital, I didn’t have a psychologist. I did do movement therapy, which helped me greatly to release my emotional tension. It was here that I learned to rate my distress level – I came up with a system myself. Thhat being said, when later people asked me to rate my distress level, I was often stuck. This moveement therapist I had at the acute ward was one of the more helpful therapists I’ve had.

At the resocialization ward, I tried cognitive-behavioral therapy for a bit. It hardly worked, because I and my therapist agreed I had good reason to be anxious. Then, when I was diagnosed with DID and PTSD, the therapist pushed me to try EMDR, but I resisted. I didn’t have that severe PTSD symptoms, after all, and did have quite a bit of trouble with self-regulation and dissociation.

When I moved to my current institution, I got diagnosed with BPD. My therapist’s expertise was schema-focused therapy, an approach I’d wanted to use for a while. Unfortunately, it didn’t work out. The therapist told one of my parts, who hides her inner weakness behind a stubborn attitude, that she’s a “punitive parent” and needs to disappear. I strongly feel that each part of my personality has a function, so this dismissive attitude didn’t fit me well. Besides, though I learned some from the book the therapist recommended, most of the information was just a bit too abstract.

This therapist left in 2014 and I’ve had a new psychologist for a little over a year now. With her, I focus on supportive counseling and rehabilitation. I find this is most constructive. I do hope that, in the future, I can get some formal psychotherapy again. I have a dialectical behavior therapy self-help book, which is quite interesting. Then again, I find it hard to make a long-term commitment to sticking to one thing to focus on. That is probably the main thing keeping me from engaging properly in psychotherapy.

New Definition for ME/CFS: Exclude People with Mental Illness?

I follow a few blogs by people with chronic pain and fatigue conditions. On one of them, I came across the new Institute of Medicine (IOM) report on the diagnosis of chronic fatigue syndrome / myalgic encephalomyelitis (CFS/ME). In this report, the IOM propose a new name and criteria for CFS/ME. Most people in the CFS/ME community are mildly positive about the new proposed name, which is systemic exertion intolerance disease (SEID). They don’t like the emphasis on only exertion intolerance, but they consider it better than the dreaded term “fatigue”.

What remains controversial is the definition of SEID. It is defiined by the following core criteria:

  • A substantial reduction or impairment in the ability to engage in pre-illness levels of activities that persists for more than six months and is accompanied by fatigue—which is often profound—of new or definite onset, not the result of ongoing excessive exertion and not substantially alleviated by rest.

  • The worsening of patients’ symptoms after any type of exertion—such as physical, cognitive, or emotional stress—known as post-exertional malaise

  • Unrefreshing sleep.

In addition, a person must either experience cognitive impairment or orthostatic intolerance (symptoms being worse when in an upright position and lessening when lying down).

Problems with these new proposed definition include it ignoring common additonal symptoms, such as gastorintestinal symptoms, sensitivity to stimuli, pain, etc. I heard that these symptoms are included in an addendum to the IOM report somewhere.

What is further said to be problematic is that the definition is overly broad. Particularly, a psychiatric diagnosis does not preclude a diagnosis of SEID. Why this is a problem, I wondered, and it led to a heated debate.

I have written about this before, and got many defensive comments from ME/CFS sufferers saying that a physical illness requires different treamtent than a mental one. I agree, and I think (and just checked to make sure) I said that there is evidence that ME/CFS/SEID/whatever is physical in nature. The fact remains, however, that no blood test or whatever can diagnose it, so there is no way to distinguish it from somatization (psychological problems leading to physical symptoms).

I understand that there is a huge stigma associated with mental illness and that ME/CFS/SEID sufferers don’t want to face the same stigma. I also understand that bloggers cannot advocate for every single person or group of people in the world. Then again, the solution isn’t to purposefully exclude groups of people from the treatment or rights you advocate for.

So let’s get the facts straight. ME/CFS/SEID leads to profound physical symptoms. There is, however, no test to diagnose it, like a blood or urine test or whatever. No mental illness precludes people from falling ill with physical symptoms, though people with certain mental illnesses are more likely to suffer with physical symptoms. This does not mean these symptoms are due to the person’s mental illness. Furthermore, the current edition of the psychiatric manual, DSM-5, does not require a thorough physical examination and exclusion of all physical illnesses in order to diagnose somatization. Therefore, there is basically no way to differentiate an illness with physical symptoms for which there is no objective diagnostic tool, such as ME/CFS/SEID, from somatization. Whether ME/CFS/SEID is seen as mental or as physical, is largely an issue of politics.

Let me be clear that I side with the people who say that ME/CFS/SEID is physical, simply because it causes profound physical symptoms. Unless a person is faking their symptoms for external gain, there is no way to deny that they are real. But this is still a political opinion, not a medical one.

The reason people want ME/CFS/SEID to be seen as physical, is because of its treatment. Sufferers have often experienced the horrors of graded exercise and cognitive-behavioral therapy, which quite often do not work. At the same time, they seem to want people with mental illness, including those wiht comorbid physical symptoms, to get graded exercise and CBT. Fine with me if it works, but what if it doesn’t? Again, there is nothing in a mental illness that precludes its sufferers from falling ill with a physical illness too. Since there is no way to tell somatization and ME/CFS/SEID apart, you choose whether they’re both physical or mental, or you treat each person based on what works for them individually. I advocate the latter.

I have a diagnosed mental illness and largely unexplained physical symptoms, including exertion intolerance. My diagnosis for the symptoms that have been given a label, is irritable bowel syndrome, which similar to ME/CFS/SEID, is not diagnosable through an objective test. CBT has not worked for me. I tried exercise, though not a graded exercise therapy (GET) program, and it made my symptoms worse. Maybe if I did actual GET, it’d help. That would mean that, in my individual case, my symptoms (at least the ones responding to GET) are treatable with behavioral change. It would not even say whether my symptoms are physical or mental in nature, if there’s even such a distinction. However, for the sake of simplicity let’s assume that, for those for whom GET/CBT works, their symptoms are mental. That doesn’t mean that, for those whose symptoms are judged as mental, CBT/GET should work, and again, this is a political choice. It wouldn’t say anything about the next patient with my diagnosis and my symptoms. It certiinly wouldn’t say anything about a person with much more severe physical symptoms than mine who happens to have a diangosed mental illness. It’s complicated, but until an objective test for ME/CFS/SEID (and all other such illnesses) is found, that’s the fact we need to deal with.

Depression in Autistic People

When I first learned about Asperger’s Syndrome and high-functioning autism in 2002, I read an interview with Tony Attwood in a New York disability awareness newsletter. For those who don’t know, Tony Attwood is an Australian psychologist and expert on Asperger’s Syndrome. In the interview, Attwood explained that many people with Asperger’s Syndrome suffer from depression in adolescence because they are aware of their differences but cannot change their behvior on their own. While I have not personally suffered with clinical depression, I can relate to lower-grade depressive symptoms that originated for me at around age twelve when I was first becoming aware of my social differences.

Depression in autistics is often missed, because it overlaps with certain autism symptoms, such as social withdrawal, repetitive/obsessive thoughts, and black-or-white thinking. Also, some autistic people’s depression is mistaken for improvement in behavior. I remember reading in a Dutch book on autism about a young man who had had an obsessive interest that he was constantly talking about. When he stopped talking about his special interest as much, people thought he was improving. In reality, he was severely depressed.

It is often hard to treat depression in autisitcs, especially if the autism is undiagnosed. I mean, people can get their depression in remission throguh cognitive-behavioral therapy, medication or both, but their social differences will not subside. Social skills training may help, but even so, autism cannot be cured, and I’ve found social skills training that was aimed at more general populations particularly frustrating given the lack of practical instruction and the underlying idea that people with depression or other general mental health conditions do essentially possess social skills. One sort of social skills training that I’ve found some use in, is the Liberman module on social relations. Liberman modules were originally developed for people with schizophrenia. They use a lot of repetition, roleplaying etc. rather than just telling the participatns they need to listen, ask questions and reflect on the other person’s feelings. Unfortunately, the training also assumes cognitive deficits, so that for example each of the participants in my group were asked to repeat the goal of the module. I found myself being annoyed by this.

Please realize that insistance on changing socially inappropriate behavior may make an autistic person more depressed. A few days ago I wrote about my diagnostician insisting I unlearn to twirl my hair. When he said this, I was in my first month on the psychiatric ward with significant suicidal ideation. That was not the time to insist on social skills. Therefore, it is my opinion that someone who is still depressed, should not be put into a social skills program. It’s important that depressed autistics (and every autistic for that matter) learn that they are acceptable for who they are.