When Therapy Hurts

Note: for more on my experiences in hospitals, see here, here, and here.

I was in the bath recently — it was Sylvia Plath who said “There must be quite a few things a hot bath won’t cure, but I don’t know many of them” (though given that she eventually put her head in an oven one presumes she found something) — when my doorbell rang unexpectedly.

I jumped. Then I froze (despite the hot water, ha ha ha). My entire body tensed. My heart began pounding. I felt myself start to slip back into memories.

Almost two years ago, I was sound asleep, my ancient black Lab curled up next to me, when my doorbell rang. And rang and rang and rang. I didn’t wake up at first, then half woke and chose to ignore it, but still it did not stop. There was pounding on the door and even the walls. The dog was confused.

Finally, I opened the door. The police were there, and the paramedics. One of the officers told me that they were taking me to the emergency room. He had a court order.

I went; I had no choice. I was terrified, shaking and crying. No one would tell me what was happening. I was taken to the ER and forced to change into a gown, then I sat for the entire night in an uncomfortable chair in a crowded waiting room, trying to sleep.

It turned out okay; my sister came and spoke to the doctor, and I was allowed to leave. That time. But before the thing was over, it would happen again, and then again. There was the day after I experienced a loss and was desperate for help from my therapist; I arrived at therapy and was told that if I did not admit myself to the hospital she would do it for me. I spent the next several days forced to miss work, without PTO, because I was in the venerated McLean Hospital. I was more afraid than I have ever been in my entire life.

“I’m not okay with this,” I told my psychiatrist. He told me I was a tough customer, to be unhappy about being forced into a hospitalization.

The last time, my therapy team at McLean Hospital — yes, that McLean, of Girl, Interrupted fame — sent the police and an ambulance to my home again. Back I went to the ER. Again, I was forced to give up my clothes and all of my stuff. This time, after many hours in the same crappy crowded waiting room, I was taken to a holding unit, where I spent more than 12 hours in a windowless room with nothing but a table and a bed. To go to the bathroom, I had to knock to be released. During that time, my therapist of ten months called to tell me that I would not be a patient of hers anymore. In that phone call I lost my therapist and psychiatrist- who were also available for 24/7 skills coaching- my weekly group, and the supervising staff. I was left with no psychiatric care at all, of any kind.

At no time in any of these three sectionings — a term that means “hospitalized against your will” and also means “bullshit” — was I remotely suicidal or a clear danger to myself or others, which is the standard for hospitalizing someone. Hell, while inpatient I was told by the attending psychiatrist that I did not need to be there. What I learned, though, is that people everywhere on the chain, from paramedics and cops to attending evaluating psychiatrists, consistently disregard the words of the patient almost out of hand.

So what on earth happened, you might wonder? And also, why does this matter?

It matters because it should not have happened like this: I was in what’s widely considered one of the best treatment programs for my condition, the DBT Training Clinic at McLean Hospital, and their involuntarily hospitalizing me so they could fire me from the program capped off months of malfeasance. Their mistakes very nearly led to my death. And more importantly, they highlight real issues in the mental health care system. When therapists and psychiatrists are unwilling to consider the holistic patient outside of a rigid formula for treatment, mistakes are made, and they can have devastating consequences.

Dialectical Behavioral Therapy is a form of therapy developed by Marsha Linehan. DBT is considered the gold standard of treatment for Borderline Personality Disorder, a highly stigmatized and dangerous mental illness with a completed suicide rate of 1 in 10. The clinic at McLean came highly recommended from multiple clinicians and I was thrilled to get a place there. The therapist who did my intake and assessment assured me that they would help me. Treatment would consist of individual therapy weekly as well as a weekly skills groups and sessions with a psychiatry resident; additionally, I would have access to my therapist and psychiatrist via phone, text and email for skills coaching.

At first things went okay. There were parts of DBT that I was unsure about; for example, the rules dictate that after an incident of self-harm you may not contact your therapist for 24 hours, which seemed to me needlessly punitive. At first, though, we did not follow that rule, and I assumed that with that flexibility would be used when called for.

I was so wrong.

As time went on it became increasingly clear that DBT was not necessarily the correct treatment for me, at least not as practiced as McLean. The program was astoundingly rigid. My therapist set the agenda for our meetings, and there were guidelines for how I should process everything. At one point, I was experiencing intense tachycardia and had to leave group when another group member started verbally attacking me; I left because my heart rate was close to 150 and I could barely breathe. The therapist told me later that it was “treatment interfering behavior” and that I hadn’t made much progress in the program anyway. Once my therapist called — without my permission — a doctor and told him to stop treating me, an invasion of privacy that still leaves me stunned.

And I was getting worse. The rigidity in DBT brought out the worst in me: I was in the ER once or twice a month. I became more and more distrustful of my therapist. But every time I tried to talk to her about how it felt as though all we were doing was arguing, she would tell me that DBT “is not a buffet.” Apparently it was considered against the rules to use the parts that were successful for me and push aside the parts that were actively harmful and dangerous.

I started thinking seriously, and talking to my treatment team, about finding a new therapist. I reached out the director of outpatients at McLean, who told me to talk to my therapist (later, after I’d been fired, I tried her again; she told me that McLean had nothing more to offer). But my therapist and psychiatrist told me, repeatedly, that my treatment team was secure, that they were not going anywhere. And furthermore, my therapist told me — again, repeatedly — that if we decided that DBT wasn’t working she would find me a supportive therapist who could see me multiple times a week.

I did not want to leave. I still believed that DBT was my best hope for recovery. I was too far in to realize what would become apparent once I had left: I had gotten so much worse inside this program. My sense of worth was continually shattered as my treatment team made me feel incapable of healing and beyond help. I felt constantly that I was on trial and coming up short, a feeling reinforced with both supervisors I was made to meet with. I knew, though, that in studies DBT had shown positive results, and I did not want to give up.

Then it was taken out of my hands in a series of events that began with that first horrible court order and the police at my door in the middle of the night.

It was only a couple weeks after that first doorbell that I was in that windowless cell in the holding unit, alone, hearing my therapist — who had promised to come visit me but had called instead — tell me that the DBT Training Clinic was firing me. When I was transferred back into an inpatient unit — again without any significant risk to myself or anyone else — my therapist called again to clarify that she was done with me. I asked her if I’d see her again. She didn’t know, she said.

Things happened fast after that. Clinicians from the inpatient unit and from the DBT clinic told me contradictory things. I was released from the hospital with an appointment with a therapist that I had found and made myself; it seemed to occur to no one that vulnerable patients who were going from 24/7 support to zero support would require a little help finding a suitable clinician, and indeed, as a direct result of McLean, I went through two therapists before I found one that would keep me.

There was no transition and no way to say goodbye. I haven’t seen or spoken to my therapist of 10 months since she put me in an emergency room against my will — a procedure known to cause trauma.

Let’s be clear here: to be fired with no transition plan, no bridging, and no follow through, is about the worst thing that you can do to someone who has just experienced a major loss and has severe attachment trauma. It is hard to describe how devastating this was for me. At no time have I been given a chance to sit down with my former treatment team and get an explanation.

It’s been almost two years since all of this happened. I’m okay now. I have a therapist I like. We work together. We use a variety of modalities, she is flexible in approach, and she listens to me and trusts me to know myself. I have a psychiatrist who has been willing to try medication that has made a huge difference and has trusted me to accurately manage my own meds, not using patronizing contracts. Except for that time I had a kidney infection, I never go to the ER and haven’t in a long long time. It has taken an unbelievable amount of work to heal from the damage done to me at McLean, but I have done the work.

Yet that damage remains. Every time my doorbell rings I have full flashbacks. I have a diagnoses of PTSD, and it got significantly worse after McLean. It was months before I stopped jumping at noises. Still, when I hear certain songs or smell certain smells, I am right back there.

I am taking risks telling my story now. It’s never easy to come forward with an honest account of dealing with mental illness, even though I am fine now: I can say all I want that this was a blip, a period of interruption where everything came together all at once, but there’s no guarantee I’ll be believed. And yet. I want people to know what it looks like when therapy does harm.

I’m not anti therapy. I’ m not even anti DBT. Hell, I love therapy. I’ve been in it most of my life. I credit the therapist I had from high school until my late 20s with saving my life. There’s also no doubt that DBT can do wonders.

It is important, though, to reckon with the very real harm that treatment can do. As I’ve sought answers over the past year and a half, I’ve been struck by the dearth of information out there about treatment failure generally and DBT specifically. I’ve been able to find very few academic sources that deal with this. One of the few pieces I did find was written by a therapist who had fired a patient from DBT after six months. On reflection, the therapist wrote, “I was feeling completely ineffectual…was leading me to become more and more rigid in my approach…I would attempt to follow ‘the rules’ of DBT…and then get deeply frustrated and punitive when the session didn’t go the way I wanted.”

Unfortunately, punitive therapy is a real thing (“It’s SUPPOSED to be aversive!” is a real thing my therapist said to me once), and a deeply dangerous one. I’m sure my treatment team did feel ineffectual. I am not always an easy person to treat. But you know what? I work with children. I often feel ineffectual and frustrated. And I would never allow myself to become punitive just because I felt that way.

It is not uncommon, though, for clinicians to distrust and ignore the lived experience of their patients. The BPD diagnoses itself has a history of being prescribed to women who refuse to comply with the cultural norms a patriarchal society has laid down for them, and a huge part of the reason that my treatment team felt ineffectual is that I refused to comply with the rules. I did not believe, and do not believe, that rigid rules set forth with no patient input have a place in a genuine therapeutic relationship. This is different than basic personal boundaries, which do and must exist in all relationships; beyond those, though, therapy must be a collaborative and supportive process. In a world in which the mentally ill, especially mentally ill women and people of color, are considered inherently unreliable narrators, this is hard to find. But it is vital. We are people first. We are not statistics, or your guinea pigs, or people whose lives exist without consequences. We are human beings.

My hope in sharing this story is twofold. I hope clinicians read this and consider the impact of their actions; I hope that they realize how important thoughtful, considered transition is, particularly with vulnerable patients, and how dangerous rigidity in the treatment room can be. And I hope that patients read this so that I can tell them: if you, too, have had your agency stripped away, been made to feel by clinicians that you are a failure and beyond help, if you have had a clinician ignore your lived experience and the fact that you are an expert on you — well, you should know that is not okay. It was not okay what happened to me.

I saw my psychiatrist one last time. I cried the entire time. He told me I never should have come, that it was clearly way too traumatizing.

I stood up to leave. “You almost killed me,” I told him, forcing my voice to stop trembling with a sheer act of will.

I looked right at him.

“I deserved better,” I said, and then I walked out.