Monday Feb 5, 2008 session notes:
I was not in a good headspace most the day. I was talking with a friend before session. I was watching the clock. I kept saying I needed to go but not leaving. I was very early last week so I knew I had more time to stay at work than last week. Eventually, I had pushed it to 12 mins after 3pm. I still had to gather up a few things then I headed out. I got to the car with 15 mins to go.

On the drive to session I kept switching radio stations as nothing seemed to sound good. I was agitated. This sucks... therapy sucks… I don't want to do it anymore. I don't see the point of it. That's where my head was when I came to session today. Which made talking about increasing sessions very unusual. I had to keep balancing my impulsive desires to just say screw it all with the longer-term goals of being better and not losing you.

Finally, I stumbled upon "Small Town" by John Cougar Mellencamp on the radio. I let that play. It has a good beat that let me thump my hand down on my steering wheel as I drove while singing it. This let out a little amount of the energy. I had been driving more aggressive than I usually drive. I got to your office, parked, around the building, and in the first door with 4 mins to spare. I went through the 2nd door and caught it so it did not bang. I went down the stairs and went to push your button. I hit Dr. F's button at the same time and had to figure out how to turn off the light. Once I had the lights correct, I went into the waiting room.

There was a coat in the chair I normally sit in and someone else sitting further down along that wall. I ended up sitting at the end of the waiting room. I pulled out my purple ball and left everything else in my bag. After a bit a guy came in and sat down along the 3rd wall in the waiting room. As it got closer to 3:30, someone came out of Dr. F's office; the person whose office opens directly to the waiting room came out and retrieved the person that was first in the waiting room. Then the person from your office left.

A few moments later, you came out to get me and said hi. You were wearing your glasses, brown/tan capri/hiking like pants, long sleeve shirt (I don't remember sweater or not). I think I said hi back, I might not have. I was angry. We headed back.

We got in your office, I moved the pillows, sat my back on the coach, then sat down. You commented it being busy and I said yes 3:30 is a busy time, you said at least today. I said last week too. You sat down. You said something about not having a chance to check your email to see what I wanted to do about the corner. I glanced over and yes, it was the same as usual. You asked me if I wanted you to move the furniture now. I said no. You asked more about the corner. I again declined it. I said I didn't want to talk about it. You said ok.

I told you that I had wanted to talk about the more sessions a week, insurance, and stuff. You clarified the had part of my statement, wondering if I still wanted to talk about that. I said that I did still want to talk about it, that was why I didn't want to talk about the corner stuff. I was playing with the purple ball, spinning it in my hand.

I told you that I called wife’s insurance and that yes, I have unlimited number of MH visits. I said that was what the customer service person told me and then I asked to speak with someone in behavioral health. You said something about that being a good idea. I told you that they said that they do not check every claim, they do random audits and frequency flagged accounts - so sudden jumps in frequency. You made a comment about computer algorithm. I agreed.

I went on to explain how she said that if audited and denied, it would not apply to past sessions but would for future. I told you that they could even authorize only 1x wk. She didn't come out and say that directly. She said that the standard of care is 1 x wk; so, when you asked me about this, I said standard of care. You had a response to these words/this concept. I relayed that she said that she knows of a few cases that have been approved for psychoanalytical therapy but very few; that most are denied. I said that I did not tell them that I was already see you 2x week.

We talked briefly about the concept of me losing sessions. I said that I thought it would be very bad for me to start down this path and then have sessions taken away. You agreed. I said that it was funny in light of last sessions topic on how I perceive the risks of asking for things. You asked about my usage of the word funny. I said funny in that not funny way. You understood/agreed.

I made the comment about asking her the paranoid question of if just calling her would trigger an audit and that she said no. I said that I figured at that point someone calling about increasing their number of sessions to 4 x wk and talking to a LCSW in a behavioral health division shouldn't be too surprised at the paranoid question. You kind of laughed at this, in support/agreement.

You asked me how it felt to make the call. I said that it had to be done, that I needed to have information to make a decision. It was very matter of fact. I was a bit nervous of triggering an audit or having someone look to closely at things. I think we talked a bit more about this, I'm not sure. Towards the end of this topic, I said something about it not really being all that useful information. Pretty much right where I was before. I'm unsure about the order of the next few things.

Somewhere in here I told you about talking on the forums about it and how some people have this number of sessions covered a week and have them being billed as medical. You took note of that. I said I didn't know what that meant. You asked if that was here in America. I said yes. You said that you were glad to hear someone in America was covering/seeing the value of this type of therapy.

I think we returned to the topic of sessions being taken away here and the need to justify the therapy. I again stated that I thought it would be bad for me to have sessions taken away from me once started. I clarified that I meant specifically for me, who I am, and what my issues are. You agreed and stated that we will need to be thoughtful in how we proceed because of this (and I got the impression, for other reasons too). I asked you why you thought it was a good idea for me to increase my number of sessions. I continued, saying that it seemed you thought it would be a good idea; however, you could have just been open to letting me/us explore it and why I was bringing it up rather than actually thinking it was a good idea. I again got the impression that you thought it was a good idea, either through something you said or non-verbal.

You made some comment about me wanting to know the details of your thoughts/opinions, that I took as you not being sure how to answer my question, being aware that it was a tricky question. I clarified that I didn't need to know the details but more along the lines that did you think you could frame things really meet that medical needs. You said that you'd have to ask around and try to find some people that had been successful at getting it covered to see how they wrote it up and what their situation was. I understood where you were coming from on this. I wondered if you would even find someone that was successful. It does seem to be a needle in haystack situation. So, yeah, I think you think it would be a good idea or could have benefits, that might be a better way of saying it. [typing this up, made me realize that at my work they have separated out behavioral health from mental health and maybe that's part of the key there. I'm not sure how they define the differences beyond substance abuse.]

I was clear that I was wondering if you really saw reasons why this modality would be good for me in terms of issues and not just because you believe in it, that you know I am interested in exploring myself at this level - willing to explore myself at this level. It is a double edge sword... am I mentally/psychologically bad enough that I need this level of therapy and what does that mean verse no I'm not bad enough to need it, but it would be good because it would help you understand yourself better... then why do I feel so bad, I really do just need to get over myself - thoughts. It is a no-win situation. Like I wrote about, I'm not sure I really want to know "how defective you really see me". And yeah, I can't seem to frame this in any other way - I'm either highly defective or just attention seeking, neither of them are really all that positive ways of looking at this whole thing. By the way, when I brought this up to a friend, she said that if I am attention seeking at this level, then that in and of itself is a sign of how messed up I am. I’m not so sure you’d agree with that statement.

I told you about having found some links on their website about this stuff and that they define long term psychotherapy as being anything more than 12 sessions. You said something like 'what does that say about how they view mental health'. I said maybe it was 10 sessions. I said that I put the links on the website for you. I think it was here that I went on my soap box about mental health care. You just kind of let me rant here a bit. We've talked about this stuff off and on so nothing new and I've been left with the feeling that we agree on many of these topics. I said something about treating the symptoms or the causes. You responded, I don't remember if you said something or just nodded. I went on to say how my work is doing this big push for mental health right now and I don't know who to talk to about my experience.

I brought up the fact that regardless of modality, almost universally across the board, the one thing almost everyone can agree upon is that it is the relationship that is key to the success of psychotherapy. You agree and said the alliance or therapeutic alliance. More was said here, I don't remember.

You brought up the concept of having them cover 2 of the visits as out of network. I said that I had thought about that. I said that as an employee, the insurance I get does not allow for any out of network providers not even in mental health. So, if I've been working with someone and established a good relationship then to become a new employee and be told that it won't be covered at all is harsh. You question the no out of network. I said that as long as my insurance has someone that provides the service, no out of network coverage is allowed. It is only if my insurance does not provide the service will they refer out. You wondered then that maybe my insurance doesn’t offer psychoanalysis/psychoanalytical modality, then maybe we could use that as a way to get it covered. I said something about thinking that they would take the concept that they offer psychotherapy and that is good enough. It is something to ask about, I just don’t know who. I thought about you looking to get into my insurance’s network; I did not bring it up. I remembered you stating that it was something you were not interested in pursuing.

I talked about how sure one can connect to more than one therapist, but for some people based on issues/needs that might be easier said than done. Also, seeing the wrong therapist could actually cause harm. I don't think you agreed with that statement. I do. I've heard enough stories on the forum of how bad interactions with therapists can set back a person's progress or add another layer to the issues/experiences. I again state something that means if my work is going to be tackle Mental Health in a serious way then they need to change their whole mindset on what Mental Health means.

This lead to the concept of maybe me paying out of pocket for some of the sessions. You asked me if I'd want 3 or 4 visits a week. I paused and looked down. I had been spinning the ball and moving it about in my hand throughout this discussion. I focused on the ball. I didn't have an answer for you because in the moment, I wasn't even sure any therapy was being helpful. I spun the ball. I think it was here that I said I was mad. You said you could tell. You looked at the ball. Yes, the ball. I had grabbed it as a last minute thought. I talked about the th-m swing. I said that I'd start with 3 and see. Either M-Th-F or M-W-F. I asked about what your thoughts were about extending your availability, in general. I commented about maybe your thoughts were just to open up W for a while, which wouldn't help me on that Th-M swing. I said that that I wouldn’t be able to afford it in the long term if I was paying out of pocket but maybe I could afford it long enough to do a taper back down. You asked me how much I thought I could afford. I said I’d have to look at my budget and decide which items would have be adjusted and such.

We talked a little about time of day of appointments. I asked you if you knew if people coming this often had an easier time outside of session; would it be easier to leave session and go to work. You said that some people find that it is easier because of knowing they’d see their therapist the next day. We acknowledged that it probably also depending on what they were working on at any given time. We’d talked about doing a M-T-Th-F roll of thing. You made the comment that I could actually do a M-T-W-F or any combination.

Somewhere around talking about me paying out of pocket for the sessions, I said that if I was to pay out of pocket I would want to discuss more those details as to why you think the increase in sessions would be helpful. Mostly, I think what I am looking for is what you think I would gain from the increased sessions. I keep waffling on wanting to know and not wanting to know what your thoughts are about me from a clinical perspective. We've talked about this off and on in the past, or I should say that I've told you what my thoughts are around this and you've listened. With the exception of acknowledging that I was depressed when I first came to see you and at the time we had that discussion, you felt I was no longer "clinically" depressed.

This topic seemed to be winding down and I brought up how I didn’t feel like Elio this weekend. That I knew my likes and history, I just didn’t feel like I was Elio. That I wondered what were Elio likes. I said that I talked to a friend about this on how common it is and how we agreed we are not a good control group. You asked me what if it was common, I said something like then ok, it’s fine. You asked me how I’d feel if it was uncommon. I said that it would be ok, it is where I am. I was distant here, emotionally apathetic. I was playing with the ball more just moving it in my hands rather than spinning.

You asked me something like who was Elio. At first, I said I didn’t know, not me. Then I said focused, dedicated… I don’t remember what else. You said something about having an equation of Elioness. Then you asked who I was or something like that. I didn’t like your question. I was me, of course. It felt like you were looking for me to give you another name or something. I think something was said here, I don’t remember.

Then I asked if you watched the Super Bowl. (Yes, I was done with that topic.) I didn’t like how it was going and didn’t want to talk about it anymore. You asked if you should answer it. I said something, I don’t remember. You said, that you didn’t watch the game.

I looked at my watch and saw that it was close to time. I pulled out my phone and shared with you the video of the ballad to a therapist. You asked me what I thought about it. I said that I thought it was funny. I said that it’s stuff that comes up on the forum and sounds like someone who has been in therapy before. I then brought up the part at the beginning when the therapists says that they are going on vacation and how Kristen responds in that slightly shut down way. I said, it’s the “we can handle this” look/feeling. You said separations can be hard. I asked you if you knew of Kristen Bell. You said you didn’t. I said that she’s been a strong proponent of Mental Health awareness and that she’s been diagnosed with major depression (I looked it up, depression and anxiety, not major depression – per articles on web).

At some point, I brought up the topic of wanting/needing to know something is in place if something bad happened to you. I told you that it seemed you were surprised or amused that I even questioned if you had a plan. You asked me something about how that was for me. I said at the moment it was fine. You asked about later. I said it was still fine. I told you that I was thinking earlier in the day, ‘Why wouldn’t I question if you had something, my parents didn’t take care of me’. You agreed, given my history, why wouldn’t I question if you had something or not. I said that I understood that you were trying to give me space to explore and figure this out. You said that you were trying to. I think I might have said thank you to that. I’m not sure I’m grateful for it. It’s really hard to sit with it, to balance all the elements of it, and to try to figure out what it is I need so that it is not an issue. There are moments, many moments, that I wish you’d just tell me, yes you have something worked out, I’ve got you covered OR just say, nope, not going to put anything so formal in place. Though I think that later one would be very hard for me to swallow.

Time was up. I gave you, your journal. You waited for the I love you. I didn’t want to tell you I love you. I wasn’t as mad. Finally, after several breaths, I act like I’m going to get up. You say ok, and something else about seeing me on Thursday or having a good weekend or something along those lines. I stayed seated, breath, and tears start. I repeat to myself, I’m not sure if I say it loud enough for you to hear or if it was just in my head, ‘you have to go’. I am trying to get myself to move. Finally, I say that I don’t want to go. You said, “I know”. I said that I didn’t want to tell you that I love you because that means I have to leave. You started to say something, “even if you…” I interrupted you and said even if I don’t say it, I have to leave. You started again and said, “even if you don’t say it, I know.” I said that even if I don’t say it, it doesn’t mean I don’t feel it (I’m thinking I might as well say it, I feel it). I think you said I know to this, things were kind of swirly at this point. I said I love you. You said, “I know”. I said that sometimes I wish I didn’t. You asked if I thought it might be easier if I didn’t. I said yes.

That’s not really true because when I lose that loving feeling, I feel so much worse. After session, I wonder why I even said it. Was I mad at you, was I trying to take out any of my anger out on you? Did I hurt your feelings? It was such a mean thing to say.

I get up and slowly work my way to the door. You are wishing me well and see me in short order. I don't think I really respond. Out the door, up the stairs, and out to my car.