Last Summer I remember looking at some paperwork my Therapist had prepared to send in to my insurance company. Paperwork that I had to sign prior to submission. I had not seen my chart, not once had I read the notes she documented from week to week. She seemed nervous when she handed it to me, and she said in a quiet voice, "I wrote it in pencil, so if there is something you disagree with we can talk about it."
It was a one page document, how much information could be on it?
What was on it was this:
severe PTSD symptoms, depression and anger
sleep disturbance, recurring suicidal ideation and increased self-injurious behavior.
ETOH comsumption increased as a result.
Acting out in therapeutic alliance - issues with safety and trust.
Eating disorder continues but not life threatening.
Patient needs assistance with distress tolerance, containment and emotion regulation as well as support around poor self care and self destructive behavior patterns.
It was as though I was reading an assessment about someone else, and whoever it was - I sure felt sorry for her. She is a mess! The reality that this clinical assessment was about me didn't soak in until days later.
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