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Wednesday, June 10, 2009

Panic, Family Systems, and Psychoeducation

Sometimes it's easier not to blog at all than to try to explain systems in plain talk. But let's try anyway.

I'll just go stream of consciousness, if you don't mind, and you guys put it together, because there's so much work to do (other than this) and time is always nagging at me. I just grocery shopped, for example, something normal people just do, worry-free(not thinking about time) and did the self check-out. It all went fairly well, but as I left, it was clear-- a waste of time, self check-out, if you have a big order, if you're me.

And those beeps are louder when you're the one making them.

THE STORY:

Last night I got a call from a patient, one of the handfuls of patients I encourage to call me when they're under the influence of panic. The job, of course, is to teach the family to do this, to address the panic, to get myself out of the system. But often it is the family that is stirring the panic.

So the therapist has to treat the family members, too, for they have to know how they're doing it, stirring the panic, and they have to want not do it. Getting all of the above to happen requires time.

So we're not there yet, not last night, the family is just beginning to get the big picture, and the patient calls me, and it's good timing, actually, so I start a game of Spider and take the call, because for some crazy reason, I can play Spider Solitaire and concentrate on words at the same time. I'm no longer addicted to this game is the truth, rarely even play it, but FD started to play it, and as a result, I'm playing it again when I need something to do and have to concentrate at the same time, hear what someone's saying.

Or can't sleep and it's too late to learn anything and have canceled all the fashion mag scripts and am tired of reading and writing blogs.

Anyway, I talk her down via psychoeducation. The beauty and the beast of psychoeducation is that people want to know why things are happening to them, that's the beauty. But we can't explain it all on one foot, is the beast. And the irony is that although we know about the triggers, can recognize things that aggravate arousal, we can't explain everything, not that it isn’t a worthy endeavor to try. The investigative process, however, should be something you do in the office. But sometimes things need to be reinforced, and sometimes, in pre-panic mode, you get new insight, new information, never been told before, not yet processed.

Raw.

So I like to get that information, as long as it's before 9 o'clock.

I need it pre-panic because people can’t process rationally while under panic. Panic turns the brain to junk, basically. Which is why I say, Catch it pre-panic. If you’re going to call, call me pre-panic. We can head it off.

So we take a quick look at the thought, air it out and examine it, and we find, lo and behold, that someone else in the family has expressed the same thing in the past, the same negative thought.

And since personal boundaries just stink at some stages of life, certainly young adulthood, when the thought pops into our minds we don't know why it's there. It can happen that someone else’s thought becomes our thought. And this is really scary. The thought itself is scary, and not knowing where the hell it came from is scary, or why we have it. You can see how people think they're possessed.

But they're not. They just have poor boundaries.

Sometimes the person who has expressed the negative thought originally in the past is doing it now, in the here and now, stressing the patient unknowingly. Or maybe knowingly.

(As an aside, panic isn't always triggered by negative thoughts, and it’s not always about boundaries, it’s never always about anything. We're just looking at this slice of psychology right now).

So a family therapist will yank the original thought-keeper into the therapy, the one who also has this thought (usually a parent, but not always), or something similar, and will work on a multi-system level, will address this person's thoughts and how negative thoughts originated, how they still disturb, and how they are affecting others, meaning the identified patient, my patient.

And we can help this person cope without dragging vulnerable others into the coping process, polluting the identified patient's thoughts. We set all kinds of boundaries in therapy. Someone asked me to post on boundaries, and you see I can't, post on them in any generic way. There are simply too many.

Hopefully, depending upon how deeply the original thought-keeper suffers from features of personality disorders (how oppositional, usually, or narcissistic) we'll get a good result. Voila. Magic. Everybody begins to heal.

What if, however, you can't do that, can't get that other person in the family into therapy, can't engage the one still triggering emotional distress?

It's harder, but we help the identified patient with insight, understanding, and work towards behavioral change. We look at the negative thoughts and tag them as old stuff as unresolved childhood junk, and counter them. Ultimately it is about shoring up the boundaries of self, differentiating, becoming one's own person, impervious, if not insensitive, to the noise and distressing energy in the family. There can be so much of that.

Family therapists find at least one significant other, a sibling perhaps, or all of them if possible, and their spouses, educate everyone about the situation, the patient’s needs. We’ll have the patient do it as much as possible, tell over the psychoeducation that has been learned in therapy. This reinforces the learning. This is extremely intimate, you know, telling someone you have a problem and need that person to help you on occasion.

With time a person doesn't need anyone to reinforce rational thought. The brain will go there naturally, and you'll be okay.

And I'll miss that solitaire game, you know. But I lost it anyway.

therapydoc

14 comments:

Anonymous said...

On phone calls I enjoy Bejeweled. Its where you match up jewels and they disappear and more fill their places and its relaxing somehow. I like to put it on 'endless' so the jewels keep falling into place and I keep searching for 3 or 4 in a row or in the shape of an 'L' and making them disappear. They collect points but that's not why I do it. It's somehow calming for my mind to see the patterns emerge and make the connections.

therapydoc said...

Thanks! Where do I get this?

Glimmer said...

So, first you wrote about my divorce and remarriage. Although we've never met and you are not my therapist. I knew you were writing about me (wink wink) because you talked about patient blaming everything on the other person. Then dragging same ole into the second marriage.

The good news is that the light bulb is finally on. I had enough counseling for the switch to be thrown.

And now, you are writing about my family, generational panic, etc. I am fascinated to see it explained in this way. I moved 700 miles to escape, which of course didn't "work." I merely self-punished, deprived myself of comforts of home, old friends, etc.

Lessons in both cases: Stop running, focus, ask for help.

You are doing such incredible work here.

Cat said...

MST is the therapy that the court had ordered my oldest teen and the family participate in and I would like to say, for the record - I really believe that parents - all parents and families should go through some kind of training - something like this - BEFORE the problems appear years later... and the parents are left with their hands out - palm up thinking how did this happen...

MST should be required for all teens with trouble in the past. It has done wonders for our child and our family as a unit and we are all better because of it.

Marie said...

Hi, TherapyDoc -

I so appreciate your willingness to share the details . . . sometimes the "big picture" is good for context, but the detailed picture really brings it home for me. I appreciate the time you put into recording what happens and passing it along to us!

- Marie (Coming Out of the Trees)
http://mmaaggnnaa.wordpress.com/

Sandy,PhD said...

Good stuff, Therapy Doc. I am a great admirer of therapists who can manage an entire family in the room. My limit is two and that is plenty.

therapydoc said...

Sandy, I really should post on how to do that. It isn't without a lot of planning, that's for sure. I'll get to it, thanks.

porcini66 said...

I'm curious, TD. How do you handle folks who you really like as people, not just as "clients"? I know from my own experience as a teacher that there are students who are just amazingly fun, talented, creative, etc. I enjoy them in class, but would never socialize on a personal level. That said, once they graduate, I have the option of keeping in touch with them and have built some long lasting friendships with many. My industry is so different from yours, though and I am just wondering how you deal with that as a therapist? Do you ever regret that you can't be "friends" with clients because of the ethical boundaries? I'm asking for your personal perspective, but understand if you can't answer this. Just thought I would ask. Boundary issues are so interesting to me! Thanks, p

therapydoc said...

For me, there's no time to hang out as friends with anyone, never was. Certainly not people I see at the office. So it's not an issue. I barely have time for the friends (and family) I've got, but I thank G-d for them every day.

Like everyone else's time, mine has to be carved out, and there's competition for it. That I blog is a miracle, but because it's a priority, reaching a lot of people, I carve out time for it.

And clearly like it.

This is what it means to have to pay for someone's time, however. Real time is precious, expensive, and no, as wonderful as people are, I don't need to be with them as anything other than people who sit across the room from me.

I'll blog on this one, P., because there's plenty more to say. Thanks.

Lisa said...

I do, at times, have clients that I think I would be friends with if I weren't the therapist. But then I remember that I have a high tolerance for "odd" or "crazy" or "drama" or whatever people say about us all in lay terms when we have issues. SO I have to remember that my high tolerance usually takes me back to the fact that I'm doing therapy. So friends on the outside is a no no for me. And I'm with you. I have very little free time. And when I get it, it's either with a choice few, or ALONE, which I never get enough of!

Emy said...

I'm somewhat surprised you even remembered me. I'm weller than I was, and unfotunately too busy to blog these days.

First time I've heard of anyone else playing games to listen. Doing something with my hands helps me listen, though granted not all the time.

My theory is that it engages me just enough so I don't completely tangent (isn't there something like this with hypnosis?). I doodle in meetings, play Spider while on the phone, and play spider or Sudoku on my Blackberry while listening to audiobooks (don't read much after anymore because it kills my eyes to do it at work AND at home). It also helps this insomniac actually get into a state where the ambioff works, though traditional relaxation techniques work too.

Anyway, it prevents me from getting bored and drifting. Especially with a sister who would still be talking to herself an hour after the phone got disconnected. Or in 4 hour meetings, 10 minutes of which apply to me.

Emy said...

Haha, I was trying to find this article I read recently about how often people zone out, and the first result for "Discover magazine daydreaming" was Bad News for Teachers: Research Says Doodling Boosts Concentration

The article I was looking for is here: Stop Paying Attention: Zoning Out Is a Crucial Mental State

>On average, the students reported that their minds wandered 5.4 times in a 45-minute session.
>Depending on the experiment, people spend up to half their time not thinking about the task at hand—even when they’ve been told explicitly to pay attention.
>
And with an fMRI study, "In nearly half those cases, they said they hadn’t been aware of their inattentiveness until the scientists asked."

If other people aren't present half the time, I feel like I must not be present 80% of the time.

therapydoc said...

Yeah, I tend not to forget. Thanks for saying hi.

therapydoc said...

Perfectly normal :)