What is Borderline Personality Disorder

One of my favorite critics told me that the post below isn't clear, that people don't realize how hard it is to have this disorder, and how hard it is, sometimes, maybe even most of the time, to live with someone who has the disorder.

Rather than go through the DSM checklist (I think it's in a post in a link at the end of yesterday's post) let me quote Randi Kreger. She defines Borderline Personality Disorder as follows in her book, The Essential Family Guide to Borderline Personality Disorder (italics are mine):

Borderline Personality Disorder is a serious mental illness that causes those who have it to see people and situations as all good or all bad; to feel empty and without an identity; and to have extreme, blink-of-an-eye mood swings. People with BPD act impulsively; their self-loathing and extreme fear of abandonment can cause them to lash out at others with baseless criticism and blame. Some practice self-harm or see no other option than suicide as a way to end their pain.

People with BPD experience the world much differently than most people. For reasons we don't entirely understand, the disorder distorts critical thought processes, resulting in emotions and actions that are out of the norm.

There you go. Now maybe the post below will make more sense :)

Thanks for your opinion, MK.

therapydoc

Borderline Personality Disorder and The Fake

Originally I just wanted to tell the story about the stand underneath my fish tank, how I found it at Bed Bath and Beyond while shopping for a gift for a shower (yes, I had the coupon), shlepped it to the office myself, borrowed a screwdriver, for mine is never where it's supposed to be, and put it together in little under two hours. Of course I knew the secret about the cam screws. Put them in, tighten them up, last.

I see this sort of behavior as fairly normal, if a little impulsive, sure, because ordinarily I'd ask FD to put it together for me. But doing something physical and challenging is a nice way to distract a person from thinking, and sometimes we just think too much. So I'm always telling people to do something. You feel better if you can distract.

And the computer desk that supported the tank just didn't cut it.

Then I found myself talking about Borderline Personality Disorder, BPD. This disorder is very much about impulsivity, which substantiates the rule that things that are thought to be pathological can be perfectly normal in a different context.

Impulsively buying a bookcase that matches your furniture, even if it weighs more than you do, and putting it together yourself, even if your best tools are a hole puncher and a nail file, beats impulsively getting drunk to feel less edgy (a "borderline" thing to do), impulsively cutting one's self (another "borderline" thing to do), or impulsively whacking someone across the face because you're jealous or in a bad mood. You get the idea.

And if the impulsive act also functions to build your self-esteem, as opposed to, say, lowering it, then it's a good thing to be impulsive, right?

But people who suffer from BPD have a helluva time trying to reign in their impulsivity, and the folks who try to love them, who want to help them, get worn out by the drama.

It's easy enough to start to write something, quite another to finish, and that's what happened to this post. Then then something cool happened. Retriever wrote to me to ask what I thought about something going on at Dr. Helen's Blog and Dr. Bliss's blog over at Maggie's Farm. Both docs are writing about BPD, and lo and behold, Doc Helen has a video interview with my new favorite self-help guru, Randi Kreger.

Randi Kreger (Walking on Eggshells) has a fairly new book, The Essential Family Guide to Borderline Personality Disorder. I read it cover to cover in a night only a few weeks ago, found it a terrific resource, funny, easy to read, and full of information that everyone should know. Especially if you have someone in your family who is "impossible", who can't regulate his or her emotions, who acts impulsively to dampen heightened negative arousal, like anger.

And she has a great section called Tools in the back of the book.

I'll throw one at you right now, a favorite I've suggested many times to people in therapy. Randi would call this intervention an incompatible behavior. I've always called it The Fake.

The idea is that a person can't be obsessing and angry about something if something else is a more attractive option. It's no different than distracting a whining three year old with a shiny yo-yo. All of a sudden the icecream he wants isn't important anymore.

With kids it's always,

Outsmart them. You're older. You can do it.

With older people who simply can't let something go, who are stuck on abusing you or raging about something or someone, who really will not stop to listen to anyone else's point of view or entertain other positions, it has to be,

Did you hear the one about. . .

Or

Did you hear what happened to So and So?

Good gossip is sheer genius. Gets 'em every time.*

My favorite fake is laughter. You laughing at your tormentor.

This person is tormenting you, criticizing you, ranting, and you break into hysterics, literal belly-bending, on the floor, doubled over with laughter hysterics. You do it respectfully, though, for you are complimenting the person who is clearly trying to upset you. But now the abuser sees himself, herself, as a good person, someone who can make you laugh, not just laugh, but laugh hard, and that fleeting self-esteem returns with your praise. Now we're all comedians, should work stand-up.

If you throw someone off like this, anger and blame are impossible.

And the truth is, most people with this disorder are smart, and they can really be very funny.

Traditionally with people who have Borderline Personality Disorder, once they're flying, meaning angry, there's no stopping them. The anger is a manifestation of pain. If you can't see that, then there's no helping your spouse, your child, your friend, your mother, whoever it is who is unable to regulate emotion. When the plate needs shattering, it will shatter. When they need love, they'll find someone to sleep with. When a car needs to be keyed, it will be keyed.

When it's all over, it's What's for Dinner? As if nothing happened. So in therapy we're forever working on strategies that will work, that will distract, end an episode.

If you think of this as an episode of true psychopathology and pain, then it's a lot easier to swallow the negative behavior.

And you have to see them as capable of seeing life differently, seeing themselves as their greatest allies, capable of rational, laudable behavior. Good lives.

I work dialectically with suicidal, self-destructive people who have BPD , for you have to do this, dialogue in an empathic way, one that reaches them, meets that place in the ego that wants to live. Typical questions from me include:

(1) Would you want your niece to cut herself? No? Then why are you setting an example? You think she doesn't respect you, look to you as a role model?

(2) Do people deserve to have quality lives?

(3) Aren't you a person?

People tend to agree. They deserve better. They are capable of better. They want more out of life. They want quality lives.

Then the question becomes how to get it.

And it isn't an impossible quest, an impossible, reprehensible therapy. I've referred to ACT, Acceptance and Commitment Therapy here in this blog, and it helps to know DBT, Dialectical Behavioral Therapy, and Schema Therapy. There is progress and people do get better, so I'm a little miffed, frankly, at all the negativity I read on the Internet about BPD, avoiding BPD patients.

Yes, people can be difficult. They can be high maintenance, and yes, group therapy surely helps, and for sure, without a team it is so, so hard to work a successful therapy. I get it that people with Borderline Personality Disorder can be more than difficult, that they can and will make your life a living hell without help. And yes, therapists try to avoid treating the disorder, need help for ourselves to cope with all the drama.

But with help? With time? (lots of this, endurance is the essence)

There's no greater therapy, no greater pleasure, no greater success than helping someone with this disorder get well.

That's all I'm gonna' say. I have some algae to scrape off my tank here at home, and spilled some sugar behind a cabinet. There's a lot to do, basically.

therapydoc

*Okay, not every time. Go ahead, talk about it.
See the Second Road on Self-Pity.
Other posts by me about BPD

Humble Request

If you can think of names of songs, movies, Youtube clips, anything that relates to sexual assault,harassment, or otherwise asserting sexual power with coercion in relationships (a form of sexual assault) would you let me know?

Thanks in advance,

therapydoc

Anyone's Kid

That's my helmet, my bike path.

Two relatively short stories coming up. There have been complaints from the peanut gallery that my posts are too long. For the record, in my defense, I did not write President Obama's speech.

Okay. You should know, before we begin, that if there were an avatar of me right this minute, it would be Therapydoc, Sad. News has it that an SUV rolled over a neighborhood five year-old on a bike crossing an alley. Now she's gone, going on two weeks now, an innocent little girl.

Three young mothers, all patients, called me the week it happened, distraught. Another parent spent twenty minutes of appointed therapy time discussing the tragedy.

"It could have been my kid, my five year-old."

And,

"What do I tell her?" Meaning what do you tell a mother who has lost a child?

You say nothing, is what you say, when you visit a mother who has just lost her child, but hold her hand if she's amenable, sensitive to the fact that she might not want to be touched.

And we're not even to the stories.

STORY ONE:

I'm riding home from work last night at dusk along the Chicago River. The path and surrounding greenery are all park district, the only real dangers--

an occasional Chicago cougar, the feline type, not the human
head-pecking birds
people who don't understand that On your left! is a warning about an on-coming bicyclist,

and kids on tricycles.

If you wear a helmet, the birds don't bother you. And if you're a nice person, you don't mind slowing down for children. Nor do you mind shouting, YO! instead of On your left! to get the attention of folks who don't speak much English, people who also have a right to the path, even if they're just walking.

Of course, if you're all about you and aggressive at that, then these things, especially people in your way, bother you a lot.

Let's break for a rant:

People everywhere are riding bikes without helmets. Gorgeous, slick, young people who should know better, windblown and smiling. It bothers me, this carelessness, because I picture them fallen to brain trauma or worse, death.

This has nothing to do with that little five year-old girl, by the way, something altogether different, you can't hold a child accountable. But it seems fairly obvious that accidental death and morbidity are not reserved for reckless automobile drivers, luckless pedestrians, and motorcyclists. Some call the latter organ donors.

So readers, help me on this one. What's with the denial? Is vanity that important? Is it? Am I missing something? Because the ugly truth is that if you're going to ride, you're going to fall. It has to happen.

There. I feel better.

So I'm riding along and coming toward me is a little girl on a little two-wheeler. Her blond hair is sneaking out of a white helmet and her eyes lock on mine. She's talking to me with defiant, proud, six year-old girl eyes that say,

"See? I can ride. I can ride this. And this is my bike and there is nothing like it, me on my bike, nothing stopping me. I'm free."

Me, fifty years ago. And probably many of you, too.

STORY TWO:

You have to give credit where credit is due, when you learn something from someone. So I'm glad for that incident with Professor Gates and Sgt. James Crowley this summer. Especially for that delicious use of language, The Teaching Moment.

Sgt. Crowley, if you recall, arrested Professor Henry Louis Gates for breaking into his own home. Generally white people aren't arrested for suspicious behavior like breaking into their own homes. But people of color are suspicious for breathing, even now, depending upon the zip code. (Check out a good novel about racism, Mudbound by Hillary Jordan. You're always asking me for book recommendations, and the truth is I don't read as much as I'd like. But Mudbound is worth the trip on many levels. I especially like the marital relationship and women's issues).

Anyway, Professor Gates is a man determined to use everything that happens to him as class material. He's the master of the teaching moment and referred to the incident with Sgt. Crowley as a way to educate people, in this case a very, very, very large number of people, the entire intercontinental news guzzling public.

Professor Gate teaches about race relations. And hate. Hate is about scape-goating, triangling really, marginalizing others to feel better about one's self. In therapy we sometimes use a psychological defense to describe this process, displacement. She's the problem. He's the problem. They're the problem. Blame them. Couldn't be me.

Unfortunately, President Obama inadvertently ratcheted things up, made a bad situation worse by saying that Sgt. Crowley "acted stupidly." But he took it back right away with this marvelous syntax

". . . I could have calibrated those words differently.”

Calibrated.

President Obama and Vice President Biden (almost forgot his name!) sat the professor and the officer down for a beer in the White House gardens to make amends, to desensitize them. The VP drank a non-alcoholic beer and the President drank the most popular beer in America, what else, Budweiser. Thus the incident became the administration's teaching moment: (1) don't drink, (2) if you do, drink like your brother, and (3) for heaven's sake, get to know your neighbors.

And that very day, I had my own teaching moment.*

I'm riding the bike to work; it's a little muggy, but we'll take it, no rain, and a diminutive fellow from southeast Asia passes me on his bicycle, one that he surely threw onto the boat to America. The bike has the wide tires and baskets that allow for balance, lend it to tricks like, Look Mom! No hands!

Anyway, he sees me riding behind him and flirtatiously throws his arms out, does that trick we used to do as kids, rides with no hands, arms out to the side. He's clearly enjoying showing off and I'm enjoying the show. Except it bothers me, you know. No helmet.

Being me, when he turns the corner and peeks back, I smile and shout,

"Where's your helmet?"

He doesn't get it, smiles incomprehensibly. I tap mine and he nods a universal, if exasperated, I know. I know.

therapydoc

President Obama to Children on their first day of School

This is not a political post. I am not a political blogger. But still.

It one falls under,

I'm proud to be an American. People don't say that as much, lately.

And we don't even have that on the sidebar.

Our President's speech to young people who might not feel like trying hard in school.

Prepared Remarks of President Barack Obama
Back to School Event

Arlington, Virginia
September 8, 2009

Hello everyone -- how's everybody doing today? I'm here with students at Wakefield High School in Arlington, Virginia. And we've got students tuning in from all across America, kindergarten through twelfth grade. I'm glad you all could join us today.

I know that for many of you, today is the first day of school. And for those of you in kindergarten, or starting middle or high school, it's your first day in a new school, so it's understandable if you're a little nervous. I imagine there are some seniors out there who are feeling pretty good right now, with just one more year to go. And no matter what grade you're in, some of you are probably wishing it were still summer, and you could've stayed in bed just a little longer this morning.

I know that feeling. When I was young, my family lived in Indonesia for a few years, and my mother didn't have the money to send me where all the American kids went to school. So she decided to teach me extra lessons herself, Monday through Friday -- at 4:30 in the morning.

Now I wasn't too happy about getting up that early. A lot of times, I'd fall asleep right there at the kitchen table. But whenever I'd complain, my mother would just give me one of those looks and say, "This is no picnic for me either, buster."

So I know some of you are still adjusting to being back at school. But I'm here today because I have something important to discuss with you. I'm here because I want to talk with you about your education and what's expected of all of you in this new school year.

Now I've given a lot of speeches about education. And I've talked a lot about responsibility.

I've talked about your teachers' responsibility for inspiring you, and pushing you to learn.

I've talked about your parents' responsibility for making sure you stay on track, and get your homework done, and don't spend every waking hour in front of the TV or with that Xbox.
I've talked a lot about your government's responsibility for setting high standards, supporting teachers and principals, and turning around schools that aren't working where students aren't getting the opportunities they deserve.

But at the end of the day, we can have the most dedicated teachers, the most supportive parents, and the best schools in the world -- and none of it will matter unless all of you fulfill your responsibilities. Unless you show up to those schools; pay attention to those teachers; listen to your parents, grandparents and other adults; and put in the hard work it takes to succeed.

And that's what I want to focus on today: the responsibility each of you has for your education. I want to start with the responsibility you have to yourself.

Every single one of you has something you're good at. Every single one of you has something to offer. And you have a responsibility to yourself to discover what that is. That's the opportunity an education can provide.

Maybe you could be a good writer -- maybe even good enough to write a book or articles in a newspaper -- but you might not know it until you write a paper for your English class. Maybe you could be an innovator or an inventor -- maybe even good enough to come up with the next iPhone or a new medicine or vaccine -- but you might not know it until you do a project for your science class. Maybe you could be a mayor or a Senator or a Supreme Court Justice, but you might not know that until you join student government or the debate team.

And no matter what you want to do with your life -- I guarantee that you'll need an education to do it. You want to be a doctor, or a teacher, or a police officer? You want to be a nurse or an architect, a lawyer or a member of our military? You're going to need a good education for every single one of those careers. You can't drop out of school and just drop into a good job. You've got to work for it and train for it and learn for it.

And this isn't just important for your own life and your own future. What you make of your education will decide nothing less than the future of this country. What you're learning in school today will determine whether we as a nation can meet our greatest challenges in the future.

You'll need the knowledge and problem-solving skills you learn in science and math to cure diseases like cancer and AIDS, and to develop new energy technologies and protect our environment. You'll need the insights and critical thinking skills you gain in history and social studies to fight poverty and homelessness, crime and discrimination, and make our nation more fair and more free. You'll need the creativity and ingenuity you develop in all your classes to build new companies that will create new jobs and boost our economy.

We need every single one of you to develop your talents, skills and intellect so you can help solve our most difficult problems. If you don't do that -- if you quit on school -- you're not just quitting on yourself, you're quitting on your country.

Now I know it's not always easy to do well in school. I know a lot of you have challenges in your lives right now that can make it hard to focus on your schoolwork.

I get it. I know what that's like. My father left my family when I was two years old, and I was raised by a single mother who struggled at times to pay the bills and wasn't always able to give us things the other kids had. There were times when I missed having a father in my life. There were times when I was lonely and felt like I didn't fit in.

So I wasn't always as focused as I should have been. I did some things I'm not proud of, and got in more trouble than I should have. And my life could have easily taken a turn for the worse.

But I was fortunate. I got a lot of second chances and had the opportunity to go to college, and law school, and follow my dreams. My wife, our First Lady Michelle Obama, has a similar story. Neither of her parents had gone to college, and they didn't have much. But they worked hard, and she worked hard, so that she could go to the best schools in this country.

Some of you might not have those advantages. Maybe you don't have adults in your life who give you the support that you need. Maybe someone in your family has lost their job, and there's not enough money to go around. Maybe you live in a neighborhood where you don't feel safe, or have friends who are pressuring you to do things you know aren't right.

But at the end of the day, the circumstances of your life -- what you look like, where you come from, how much money you have, what you've got going on at home -- that's no excuse for neglecting your homework or having a bad attitude. That's no excuse for talking back to your teacher, or cutting class, or dropping out of school. That's no excuse for not trying.

Where you are right now doesn't have to determine where you'll end up. No one's written your destiny for you. Here in America, you write your own destiny. You make your own future.

That's what young people like you are doing every day, all across America.

Young people like Jazmin Perez, from Roma, Texas. Jazmin didn't speak English when she first started school. Hardly anyone in her hometown went to college, and neither of her parents had gone either. But she worked hard, earned good grades, got a scholarship to Brown University, and is now in graduate school, studying public health, on her way to being Dr. Jazmin Perez.

I'm thinking about Andoni Schultz, from Los Altos, California, who's fought brain cancer since he was three. He's endured all sorts of treatments and surgeries, one of which affected his memory, so it took him much longer -- hundreds of extra hours -- to do his schoolwork. But he never fell behind, and he's headed to college this fall.

And then there's Shantell Steve, from my hometown of Chicago, Illinois. Even when bouncing from foster home to foster home in the toughest neighborhoods, she managed to get a job at a local health center; start a program to keep young people out of gangs; and she's on track to graduate high school with honors and go on to college.

Jazmin, Andoni and Shantell aren't any different from any of you. They faced challenges in their lives just like you do. But they refused to give up. They chose to take responsibility for their education and set goals for themselves. And I expect all of you to do the same.

That's why today, I'm calling on each of you to set your own goals for your education -- and to do everything you can to meet them. Your goal can be something as simple as doing all your homework, paying attention in class, or spending time each day reading a book. Maybe you'll decide to get involved in an extracurricular activity, or volunteer in your community. Maybe you'll decide to stand up for kids who are being teased or bullied because of who they are or how they look, because you believe, like I do, that all kids deserve a safe environment to study and learn. Maybe you'll decide to take better care of yourself so you can be more ready to learn. And along those lines, I hope you'll all wash your hands a lot, and stay home from school when you don't feel well, so we can keep people from getting the flu this fall and winter.

Whatever you resolve to do, I want you to commit to it. I want you to really work at it.

I know that sometimes, you get the sense from TV that you can be rich and successful without any hard work -- that your ticket to success is through rapping or basketball or being a reality TV star, when chances are, you're not going to be any of those things.

But the truth is, being successful is hard. You won't love every subject you study. You won't click with every teacher. Not every homework assignment will seem completely relevant to your life right this minute. And you won't necessarily succeed at everything the first time you try.

That's OK. Some of the most successful people in the world are the ones who've had the most failures. JK Rowling's first Harry Potter book was rejected twelve times before it was finally published. Michael Jordan was cut from his high school basketball team, and he lost hundreds of games and missed thousands of shots during his career. But he once said, "I have failed over and over and over again in my life. And that is why I succeed."

These people succeeded because they understand that you can't let your failures define you -- you have to let them teach you. You have to let them show you what to do differently next time. If you get in trouble, that doesn't mean you're a troublemaker, it means you need to try harder to behave. If you get a bad grade, that doesn't mean you're stupid, it just means you need to spend more time studying.

No one's born being good at things, you become good at things through hard work. You're not a varsity athlete the first time you play a new sport. You don't hit every note the first time you sing a song. You've got to practice. It's the same with your schoolwork. You might have to do a math problem a few times before you get it right, or read something a few times before you understand it, or do a few drafts of a paper before it's good enough to hand in.

Don't be afraid to ask questions. Don't be afraid to ask for help when you need it. I do that every day. Asking for help isn't a sign of weakness, it's a sign of strength. It shows you have the courage to admit when you don't know something, and to learn something new. So find an adult you trust -- a parent, grandparent or teacher; a coach or counselor -- and ask them to help you stay on track to meet your goals.

And even when you're struggling, even when you're discouraged, and you feel like other people have given up on you -- don't ever give up on yourself. Because when you give up on yourself, you give up on your country.

The story of America isn't about people who quit when things got tough. It's about people who kept going, who tried harder, who loved their country too much to do anything less than their best.

It's the story of students who sat where you sit 250 years ago, and went on to wage a revolution and found this nation. Students who sat where you sit 75 years ago who overcame a Depression and won a world war; who fought for civil rights and put a man on the moon. Students who sat where you sit 20 years ago who founded Google, Twitter and Facebook and changed the way we communicate with each other.

So today, I want to ask you, what's your contribution going to be? What problems are you going to solve? What discoveries will you make? What will a president who comes here in twenty or fifty or one hundred years say about what all of you did for this country?

Your families, your teachers, and I are doing everything we can to make sure you have the education you need to answer these questions. I'm working hard to fix up your classrooms and get you the books, equipment and computers you need to learn. But you've got to do your part too. So I expect you to get serious this year. I expect you to put your best effort into everything you do. I expect great things from each of you. So don't let us down -- don't let your family or your country or yourself down. Make us all proud. I know you can do it.

Thank you, God bless you, and God bless America.

Thank you, Mr. President.
therapydoc

Will Treating Depression Treat Heart Disease?

That's the title on page 8, WSJ, thanks Shirley S. Wang.

I wondered when this would become news. It is true, or so it seems in my practice and clinical sense, that having a cardiac event puts a person at risk for depression. And being depressed puts us at risk for a cardiac event, given the genetics, probably, or self-abuse, like smoking and drinking, and let's not forget, stress.

It makes sense to treat it, obviously, because what could be more life-threatening than suffering times two from life-threatening illnesses? They both kill, depression and heart disease, or they can, without treatment.

Exercise, keep your cholesterol low, watch your blood pressure, take your heart medication if it's indicated, and talk to people about your fears, if you have heart disease. It has to be very scary, having this condition. And depressing when your activities are restricted, when you can't add a little salt.

And we know people who would die rather than give up that sirloin.

Anyway. WSJ tells us that patients who develop depression after heart attacks fare worse in the long term than those who don’t. A recent article in the Archives of General Psychiatry found that patients who develop severe depression post hospitalization for a cardiac event remain depressed for at least 6 months. They have double the risk of dying over the next seven years.

Thus cardiologists and behavioral scientists are wondering if treatment will improve prognoses, and if early screening is necessary. We already know that 6.7% of the general population gets depressed in any given year (National Institute of Mental Health).

Research is inconclusive regarding the effectiveness of treatment and screening, but I think most family physicians, probably internists, too, are sensitive to depression, ask about it as a matter of course. They know people kill themselves, and no one wants this on their conscience. Family physicians have always used us, the mental health professionals of the medical network, to treat this, depression. Tweak a bit with the meds and the psychotherapy, and voila, a better quality of life.

It's about time the cardiologists caught on. We've always been here.

therapydoc

Your Worst Nightmare

Some of you who have read old posts might remember that I have had recurrent home invader dreams once or twice a year for as far back as I can remember. Always the same thing. Some big, unshaven, muscle-bound criminal-looking type, sometimes more than one, pushing against the front door to my family home. Me alone, pushing to keep it closed from the inside, trying to keep him out.

Poor FD. I always lost the struggle and woke him up.

Then, for no apparent reason, they stopped. The nightmares just stopped.

As much as I like doing anger management with people, there’s anger management and there’s anger management. I generally don't work with people who are court-ordered, very few hardened criminals. An occasional sex offender, is all.

And if a patient has a psychosis that is disinhibiting, or is ruled by voices in his head and doesn't like the medicine they tell him to take, it's likely I'll punt him along to someone who likes this kind of challenge. An ER doc, even. I won't be discussing identity or teaching any muscle tension and breathing.

Most people who have anger problems aren’t in it to hurt anyone. They’re just poor emotional regulators, and tend to have trouble with very strong emotions. We all have them, you know, strong emotions. And they can make some of us feel like hurting ourselves, or hurting someone else.

Even telling someone off reduces tension, sarcasm, too. People who suffer from Borderline Personality Disorder are particularly vulnerable to this solution, hurting themselves, hurting others, in any kind of way, and we see this disorder present quite often in therapy. We’re getting better at helping people with BPD, and in the process, recognize how difficult it can be, emotional regulation.

Therapists have weeks in which this is all we work on, above all else, it seems, emotional regulation, behavioral blunting. Stop signs.

I think it's what makes this a dangerous profession, that which Freud called id, the very human drive for aggression. We’re not an endangered species, but therapists are at risk for harm.

And we take in a lot of verbal abuse. We either don't take it, won't see a verbally violent individual, or learn to address it dialectically.

"You can get away with talking to me that way," I will tell a patient, "but it won't make you popular at parties."

Some of us get good at this kind of challenge, even welcome it, say, bring it on, even, to change the behavior. We won't debate facts, won't get into it like they want us to, just talk about quality of life.

"Is this what you want to do, put other people down, yell and scream and distance people from you? Or would you rather try to get a tennis date?"

That's DBT, Dialectical Behavioral Therapy, changing the meaning of a person's behavior. Some people do it naturally. We call them masters of the paradox. But ultimately what it is, is getting through. If a therapist never learns how to do this, get through, then there will be no therapy, no changing anyone suffering from Borderline Personality Disorder.

Very occasionally, for it has to happen if you work with people, a therapist will encounter someone in the throes of a psychotic episode. That person might be on the brink of hurting himself or others, might be paranoid or psychotically depressed, or flying manically, not in control of thoughts or behaviors. Out of reality times three might be an apt description, unaware of person-place-time. And this can get violent. People do get killed.

I've been lucky. My only encounter with one of these individuals who actually lost it with me was with a psychotic ten-year old. Never saw him before, but you don’t easily forget the brute strength of a psychotic ten-year old throwing table lamps. Not that I was really at risk. Truth be told, I’m pretty strong when my adrenaline's pumping. FD doesn't sneak up on me anymore.

So yesterday, I’m working with a kid on anger problems, no less, and we’re talking about how it's worse when you don't have parents who want to help with this thing we call emotional management. At least her parents are into the process, we agree, want to learn about it themselves. We finish and she goes out to the waiting room. Her mother takes her place. Mom and I are talking about how in her family there were eight kids and her mother, like her, couldn't control the aggression between her many siblings, and how powerless she feels when everyone totally ignores her efforts at Time Out. Can you imagine that? Time Out doesn't always work. When suddenly . . .

We hear banging on the sliding door of my office (the door for my bike, not people). I jump up and open the usual other door, the one with a handle. I see her. She’s my height, my build, in dirty jeans and a man’s shirt, tennis shoes. I don’t know her, but I know psychosis when I see it, glaring at me with fury. She scowls at me as if I'm dirt, snarls loudly,

“You a doctor?”

I’m sure I blanch. But she's not well, I get my cap on (the therapy cap) and respond in the most quiet, gentle, compassionate voice I can muster, a clinical voice.

“What can I do to help you?”

She pulls up her shirt sleeve, rips off a flimsy Bandaid to show me a freshly wounded, bloody forearm. The blood has already dried, doesn't seem to need any stitches. “You can fix this!”

Now I’ll be honest. I don’t want blood on my carpet, so I’m getting nervous. And I don’t want to turn to my desk to call the police, because I’m afraid that if I turn my back on her she’ll attack me from behind. She’s flying. This is anger. That other stuff we talk about is frustration, powerlessness, aggravation, the other words.

“Oh, that needs a doctor’s attention," I suggest, concerned. "I think we have a doctor downstairs.”

She furrows the brow, lowers an eyelid, then backs out of my office slowly, never taking her eyes off of me, like a bank robber in the Wild West holding a gun to the people in the saloon. The crazy part of this is that if I had to pick her out of a line-up, I’m not sure I could. I'm not thinking, look for birthmarks, eye color.

She’s backing out to the waiting room from my suite, past the door that should never have been left unlocked. I follow her. She points down stairs. “Down there?” she asks skeptically. "There's a doctor down there?"

“Uh, huh,” I reply gently. “Down there.”

My patient is in the waiting room now, too, has followed me out and is with her daughter. "It's okay," I tell them. "Please come back into my office. I'm pretty sure nobody's working downstairs today." They join me and I lock the outer door to the suite after them. Inside we process what happened, they hadn't felt threatened, particularly, didn't realize what was going on.

They're my last patients of the day. I lock up after them. Locked doors make me happy, the one time I forget to lock up, this happens.

I realize I hadn't called 911. Should have called the police.

Moments later, calm, I hear a loud bang on the door to the suite. I shiver, ignore it.

Then the phone rings. It’s my patient. “You have to see this,” she insists, breathless. “You have to come outside and see this.”

"Was that you banging?"

"Uh, huh."

Okay, okay.

Out on the street, about a half block away, three big policemen are working to subdue her. They’re having trouble, too. Arms and legs are flailing.

I feel absolutely terrible, as if I could have talked her into waiting for them, convinced her to surrender peacefully. She would have had a free ride to the ER for her wrist. Instead it seems likely that someone hit a panic button. And she’s treated as a savage.

My patients are spellbound. “How did you know?” the mother asks me. “How did you know she was crazy?”

“I never used that word,” I object. “I said she has a mental illness, isn’t a well person.”

“But how did you know,” she insists that I tell her, “that she was dangerous?”

“You just know, is all.”

therapydoc

FYO, all of the details of the story have been changed to make it fiction. But I think you get the gist of it. The truth is, truth is better than fiction, but sometimes you go with fiction.