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Thursday, September 03, 2009

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.

32 comments:

Anonymous said...

i think you should have called 911 therapy doc! she was really spazing out but I think you should have called for help. She may be sitting in a cell not getting the mental help she needs-I know you were protecting your people but still....
40 lashes with a therapic noodle for you!

Jim Valeri, LMHC said...

You do just know! I think it also has to do with knowing your limits regarding your clientelle. I've worked with psychotic clients before, but its not my area of expertise (my approach is more Cognitive-Behavioral), so I usually refer out.

Crisis management is something they really don't teach you much in shrink school, but having your wits about you so your office is safe for yourself and your clients can only do good things for your practice. :)

Nainja said...

I think, you acted very sensible regarding the situation by getting her out of your office and making sure that you and your patients are safe! Of course calling 911 would have been the right thing to do afterwards, but it's always easy to say that once it's over.
My experience from extrem situations is, that you can be glad, if you manage to do about half of the things that would have been sensible at that point. The "I should have" comes always up. Or even worse the "Why on Earth did I do this?!"
It probably gets better with repetition. Next time there will be the 911 call. But I very much hope for you, that there won't be a next time!

porcini66 said...

Wow. Your job IS more exciting than mine! LOL I'm glad that you and your patients are safe, I'm glad that you were able to keep your wits about you. Kudos to you for not endangering others to go into "hero mode" and rescue this poor person. Time and place, ya know? You focused on keeping a safe place for your peeps....safe. In my opinion, ya done good.

Syd said...

Here's my codie talking...I'm glad that you were kind to her and were calm. I would say that was great. Probably she sensed that you would do her no harm. Like a cornered animal. Thanks Doc.

Anonymous said...

I am a LCSW-R as well as Mom of a young man that has been carried away many times in an ambulance to the Psych Center.Not sure on this one - only YOU know in your heart. (and I think that you do know)

TechnoBabe said...

I hope your nightmares don't return.

blognut said...

Wow.

I hope you don't get another day like that.

The Blue Morpho said...

I have a relative with a terrible fear of intruders (that we call 'bandits' in an attempt to be light about it). Sure wish you knew why those dreams stopped, since you'd make a mint with that cure. I'd buy it.

The situation you were in was quite something - as you say, truth is always stranger than fiction so I wonder what didn't get written. You did a great job keeping the situation calm, and keeping everyone safe. Hope that was one night you slept well, in any case.

The Blue Morpho
anxietyland.blogspot.com

Anonymous said...

So you sent her "downstairs" telling her there was a doctor, knowing there wasn't, and not calling to get her help??? I would expect more from a regular person.

Lou said...

It was a dangerous situation, and you had other people to think of. I have had people attempt to hit me, pull my hair, and throw objects at me in the ER, particularly if they are under the influence of God knows what. It is always scary, and hard to make logical decisions under those circumstances. No one really can say how they will react when confronted by someone that there is no reasoning with.

retriever said...

It must have been alarming for you, nervous for your own physical safety, and wanting to keep your patients safe. I am glad you weren't hurt!

At the risk of sounding unsympathetic, tho, I have to say that professionals can choose to treat or retreat, to talk or lock the door,to call the cops or engage the person.

A parent cannot. If you dream once or twice a year of a home invader, I have nightmares at least once a month of my own child killing me. Even tho it's years since he last tried to...but will post on my own blog tomorrow about it, not here...

:)

therapydoc said...

Thanks all. Now let's up the ante. Maybe she was a he, my worst nightmare, and he's big and strong, maybe a skinhead or a gangbanger, and he's in leather and he points to his face and you see a razor cut, a nick from shaving with a little tissue on it, and he says, "You can fix THIS!"

Now whaddaya' gonna' do?

Glimmer said...

You totally did the right thing.
She was not your patient. You had people to protect, people who trusted you to do that, people you were unable to protect on your own.

I have been left quite vulnerable by the impulse to "do the right thing" with strangers who showed up flashing neon "something is very wrong here" vibes from a mile away.

I am sorry about the woman. But your office, especially, must be a safe place. If not, then I would be out of there.

If you were my therapist, I would be very reassured by your handling of the situation.

Margo said...

Just because you can recognize a mentally ill person for what he/she is when you see them doesn't mean you are (or ought to be) immune to basic, visceral reactions like fear.

This also isn't the first time your line of work has put you in touch with a scary person—I'm sure each incident gets under your skin so that your danger-radar is better sharper for the next time.

It's so easy under stress to forget the *obvious* Right Thing to Have Done (in this case, probably call the police once she/he/whatever was gone) and smack your forehead over it later. We've ALL been there.

Anonymous said...

Agree with Margo on this. It's easy (easier?) to see the different paths we could have taken *after* the fact.

What puzzles me is that it seems hard for you to admit the woulda SHOULDA coulda, TD. I'm guessing it's related to some sense of proper protocol for a therapist under these circumstances -- esp. the *shoulda*? (I'm making the assumption that they *do* address these kinds of things in therapist training) Maybe you didn't do what you were *supposed* to do (too shaken up by the incident -- the parallel with the recurrent nightmares) and that you're processing it here? Just wondering if there aren't some "feelings" that are implied but not clearly stated in this post.

Lisa Marie said...

Oh my. In the haze of adrenaline, you did an amazing job. Your patients did not feel threatened by her because you remained calm and protected them. Kudos to you.

Hindsight is probably giving you all sorts of options, but we all know how that goes.

Pleasant dreams, therapydoc.

Jack said...

I have a few stories like that I wish I didn't have. If it makes you feel any better those of us who are bigger don't enjoy dealing with people who are totally flipped out either.

Short story. Jack (me) is a junior in college. I have oodles of time to work out. It is not an exaggeration to say that I am musclebound.

I am at a friends apartment. Get up and use the bathroom. While I am in there I hear a loud noise and then a crash.

I exit the bathroom and find that someone has burst in and is beating my friend silly.

I give him a shot that would have knocked Mike Tyson cold and he turns on me. The guy is high, flying and he doesn't feel any pain.

Turns out my good "friend" was a drug dealer. It was a less than pleasant experience that I wouldn't want to deal with again.

I don't blame you for taking your position on this.

Annie said...

therapydoc-
what a thrilling piece of fiction/nonfiction. I too worked with dangerous young people when I was a therapist. What I call your treatment with the patient was "embracing the total person". It is frighting in such situations but perhaps the ultimate challenge of our compassion. To me "embrace" in this situation means experiencing the person from 180 degrees and looking at them through your minds eye. You truely met this person with honesty. It could not help but be helpful. Since I have been on both sides of the room I know how important it is for therapists to have the sentivity that you describe in this post. Thank you. Annie
apsychoptherapistwithbipolar.

Wonderingsoul said...

I'm both interested and mystified.

Your comment about upping the ante... I get it... And it interests me because it's a good point.
Because it is a 'she' in your post perhaps it seems easier to make judgements... to think she ws less dangerous in some way than th leather clad skin head guy.
What do you do?
Protect those you love and keep yourself safe.

I've been in dangerous situations many times.
Usually safety and survival wins out over compassion in the moment.
This is the world and it is one hell of a dangerous place. Therapy or no therapy.

Anonymous said...

Thank God you are in this profession! Truly, you're amazing. Trying to help the emotionally volatile.
However, it does seem as though you didn't quite understand the 'job requirements' when you signed up.

therapydoc said...

One of the points of this post that I didn't clarify (as usual) is that we have so much subconscious stuff in our heads, who knows where it comes from, these fears, and mine, obviously are about annihilation. I've wondered if it's one of those Jungian collective memory things. Jews have been, historically, hunted, beaten, killed, persecuted.

The second thing I think about, vis a vis this story (and thanks to all of you for being sure to catch it), is that here I am, a professional with all kinds of training, and I'm essentially a deer in the headlights of an on-coming, speeding car, maybe one that's way out of control, and I can get out of the way, can talk even, can protect myself and my patient, but forget, still paralyzed by fear (like a regular person, indeed) to call 911 to warn state police that someone's really driving badly.

Sometimes we're just regular people, all the time, is the truth.

Jas said...

Therapists/psychologists never have it easy, isn't it?

I'm a psychology student. Above all, I've been diagnosed by a psychiatrist to have schizoaffective major dep type, avoidant and paranoid PDs, and a few anxiety disorders. From the questions my clinical psychologist asks me, it's not difficult to connect them with what I learn in class to confirm Borderline as well.

And borderline I am. My relationships are highly unstable - I'll stay too far away or get too close after a while. My drastic moodswings can see me crying for two hours and 15 minutes later, slowly sipping my drink. I slef-mutilate and engage in risk-taking behaviors - but oly managed to cut once.

Looking at the amount of energy and time my therapist has invested on me has made me feel both worthy and unworthy at the same time - for the same reasons.

Nainja said...

Well, in a course for sea survival training (where you learn what to do if the vessel gets into distress at sea), I got told that 80%(!) panic and loose their head in case of an emergency. And that includes the well trained crew as much as the passenger. From my experiences in extrem situation, I would say that I am definetely among this 80%. I think, the only way to still do the motions when panicking is a lot of training and clear interalized emergency plans. And most crucial is experience. I am sure that all my first aid courses won't help me much, if I ever get into a situation, where I might need them. Or maybe I will remember and do 10% of what I learned...

Anonymous said...

It was nice to read your post. I had a session today with a BPD client and it can leave you dizzy. I liked the paradoxical statements you mention and I think it encapsulates the paradox of BPD. In my case the client keeps on walking out of therapy but then coming back.
Whatever....

T. J. said...

Hi Therapy Doc!

I was suffering from insomnia during spring semester and I finally gave in and went to the doc. She prescribed a sleep med and shortly after I began to take it, I started having horrible "attempted attack" dreams in which I would wake up just before the attackers were upon me. I didn't link the nightmares to the medication for about two weeks.

It was a crazy time. I was afraid to go to sleep because of the nightmares, so I made sure I took the meds! I was even cutting the dose in half, and it still affected me that way.

I know I have some fears about working in child welfare, and I think they are healthy fears. One of the caseworkers at my field practice is currently "grounded" due to perceived threats from a client.

It helps me to read about the realities of our field. I also believe we need to continue to lobby for our safety while we are out there doing the deal!

~Ms. T. J.

Margo said...

(the other Margo, here) wow, thanks for sharing this story. It's so interesting when you said that you're not sure you would be able to pick her out of a line up. Your job sounds much harder than playing a psychiatrist on tv :)

Cat said...

It is scary, people behaving in ways that are stange to you, or others, strange from the norm, but there is something about them, maybe in their faces that sets them apart.

When i was a teen I tried to kill myself, in a small town where there was one mental ward I was placed in it with all of the other - much older - much stranger people and I will never forget how it felt to visit that foreign land...

therapydoc said...

Right. We communicate so much, certainly pain, with body language, facial expression.

Made you never want to get that sick again, I imagine.

A.Decker said...

I like fiction better. Nice job.

catatonickid said...

of course you have the tools. this is part of who you are but when the adrenaline kicks in, you don't necessarily have access to those.

it isn't about skill or empathy or connection in that kind of situation. i've been in many like it, and it's a roll of the die.

one of the 'nice' ones, the funny one i tell people is how i am sitting in the lounge room of my new apartment when two young adults, boys, high as kites, jump over my wall and pry open the window behind the blind.

they can't see me. i glimpsed them. enough to know. like you did.

there is no thought, then. no time for it. only act or not, lock it down if you can. protect.

so i scared them with a booming impression of my father at his good old Aussie worst but i was lucky. one word, Oi!

you take your chances based on the information you have at the time and there's no such thing as 'should'.

you don't give away all right to think of your own/others' safety just because you're a Doc, or a nurse or had a phone that you might have had time to dial, if only you weren't quite so busy dealing with the nightmare that has suddenly emerged from its container and which stubbornly refuses to issue you with a map and directions.

if you get out in even vaguely one piece, you did it right. i'm just saying.

therapydoc said...

fabulous, Catatonic