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.