Monday, April 29, 2013

Practice Snaps

Oh, I will ramble a bit. Take it in pieces or go get a sandwich.

DBT Made Simple Worksheet
(1) The Perfect Patient Mix

Everyone knows who the worst patients are. But one man’s silver is another man’s gold. Meaning my  nemesis isn't yours, my ideal patient, not your ideal patient.

By best and worst we mean type of personality, type of disorder, type of patient who jolts us out of our hum drum, our oh bla di, those who grab our attention whether we like it or not.

What makes for the best or the worst? Too many things. But if my father had borderline personality disorder, then it might mean that I’m pretty comfortable with people who have it. Or, it might mean that someone with that disorder makes me extremely uncomfortable. Therapists all have interface of some sort or another. We have our triggers.

Before we're let loose on the therapy-seeking public (a clinical population, as opposed to our friends and fellow students, unless they, too, are in therapy), those of us trained to be therapists usually have identified our comfort and discomfort zones. But these zones are squirrely, they can change, especially as we absorb new knowledge and want to try out new skills.Meaning, the zones change.

At a great continuing education workshop, for example, we might have learned volumes about dom-subdom relationships. We might want to work with this population, understanding that their issues are varied like all of ours. Feeling confident, we advertise as an expert and begin to get referrals. Things are going well.

Then one day a dom tells a what happened to me on the way to therapy story that changes things. Perhaps he stopped for gas. While waiting for a teenager to finish at the pump, he fantasized about taking out a tire iron and killing the teen for being so slow. The patient is a Vet, has killed before.

"Would you really do that? Beat a kid with a tire iron?"  We have to ask.
"Yes, if the moon is high."

Still comfortable with the dom-subdom patient mix? Nothing to do with interface, either, or an average dom. This one probably came for his four-year old's toilet training issues. It happens all the time that things aren't the way they seem. A presenting problem may not be the problem. One homicidal patient and you question what you're doing, are much less comfortable around people who are comfortable delivering pain.

You might be wondering, how to respond to Yes, if the moon is high.
Best to keep the conversation going, not judge, follow through. Ask: "How do you feel about being a man who would do that, beat someone up because he's making someone wait?"

(2) Absorption

Some therapists watch their patient mix, so as not to absorb too much emotion.  Emotion gets all over us.

A mentor of mine told me that if I found myself getting too depressed because my patient mix tipped toward depression, then I had to put a limit on how many depressed people I treated.

That makes sense. But if 90% of the human race suffers a major depression at some point in a lifetime, then it is likely that a good chunk of new referrals are in the throes, first call. And let's not forget that angry people are usually frustrated, but sad is the true emotion deep down. And our anxiety sufferers cry, the anxiety can be so debilitating. It is exhausting, so much sadness, so many tears. We may as well stop working if we're going to limit depression.

On the other hand, there's depression, and there's depression. Not everyone rates an Axis I.

(3) Punting

No matter what we might hope for, no matter how we try to watch our personal discomfort barometer, we can’t merely reject someone who comes for help, not in good conscience, once he is there in the room. We might say, as the patient tells his story, that we have a colleague who would be a better fit. If we have that colleague.

Using our best self-relaxation, anxiety reduction skills, listening for the patient's real needs, we find that we can handle it, whatever it is, all of the time. It is true, what they tell you when you graduate, that having a master's makes you a thousand times more capable at this job than the average ear. The trick is to sit tight and trust yourself.

We dig in and treat, do the job. But it ain't easy.

Perspective: A consultant, a psychiatrist and I work as a team. We have a running gag. We’re not supposed to send one another sick patients. What we mean is no really sick people. We joke that we’re too old for it, too burnt out to treat those with demands that run too high. Or so we say.  Of course this is a joke. The only reason it is funny is that grain of truth we both know is there.

Finding the network isn't easy, but there are new docs graduating every day, ready and willing to take on what could be our worst when we aren't up to taking it on. Maybe we can even find an entire team of  DBT specialists. 

(4) DBT

Oh, but what is DBT?  It is not the pesticide that the Americans used in Viet Nam in the sixties and seventies.
Sheri Van Dijk's DBT Made Simple
Dialectical Behavioral Therapy is a therapeutic model for the self-injurious population, the brain child of prodigious research psychologist, Marsha Linehan. Dr. Linehan has authored seminal books and manuals and has thousands of protegees, therapists who follow her religiously. She understood, well before anyone else could put it into words, why the cognitive behavioral strategies that work with most everyone else, don’t always work with those who have the most severe pathology-- the suicidal, borderline population.

Cognitive Behavioral Therapy (CBT), an older school, is about behavioral change, first and foremost, whereas Dialectical Behavioral Therapy (DBT) is about accepting reality first. Yet another acceptance therapy, Acceptance Commitment Therapy (ACT) is close to both ideologically. The therapist works with the patient to develop a new narrative, very much in sync with the patient's world view. DBT might incorporate the narrative, but offers much more than a better story.

The basics include a range of emotional management/distress tolerance skills and group therapy. Individual therapists have support or they would go sleepless otherwise, and oh, a 24-hour hotline.

The founder, Dr. Linehan recognized that the very sick are often an abused and neglected population. They experienced life at its worst. For them, countering negative thoughts can be waste of time. Life's evidence is to the contrary, damning. They have witnessed trauma to the degree that they believe themselves culpable, deserving. As you sow, so shall you reap. The sentence is issued, judgment must be served. The abused adult bought into her guilt years ago, like the foster child in  The Language of Flowers, a novel, about a child punted from one group home to another. (That one should be required reading for graduate students. A nurse recommended it to me.) They are full of anger and confusion.

The behavioral therapeutic schools have shifted the blame away from parents in the past forty years, but when we talk about causality, the environmental approach to mental illness wasn't so far off the mark. Parents have the power to construct realities, to make the world heavy or light. Some literally choose to make it heavy, don't know any other way. So while blaming, judging isn't fair,  saying they had no hand in the outcome isn't true, either. We can make the connection without judging.

Remember that Holocaust movie, Life is Beautiful? There, in the horror of a concentration camp, a father, by force of his positive personality, makes avoiding Nazi barbarism a game with his young son. The game is to spare the boy's optimism, to hide the truth of his experience. The two laugh throughout the movie. Most abusive contexts aren't this way, aren't fun or funny, and parents don't have this parenting skill, the skill of finding humor, creativity and laughter. Their children can't merely wish away negative thoughts, not even with the best rationalizations to counter them, not with our best hypnotic suggestions.

Therapists, then, need to accept the patient where she is, not a terribly novel idea, and introduce the irreverence, the humor in what is real, only possible if we stop fighting it, accept that some lives are more difficult than others. We old Jews, when we speak of some things that are anything but clean, we refer to them as holy, rather than profane, switch up the words. In this way, I refer to the difficult life as a beautiful life. Abused people get it right away.

(5) Beyond Acceptance

Linehan knew what she was talking about. She experienced the worst of depression, made serious suicide attempts. I read somewhere that she had an epiphany moment, one in which she decided that it was okay that she wanted to die, but she had to love herself, it was her job. No one else had that obligation in reality. If she loved herself then she wouldn't kill herself, killing isn't loving. She had to move on and teach others how to do it, too. Accept the raunchy feelings, then have a good life. Why the hell not.

So how do we do that, exactly, accept the raunchy feelings, then have a good life?

Lucky for us, Sheri Van Dijk simplified Marsha Linehan’s work, cleared the smoke of Dialectical Behavioral Therapy with DBT Made Simple.

This manual is fresh, refreshes, and if you buy it (not cheap at $27.96 on Amazon) the patient handouts between the covers are free to use. No more dividing your college rule paper into columns and scribbling homework assignments. They are all here. And the good doctor, Ms. Van Dijk, gives us permission to copy and use them at will. Who does that? Sheri, I love you.

Among the pages of patient information are ways to act differently, and pages of columns with dozens of words to describe every emotion. Who doesn't need more words?  It feels so good to describe our angst, our happiness. So yes, it is recommended reading. Required.
The Language of Flowers, a novel

To be fair, I don't like that shade of green on the DBT book cover (above). Compare it to the cover to the right for The Language of Flowers.

There, the review is balanced.

Ms. Van Dijk reinforces acceptance and teaches self-validation to reverse the self-castigation game. She teaches emotional reactivity reduction and distress tolerance skills, even mindfulness. Support for the therapists is a part of the plan. Therapy for therapists. Like having a suite mate who reads it in your eyes and takes five minutes to let you debrief.

Yes, that is why some of you wait a bit in the waiting room. Not complaining, just saying.

(6) What if there isn't a DBT therapist anywhere to be found?

My suggestion, assuming there is no DBT therapist at a local mental health center near you, is to take the time to learn the skills we've been talking about, reducing painful emotion, increasing the positive. (These are cognitive behavioral therapies, by the way.) Watch the basics of mindfulness (see video links below). Work with a psychiatrist, a therapist, and a primary care physician. Have a suicide contract in place, and the option of insisting upon a hospitalization. If the patient is in an Outpatient Day Program, stay in touch with staff. They need your input.

One on one, no team around, the job is to help people accept and love themselves. You’re fine exactly as you are, not that we all couldn't be better people. You are entitled to your anger. You are entitled to your sadness. Why wouldn’t you be angry? Why wouldn’t you be sad? Why wouldn’t you want me to feel your pain, manipulate your therapy so that I do, so that I know what it's like?

You see, misery loves company. If you don't want the  patient to turn on you, because some do, increase her demands, to try to make you miserable, then the heart of your work must be to join her, make that joining obvious, discuss the ugliest of her truths. Much more powerful than—Let’s try this!

(7) And If You are the Patient? How Do You Help Yourself?

You help yourself by being honest in therapy, for sure, and by having compassion, patience with a sometimes deficient therapeutic system, patience with loved ones, patience with yourself, if you are your only loved one. Then add patience to that patience, compassion on top of compassion. (I'll review Jonah the Woodcutter one day. In that book by Joshua Rubin, Jonah tells the shoemaker that if we have compassion, we don't need patience.)

Read the Ten Reasons Not to Kill Yourself, while you're at it, and buy Sheri Van Dijk's book, or Marsha Linehan's about how you really have a wise self. Begin to use it, that wise self. Start working your own program.

They say Linehan suffered schizophrenia, BPD, and depression. She has at least five videos on Youtube. Watch her teach.  Try her  breathing techniques, watching the breath as opposed to controlling it. Many of us teach diaphramatic breathing  for stress management, much harder, no need. Click on the mindfulness videos at fall asleep to them.

Don't do anything to harm yourself. You only have one ultimate mother, one father, and that mother, father, is you.

(8) Politics

We can only hope that with changes in health care, money will be earmarked for the vulnerable, will move Marsha Linehan's epiphanies right along, train more teams of DBT therapists for the trenches, make mental health something we can buy at the local intermediate care center. It is a war, I tell you, that war against self-hate.

Next time I post, it will be on something light, maybe the Dove Real Beauty videos, or maybe whether or not having a mother who shoplifts expensive dresses from Lord and Taylor is likely to have a terrorist for a son.

Maybe why I just want to shake Don Draper and say, "Don, you are like your father, a terrible father, because, like him, you are an alcoholic. Kids are a real inconvenience to you."



Reese said...

I liked the article. It has taught me to have more compassion towards my therapist. These past few months I've been extremely angry at her because she can't change me. She says that I have to want to change. It frustrates me to the point of crying because I do want to change, I just don't know how. It's frustrating because she just wants me to talk about my feelings. I had to realize that my therapist is just walking along with me on this journey. She can't be my parents. She can't be my friend. She is only there to support me in words. It's up to me to look and find ways to help myself. That in itself saddens me at how alone I really am. I read one therapists blog (he was a grad student and anonymous) he was complaining abt how DBT is the dumbed down version of CBT. He was also commenting on how borderline patients are the bane of therapists existence. My experience with my therapist has turned me off from therapy. It's best if I just buy a book, help myself and involve family and actually get friends who will support me. I feel like whenever I go to therapy I just talk but I don't work through things. My therapist always takes my side and its also frustrating. I loved my previous therapist. He took everything I said with a grain of salt and made me do the work. This therapist is saying that it is not her job to make me do anything. It makes me wonder how many of her patients actually get better. If there are things that I have to learn that I didn't learn from my parents as bad as it sounds I'll go to a life coach. Therapy just feels like a waste of my time. I havent gotten any better and I've just accepted that anxiety and depression are a part of my life and something that I will have to work hard at everyday. It makes me want to cry because I see my classmates so happy and adjusted. Anon from the previous post

therapydoc said...
This comment has been removed by the author.
therapydoc said...

I wrote it for you, Reese. And others who feel they have hit the end of the road. Therapy isn't this simple thing, do it, feel good. It is a process, a long one. The first Liinehan video does a hysterical take on brief therapy, how it stretched and stretched.

I think I said in the last post, get a new therapist, btw, if yours makes you feel worse.

Just like with trying out AA groups, you have to keep looking for the right one. One will click eventually and suddenly, life looks altogether different.

Reese said...

Thanks for responding. It's very hard. I feel like I want to kill myself everyday. I think that my therapist wants me to take responsibility for my actions. I'm guessing that she doesn't want me to be dependent on her. I tend to avoid things that make me feel uncomfortable and hide. I feel afraid all the time of making a mistake or making the wrong decision. I am thinking about getting another therapist. I just don't think we are a good match. I don't want to sit on the couch and just talk about my feelings and have someone give me a handout on CBT. That isn't helpful. I can get in touch with my feelings on my own. I like therapists that confront me and call me out on my b.s. Because I tend to avoid responsibility it takes me a very long time to snap out of my feelings. I need a therapist that is going to ground me and show me a different way of living and thinking(you know, if you grew up in chaos it seems to be normal. It seems weird to see people not feeling anxious all the time and walking around with their head cut off). I'm 23. I don't want to wait until things fall apart and I hit rock bottom for me to have a wake up call. It just doesn't work and it's extremely painful. My parents can't provide me with guidance.I just feel frustrated with her. She says I have to want to change. Yes, I do want to change but I don't know how. I need some direction. If I could just do all of it myself I would not be in therapy. I would be out there doing it. I can see from that statement that I don't want to take responsibility for my actions but I am going to therapy and I am willing to try things that I learn in therapy. I can't go out there and do something if I haven't learnt anything in therapy.

therapydoc said...

Why not show her what you're reading on the Internet? :)

Maybe she can work this with you?

Reese said...

I've tried. I've tried saying that I don't think I'm doing therapy right I'm not sure where to go or what to do or what to talk about. She thinks that I have some type of trauma hence the anxiety that I'm having. I don't have any trauma. She says that she feels confused by me. She asks me if I want to change. She asks me why I don't want to impress people. School for me has never been something I do to impress people. School has always been my job and that is what I do. I'm just over therapy. I have to change myself. I've done it before and I need to do it again.I feel so scared when I'm doing my work. I also start to feel sleepy after a while(books can really put you to sleep). I've been on Wellbutrin now for a month. I don't feel as scared but the thought that I'm scared is still there. Honestly, some days I feel like just giving up.It's really hard, I'm tired and I don't see my life getting any better. I can't afford another therapist; I'm a student. I'm just going to wait it out and try the best I can on my own. Thanks again. I'll bring in some of the DBT worksheets and see what happens.

Anonymous said...

I've been in dbt for years (I'm the one who wrote in about it in your mindfulness post)-- this is the book I'd recommend--

Linehan's Skills Training Manual for Treating Borderline Personality Disorder Disorder/dp/0898620341/ref=sr_1_1?ie=UTF8&qid=1367451894&sr=8-1&keywords=marsha+linehan

Reece-- Before I got to dbt I had reached the conclusion that there was just something so deeply defective about me that therapy didn't work for me.
I recognize the self-blame and the pain of your posts. And I too had a therapist intent on finding some nonexistent trauma....

So I left treatment. Eventually I got really really really sick and I now see it as sheer grace that it took a long time to find a therapist who would see me -- that's sort of funny in retrospect but it was living hell at the time and I marvel that I made it through it-- eventually being referred out and referred out landed me in dbt... though even the first dbt therapist wasn't a good match... but in the end I found someone I could work with and my life has changed in profound ways--though I didn't even want it to change-- I was just vibrating and terrified. One of Linehan's golden rules is that it's always the therapist's fault-- never the patient's. I can't screw up. All those therapists who blame people for their own inability to help -- rage to them. The first psychiatrist I ever saw told me that there was no hope for people like me unless I took a anti-psychotic-- but I wasn't psychotic. Now my current therapist's voice has replaced that bad one's voice.

I'd really try to find a dbt program-- generally hospital clinics area good place to look and they also tend to have generous sliding scales. I don't have much money. I say I'd look for a program because the group skills class is important. Today we talked again about doing things to build a sense of mastery and went over the first page of the Adult Pleasant Event Schedule-- the whole program is a big structure. Like living in a house-- a very safe house. We go over and over the skills until they shift down deeply and when I don't know what to do I have a mental rolodex of skills-- and when, in individual therapy, things get overwhelming there's that safe, secure, strong structure of the skills that can be referred bad to-- that requires both me and my therapist having them very integrated.

And-- the guy that said dbt is dumbed down cbt is a moron. dbt is a mixture of cbt, buddhism, and Hegal. It has huge philosophical underpinnings and it's practical and grounded enough to keep a person alive. It blows my mind that it's still acceptable to have caustic attitudes toward really vulnerable people - that borderline is still a pejorative term for so many.

therapydoc said...

Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you, Thank you!

Reese said...

Thank you so much Anonymous. You're right. I need to shop around and see what's best for me. Thanks so much for the book recommendation. I like structure too and more straightforward skills so I think DBT is the right choice for me. I don't have borderline personality disorder but like everyone else in the world I have traits.I think I lack a lot of important skills like social skills. I'll see about the hospital clinics(?)--I've never heard about them. It's good to hear that you are doing well. I appreciate your advice.Thank you too therapydoc for putting up with me these past few days.

Anonymous said...

reece-- dbt isn't just for bpd anymore-- where I go it's used for all sorts of emotional dysregulation. I'm glad that the bpd factor didn't put you off.

Reese said...

Anonymous: I have seriously problems with emotional regulation. It's gotten to be a huge problem. Thank you so much for the advice.

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