|DBT Made Simple Worksheet|
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?"
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.
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.
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.
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|
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?
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|
There, the review is balanced.
Yes, that is why some of you wait a bit in the waiting room. Not complaining, just saying.
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.
Don't do anything to harm yourself. You only have one ultimate mother, one father, and that mother, father, is you.
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."