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  DBTselfhelp.com 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."

therapydoc

Sunday, April 07, 2013

Ten Reasons Not to Kill Yourself

Suzie Gonzalez

I read the news today, oh, boy, 
About a lucky man who made the grade, \
And though the news was rather sad
Well I just had to laugh
I saw the photograph
He blew his mind out in a car, 
He didn't notice that the lights had changed
A crowd of people stood and stared
They'd seen his face before
Nobody was really sure if he was from the House of Lords

Beatles, A Day in the Life

For some reason, I always heard those lyrics as describing a suicide.
Not a pet cemetery


About the picture to your right. They try to make them look like parks, but these are really dreary places to visit. 


Matthew Warren, son of Pastor Rick Warren of the Saddleback Church in California, dead. Matthew's famous father spoke at President Obama's first inauguration. He wrote a letter to his congregants to tell them that Matthew had taken his own life, had lost his battle against depression. It was a self-inflicted gunshot that killed the 27-year old.  


Huff Post quotes the father  “No words can express the anguished grief we feel right now,” Warren wrote. “He had a brilliant intellect and a gift for sensing who was most in pain or most uncomfortable in a room. He’d then make a bee-line to that person to engage and encourage them."
“In spite of America’s best doctors, meds, counselors, and prayers for healing, the torture of mental illness never subsided."
We would say that Matthew had bad disease. What we lost, a picture of Matthew Warren.
THE STORY
I need to remind the reader at this point that the caveat at the top declaring much of what you read here as fiction is there for stories like these. 
A few years back I’m sitting across from an extraordinarily handsome young man in his early thirties. He has an excellent vocabulary and an eastern seaboard accent. He narrates about the mental illness in his family—schizophrenia, the schizo-affective disorders, bi-polar disease. He's been on his roller coaster of disorder and chronic drug and alcohol abuse, with multiple physical problems (as if these can be separate), too, all his life. 
He is talking and I am thinking, Oh My.
There is a feeling the therapist gets and I have it, a worried feeling that her patient will not make it, will kill himself, and it will be on her watch, and she will be held responsible for not getting him to the hospital in time, and even if she isn’t responsible, she will feel she could have intervened somehow.

He tells me that he knows he will kill himself one day, as sure as the sky is blue.

I tell him: Not on my watch.

He laughs and thanks me for that. He needs a great deal of direction in general.

Time passes, my friend leaves the city. We speak about continuing our work on the phone but I am reluctant. I want someone to lay eyes on him, as I like to put it, to feel him.  When we're with the patient we can get that feeling, some of us, that things aren't right, that the psychotic part of the depressive continuum is ascendant. The patient has checked out, wants no help, intends to finally carry through a plan that is always on his radar. He won’t tell any of us this. No, we won’t hear about it from his lips. In fact, when we try to get near to it we hear a resonant objection and a defense of his mental health. “I’m fine! Go back to your nap.” This I do hear, for he knows full well that a good nap does a body good.

He leaves, has a new team in another state, miles and miles away, people to keep him alive. Somehow. 
Six months later I get a call from his wife that he has finished the job. I am startled, surprised, upset, and very, very sad.  This was a pleasant man, a likable person. Surely he could have done something wonderful with his time on this planet, even if was some kind of volunteer work. But he is out of his pain, finally, is what everyone will say.

His wife, on the other hand, is furious at him. Selfish bastard! How dare he do this?  Why in the world would he do this to her? She would have stayed with him, headaches and all, no matter how difficult, no matter the drama! He was in total sobriety and on the right meds, in stable condition, as stable as he had ever been. He should have loved her more than to leave her like he did.

She hates him for this. She will never love anyone as much, or hate anyone so much, all in the same moment. We hold hands over the phone as she cries.

There are others he has left in his wake, parents, siblings, therapists, doctors, people kicking themselves, wishing they could have done more. Even I am thinking, Should I have called him once in awhile? No, he wasn’t my patient. But could I not have just checked in? Is that such a crazy thought?

Oh, it is water under the bridge. Sometimes there is nothing we can do. People leave clues, they tell us as much, that this is the plan, this is as it should be. We can call the police and the patient will charm her way out of an admission. Shlep a man squawking to the hospital, and if he is admitted, he is eventually released, and when he is, if he can get his hands on a gun, he’ll shoot himself. Or use a rope. A woman will ingest all of those meds she’s been hoarding for just the right moment. 

Sometimes we just have to face it. People are hell bent on suicide, either need a release from their pain or want to take others down with them as they go, make sure they are missed. We may not be able to stop it but we can try. 

We can say, "Not on my watch." 
And they can say, "Why not?"
And we have to find reasons why.

Maybe there is something we can do about it to slow it down, for this wave of youth killing themselves does seem to be an epidemic. We need to call it what it is, let’s talk, self-inflicted murder, no different from homicide except that the one pulling the trigger is the most obvious victim. 

To call attention to the problem we should support suicide awareness, visit AFSP's website. We can join in on their walk, donate. AFSP, the American Federation of Suicide Prevention, could use money to promote their anti-suicide campaign. We should make it our anti-suicide campaign. 


Taking a walk to draw attention to a cause is a nice idea. Good people do this. 

There's something else we must do. We have to counter the forces of death on the Internet. I feel it is a Star Wars mission we're talking about. We are the Jedi. 

If you aren't aware of this, you should know that there are websites that feed vulnerable, depressed kids step by step instructions on how to kill themselves. Here, where we are at this moment, people give advice on how to die. Go ahead. Open a new browser and Google: How can I kill myself? You'll fall off your chair there's so much advice out there. Sites share specs on lethal doses of poisons with anyone who asks for information. I imagine they teach rope knots, too.

This upsets me, that the Internet has become the Wild West, a dangerous place, because I like to shop here. There is nothing quite as amazing as Amazon, or useful as a university database, or Hulu. This is a wonderful place, cyberspace. A few rotten apples. Right? No. The tip of the iceberg.

They have to be shut down.

 Suzy Gonzalez was a child. 

Hear her story.





Suzanne's case has an unusual twist. She frequented an Internet newsgroup called called ASH, short for Alt.Suicide.Holiday.  Members of this news group trade advice on how to commit suicide, using code words like 'transitioning' and 'exiting' and 'catching the bus.' Suzanne found this group nine weeks before she died, posting nearly one hundred messages detailing her plans.


Her parents are grieving, her friends and teachers are, too. And it is clear that Suzy had much to offer. People who are very much still alive who say they've been there and respected her wishes to end her pain, persuaded her to hide away in a Florida hotel room and take cyanide.

They told her exactly how to do it so she would make no mistake. Hers was a copycat suicide. They coached her, told her over recipes to die.

Recipes for suicide.

So yes, THIS has to stop. These websites are taking free speech too far. Throw the perpetrators in jail. Pass stiffer laws. I plan to email my congressman. He writes me to say Mazal Tov! whenever something nice happens in my family. Time he did something more.

Is it possible that bloggers like me, bloggers like you, or just readers with Google circles or Facebook pages, Tweeters, any one of us, might participate or better, start a chain, post the reasons that suicide is a very bad option, all things considered?  I'm not technologically savvy enough to know how to do that, but some of you are.

 Feel free to cut and paste. 

         Why suicide is a bad idea. 
(1) There's an agent for everyone. We have new and better medications. Be patient. There's one coming out at a pharmacy near you soon.

(2) Brain research and the fields of psychology and neurobiology are exploding. There may be a cure for depression, a laser, a surgery, who knows? Think about it. One day, zap. You're better. Things are likely to get sunnier if you wait it out. Study up on these things. Learning anything makes you feel life is worth living, too.

(3) You are not bad, not evil, not the source of all that is wrong in your life, your world, the universe. The world will not be a better place without you, no matter what the relentless, unceasing voices in your head are telling you. This is as wrong as 2 plus 2 equals 1 to think that you MUST do this, totally irrational, the thinking of a sick mind, a mind on psychosis  It's not about you, frankly.

(4) People love you, so you can't do it. You don't have this right, no matter what anyone tells you. People love you and if you believe in God, that Higher Power does, too. She has declared all forms of murder out of bounds, even yours. We don't mess with God, but it's not just God. The people who love you will really, really hurt if you kill yourself. It is one thing to feel pain, quite another to give it to others. Wait because you  probably do have love inside, although it is surely fogged over by disease. But you loved and you will continue to love at least someone, or something, and others love you. Love is ephemeral, holy, and all that is good.. Why lose that?

(5) Tough it out because you are already in the process of change, you can't not change. Our cells change over every day. Our moods can, too. We have so many ways in therapy to accomplish this thing we call affective change. Pay attention. 

(6) Change your therapist if therapy isn't working. This should be obvious, but it isn't. A new set of eyes on you is refreshing. Therapists all get a little boring after awhile.

(7) You haven't even tried aging yet. It's not so bad. Age a little, give life a chance. See what is in your future. It will be better, you'll see. And how can you not want to know the future? Seriously.

(8) There are things that only you can do, no one else can do them, and these things have to be done.

(9) There are things that only you are. Nobody else will be the uncle that you will be, or the aunt, or the mother, the father, the daughter, the son. These are unique jobs, very, very important ones.

(10) We need you. We need a new poster child every year, at least one every year, someone who comes out to the world and tells young people: Wait! It really is a permanent solution to a temporary problem. They weren't kidding! I waited and look at me! My picture is on a bus!

We can't judge people like my friend who moved away and did what he said he would do, as sure as the sky is blue, although his wife always will, or the Matthews, the Suzy Gonzalez's. They really didn't know they had a future.They were convinced, in fact, to the contrary, that life would not get better. But  Suzy scooted around her neighborhood in a plaid skirt and green tennis shoes. And Matthew helped others as soon as he sensed their discomfort. A girl like that, a boy like that, knew how to make others happy. We can't afford to lose kids who suffer from depression. They get happiness on a level that no one else ever will. 

So why then? Why do they do it? Sure there's pain. But I propose that they lost that tiny sliver of affect that kept them alive, the one we think of as love, that very positive emotion. We need it to stay alive, need to love something, someone, and we're not talking romantic love, here, rather a sense of connectedness. Friendship will do. For some, a hobby.

On Suzy's website the people who loved her wrote:

Suzy Gonzales was a bright girl who needed to be reminded of the good things
in life, not encouraged to end it. At the time of her death, Suzy was the 14th confirmed
suicide associated with this particular site, they claim 24 "successes" today.

I'm so sorry for her family, and for Matthew's, and for all of you who have lost someone to suicide.

therapydoc