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

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.