Dialectical Behavior Therapy - Dr. Fruzzetti

yeah just to orient of course in dialectical behavior therapy we have a treatment target hierarchy there's a there's a set of targets that we've collaboratively agreed-upon already we would have done that in the first couple of sessions and out of that collaborative endeavor would have created a self monitoring diary card where the different things that we're working on are on a piece of paper that are we calling you Andrea are we calling you Alice that Alice would be ideally paying attention to every day she's practicing noticing a variety of things in this particular case given her targets that are in the in the vignette she's paying attention every day to rating does she have suicidal thoughts does she have suicidal urges does she actually self-harm is she restricting her eating how many hours of sleep is she getting what is the quality of her relationships every day and she's doing this every day ideally the other thing we put on this is is a little thing that patients fill out just before they come into session and that varies from patient to patient what it might be but for someone with her particular targets would just be a little low box there would say urges right now right at this moment coming in a session her urges to kill herself or to self-harm or urges to restrict eating because that's one of her her targets if she were a substance user it would be urges to use substances always urges to quit therapy okay and then for somebody who's as affiliative as she is we'd also have something like how connected to she feel to me okay so great that the very beginning of the session usually like in the waiting room before she comes in and we'd have a rating get rated again just before leaving the session okay that would give us something that if there are big changes in the wrong direction that would give us something to pick up on the following week so but let's assume that there's yeah let's let's assume that we left left the last session now the thing is it with with a third session I think I'd like to make this to maybe like a fifth session or sixth session if that's like it because the first three or four sessions in DBT are this orienting and cloud establishing collaborative enterprise a commitment to treatment and establishing what the targets are so I'd rather assume that we've actually already done that or actually in the treatment now okay and so the diary card gives us of course a picture of what's been going on for the whole week and allows us then to organize the session structure the session within the hierarchy so if there's something that's life-threatening in DBT we would prioritize that doesn't mean that's the only thing that we would do in the session but we would start with that if something there's nothing life-threatening going on this past week or currently this moment then we can look at treatment interfering behaviors and then if there's nothing going on there we then look within quality of life things like eating disordered behavior and problems in her relationship with her boyfriend and a variety of other things drug use or you know whatever it might be housing problems problems at school at work whatever it might be okay good enough well how things are going in your relationships with friends and yeah tennis yeah you can do it from minus 10 to positive 10 or however you want entire records of course are developed idiosyncratically you know so Alice would have a different diary card than somebody else and even this month Alice's IRA card is going to look different in six months from now as things change her diary card will reflect some of those changes as our shift in focus continues over time so perfect thank you okay so actually what you hold on to this you just come in and give it to me because that's what you'd actually do so come on piles okay well you look terrible Thanks well okay look can I say that differently I think I stepped on your toe you look like you feel terrible is that better yeah okay how's really oh sorry did that kind of does mean that's what I skated my wife she doesn't take it the same way no I meant actually just that you look like you feel terrible I was a little too abrupt there wasn't I alright let's take a look what's going on um oh my goodness look what's going on here but what a week you've had Wow so you hurt yourself last week on Friday okay right are you having trouble even focusing right now yeah look yeah you are just quit yeah there we are you want you I want you okay okay look at me come on come on kiddo where'd you get that okay you're suicidal urges are high your urges to use drugs are high your misery is a nine out of ten and somehow you think I want to quit therapy but somehow it's because I cut myself on Friday like you said yeah okay look at me look at my reaction I'll do a little replay okay watch my face you said oh boy oh looks like a terrible week for you you look terrible yeah okay okay okay hello though thank you I appreciate that okay watch my face when I notice that you cut yourself on Friday okay watch my face you got to watch my face because you've got a different idea in your head about me than yes on history whose history mine okay that's why we know right but I'm but you don't have we don't have so much history so you gotta take 30 all right so I want to point out what you're doing right now is you are paying attention to what's in your head you know what's not what's right here no it's right here well that your history have you brought it with you right yeah but it's not have been if it's not happening right now what if it's not could you be open to that being open to the chance of it not happening you know but I'm opening to myself to the chance of it happen you know you've already decided this happened sounds like you've already got plenty of suffering as though that happens yeah so can you just be open to the other possibility try it look at me serious huh come on about my growing tumors or something what's the story here okay okay I'm looking I say oh my gosh you had a terrible week you know you're suicidal well you got to keep looking I know it's hard got a look at me because you're worried about me firing you Oh terrible I am you mean you're judging yourself right now oh you're judging I am but yeah you're right they gotta say all of the other this is hard you're making me hot okay look here's the thing here's what I don't want to do what okay I don't want you to get stuck on something that's not valid in the present moment do you think having five therapists in a row fire you is it valid that's valid but this one's not yet firing you okay yeah I know then what happened okay so tell me maybe we didn't explore this enough I thought we talked about this quite a bit a couple weeks ago what well the most recent one about what remember we talked about this right we went over each one of these okay each one and we talked about our plan for how to handle those situations it's hard to remember you talk so much I do that is true but we made we made some arrangements we made kind of some deals about how we were going to handle these situations I didn't call you for coaching because I was I knew I was going to cut myself hey hang on but but that you don't get fired for not calling for coaching you don't get fired for that well I didn't do what we agreed on yeah I never saw I was very clear with you that you don't get fired for having the problems that bring you into therapy yeah well that's what my last therapist said to you guys read the same book maybe okay well but here's what I'm trying to get at right you're kind of stuck on that right now and that's keeping us from working on what's actually going on in your life okay so if you're I guess I would say if you give me 30 seconds of your actual attention we might move past that okay I can do that all right that's all I'm asking for right now okay so 30 seconds I'm not firing you well you write it down yeah straight yeah in fact I'll even send you a mail an email we're gonna text you yeah sure I just throw away my pen my pen was hot - you dropped it up across another floor okay I'm not gonna light it on this one because I'm going to keep this but I'm going to write it on your next one okay great let me to sign it okay I won't fire you Mary's here Ellis I did I just write Alan Alan if Rosetti seems a little formal doctor boy okay dr. Alan II froze Eddie the whole thing can you read that okay you're the only one who can't but then that's good all right will that help I think that's fantastic actually if that will help now does that make a difference yeah but I mean right this moment as I make a difference that's pretty good okay if you really do really got stuck on this huh you get it but blame you for what for having this this horrible set of experiences that makes you worried about this no I really make sense to me why you would be so scared of this completely makes sense but what I want your job in this okay I've got a job in this you've got a job in this okay okay look over here yeah I know but look over here even though it hurts yeah you notice when you look over here you're feeling really ashamed right now right but if you look at me the shame will go down it you got to keep looking at me okay better you've got to look at me and see that I'm actually not not being critical of you I'm not sure i 100% understand I think I got 95% of it and if I don't you'll tell me okay I can do that okay I can but I want you to notice if you just look at me and look at my reaction to my real my reaction not the other five therapists you'll have a different experience your shame will go down right here okay well see okay now what I want to do is I want to I want to record the rest of our session now where we talk about this I just forgot to turn it on because I want you to be able to listen to this later okay because I think that you're so upset right now that some of this is just not gonna remember right it's gonna be hard to remember understandably that's what happens everybody okay and I want you be able to hear me say Alice I like you I'm not firing you you haven't done anything that I would fire you for you don't you know that no I want you to be mindful of what we talked about about that you know do you get fired for cutting yourself in this therapy from me do you get fired for cutting yourself that's right and that's not fair I promised I would not kill myself for the year you got to promise you won't kill yourself a year okay good deal then we're even but I can't control my thoughts No okay well let's work on that so right now look at you've got pretty high ridges right now they're not all the way to ten here at six right so the question is this um I mean like are you going to is there any chance that a sixth you know we just don't know each other that well that you will bolt out of the session and go kill yourself because if that's the situation that I'm going to get really anxious or sit in front of the door no I'm going to go sit in front of the door okay good because I don't like being anxious about like you leaving in the middle of a conversation yeah and if you did that my retest off yep I got up and left in the middle low conversation yeah why hey you I wouldn't expect you to okay so um it looks to me based on this that you know you did cut yourself on Friday but you kind of like on a suicide chain right now so well if your urges to kill yourself are that high right now is this the most suicidal you've been in last week right now okay so because that it was worse okay so let's go back and talk about that because you were feeling suicidal okay great well let's go back and talk about what happened on Friday then okay let's figure it out and by the way how is group you know you start a group it's only been two weeks now how's it going I'm trying to give it a chance okay what skill did you learn this week to remember alternate rebellion excellent yeah I like the smile that means you got alternate rebellion okay are you wearing boxers today no okay if I tell you this skill I used for alternative rebellion it would really mean a lot some of you don't use it as an example again I don't use it in other words I don't push you to do it again oh you got a deal another deal deal I am Thursday after um that's a group oiler in the skillet I got in a fight with John yeah and I wanted to start yelling at him but instead I walked away I've got in the shower and did something that would really piss him off yeah he hates that yeah and you didn't know Lysol afterwards yeah but he doesn't know but he doesn't know no it's not right baby laughs that's good are you sure I can use this example that's are really hot again okay all right no I think I think oh no no I promised I wouldn't without your from I won't know I think it's such a great example though actually I think it shows that you really get the skill that's fantastic ok any questions about group any questions I don't think you have any questions of alternate I think you've got that one yeah and sometimes the group leaders just go on and on yeah they're like me that way yeah but I think we'll see how it goes ok great ok fantastic well let's talk about what happened Friday what time did you would you did you cut yourself burnish would you do on Friday what time well Susie had a ton of chefs starting at 11:00 so that means she left the house it was probably like 10 10 ok at night at night 10 right okay and it looks to me if I'm understanding your diary card and you got to help me with this because we're just getting to know each other on the diary card okay it looks to me like you have been restricting your eating so you're probably hungry right that she'd been drinking I believe that when you restrict long enough your body just says you didn't miss you more I mean it gets very up so it does I don't feel hungry I just feel like sick and like I can't eat anything right yeah you know what happens right I mean you know you feel your system is just all messed up okay so well that was the last time you ate by the way and coffee food yeah I had sent her a lot dinner last night okay so you're getting some food okay um so it looks to me like no you didn't use you weren't drinking on Friday sorry it was Thursday you were drinking so you were drinking Thursday and not getting much sleep at all four to five hours to sleep on Thursday night restricting your eating so there's lots of reasons why Thursday why Friday would have been a lousy day okay then what happened what happened done I told you how John and I are trying this new thing where we take things slowly yeah and where he came over for an afternoon will be this little this idea okay and we how are you feeling at that point you're vulnerable right what do you mean well not eating not much sleeping drinking the night before leaves you vulnerable to getting dysregulated right kind of makes us it makes everybody more sensitive and more reactive right okay but you're kind of happy too he was coming over in the afternoon did that feel good or was that not so good I was looking forward to it all day I was excited but also really scared okay um and I scared it exactly what did happen okay anyone so you're kind of prepped for something bad to happen were you yeah you know when you say that it makes just my ears start to go with me you know because your idea of protecting yourself I have to say it's a little funny you're judging no long times like ineffective it's kind of like driving on the wrong side of the street well how does that protect you that's my point what that's okay that's good tell me well I think sometimes you know protecting yourself is a good idea okay but being stuck in kind of your I bet you how many how many calories of energy to put into worrying and thinking and analyzing how you're going to protect yourself before he even came over to watch the movie more than I consumed that more than you consume that day exactly and do you think that made you more vulnerable to getting dysregulated or get and harder to just enjoy whatever there was or I really think so yeah I do what don't you think so I could be but I'm also open to being wrong I know is yeah okay and so like being in the moment right just like we started out the session where you were pretty sure I was going to fire you and that really made it hard to just notice that you're here sitting here with somebody who actually likes you has thought of firing your head across my mind right you kind of missed that right and so if you're kind of churning over and over how John's gonna it up right it's it's not like he's gonna it up it's what I okay what did was so all right so tell me what to actually happen so he came home from the movie what happened well before when we watch movies he would always fooled me he's trying to take things slowly with me to see if we can get on a truck mm-hmm where and you and you said you have kind of mixed feelings about that that's hard my reasonable mind gets it okay and it's hard and your emotion it's hard on your wise mind right because you're an affiliate of person right relationships are important you like to be close to people right you like emotional closeness right area yeah and you love him right so so slow means pain for the part that's not there and it means satisfaction for the parts that's there but right you think you're the only affiliative person in the world but right now you're more affiliative than he is right I don't know that will change but right now you're more affiliative like I do about me leaving I guess I get scared of him just having enough right so what happened he's coming over were you thinking about how about excuse me about harming yourself when he was coming over had that crossed your mind yet no okay what happened I tried to get him to hold me and I asked him to hold me so I know I want to watch them you just next to you mm-hmm so you're longing for some closeness some kind of physical affection right is that reasonable I just had to disappear at him okay I just wanted him to hold me in you wanted to beat me up and can you relax when that happens can you feel more peaceful when you're close to him okay so kind of make sense that you'd want that doesn't it the longing for that and it makes sense yeah and what do you want to give it to me I just thought so what have you doing Ollie what did what did he do exactly precisely what did he do he looked at me and he said I want to hold you you know I want to hold you I need us to take this slow and I'm focused on the movie and I'm right next to you okay and that wasn't enough for me no do you see how I don't mean this in a bad way about John but you see how that was kind of invalidating no he told me what he's told me before that he wants like he cares about us and giving this a shot the right way right but there's a certain implicit I could be mistaken about this but it sounds like there's a little implication in what he said that you shouldn't want it how like because he said he wanted to go slow that you shouldn't be disappointed in that you should be satisfied with that because he said it because we need to well just because well I don't know whether you need to or not but but that's what he wants and you would like something different and that means that every time right every time you want a little more that he wants you're going to be disappointed and I don't really want you to notice how reasonable that is how completely sensible it would be every time we don't get what we want we're disappointed it hurts right okay but it didn't just hurt this time right where'd you go with it what happened next you lost it I and it was an overwhelming hurt like kind of like a black hole hurt yeah was a black hole and but I so committed I am so committed really trying so hard to going along with what he was yeah right and today killing myself right but that wait you have a black hole of emotion is rid of you at all you could do is take it to it yeah it I just wanted to me over right no so on the one hand you want to sink into this luxurious lap of closeness and you got it and you got the cold black hole instead that sink into that's a pretty big contrast that's a pretty big contrast it's awful right that's why it's okay that's okay I get that completely what I did no no hang on but what I don't get here's what I don't get but it's not that I can't get it you just have to save me I don't get how you went from feeling so alone and despondent and empty well you know having all this longing that's not fulfilled how you went from there to wanting to harm in yourself I don't get how you went from there I can remember if you use this word or my last therapist but this is a time when I feel really desperate desperate yeah okay desperate but you were desperate for for closeness yeah for death I did something good there I craft I grab one of my cab okay inverse when I grab there want to be helped oh hey so I'm aspiring fan it to the fire right even a cat doesn't want no but I have two cats so I grab the other one and she wanted to be held and I just had her and I just and what happened to so your arousal was about how high black hole sounds to me like a 10-plus out of ten right okay it's somehow you had the wherewithal to get the cat that's really pretty good right well she she she got my attention actually cuz she was okay meowing for food okay uh and then what happened to abort pay attention now what happened your arousal then when you got the cat I held her and have you thought about harming yourself yet and this is one thinking about killing myself killing yourself okay all right wasn't thinking about how I thought whether it was the long on that big or did you actually start judging yourself like you shouldn't feel this way it's your own fault or not I felt like I wanted I'm never gonna have it and I don't deserve it hopelessness okay I don't do so that sounds awful maybe just a tiny little tiny okay okay okay yeah yeah you know what if you had what do you could have done differently right there I grabbed my cat that's great that's great but but but with the judgment piece remember we talked about mindfulness you've had a little mindfulness in group now what could you have done differently with that I don't deserve it part you're pushing me and I think that's a good thing that's good cuz that's what I'm best at it doesn't feel so annoying right now um but I'm having trouble answering it oh no that's okay sure of course I mean I guess can i is it okay if I give you an idea I'm asking you I think if you just notice that saying I don't deserve it as a judgement just knowing it's a judgment might allow you to let go of it a little bit that's the judgment it is a judgment right because we're kind of committed here to leaving the judgments behind whenever we can in that the bonus here like the major bonus rocket ship out of the black hole might have been how about this it makes sense that I feel like right now because I'm not getting what I want I don't know about that one when I came back home judgmental okay well that's that's a good start but maybe you couldn't but what if you could have said that would that be worth us practicing so that a month from now you could do that would that make a difference my hands getting kind of tired yeah this is a lot this is a lot all right let's just start with the judgment one do you think you could do that yeah okay what do you think we could do this week to help you practice the judgment part I don't know believe you could think I with my cats okay let's have the cats after you notice the judgment okay so let's try this how about how many times a day you're willing to practice this you're willing to practice once in the morning once in the afternoon once in the evening - okay morning afternoon or evening which ones or it doesn't matter you just do it at least twice morning and evening okay how about if you just practice heavier can you set your give up like a smartphone or yeah something like that can you set it yeah you can do all kinds of alarm can you set it to that any time that you want to go off two times a day and then when it goes off you just kind of notice what judgments you might have been having lately we'll look especially for the I don't deserve something Part C we not when I'm having a black hole or what let's practice an easier situation first SPO an alarm I thought well it's like you learned to ride a bicycle on flat ground no that goes are you okay yeah I mean obviously here in the black lawyer excellent but obviously if if you are in the black hole and you can get yourself to remember this that would be fantastic I'll set it for 10 a.m. and 7 p.m. yes Jay I could put a message on it great but I don't know what um notice the judgment and go play with the cat okay how's that sound all right now we're just about out of time I wonder if you could just run through and we could fill out these things for right now okay so your urges to kill yourself right now what are they three okay that's good that's lower urges to use drugs like a three also I went down that's good well I didn't put my urges to quit therapy put you on it yeah what am i or just to fire you good for you you got you got it perfect what so what are what number is this real zero zero chance well no I can't say it's zero point zero zero zero zero one because I could get hit by a truck or something that's not firing you that's quitting that's different well your intention is it to get hit my attention is zero yeah so you're as a zero in mine in terms of wanting to quit I see it's like a 1 but then in terms of not wanting you to fire me as a 7 yeah I'll make that a 4.5 absolutely perfect great okay and how miserable you feeling right now hi alright that's done that's great and what about just really connected to me like I'm getting it the highest suspend so far and great 7 okay perfect okay all right it could get stuck with any of this stuff call me send me an email okay and I'll remind you I'm going to add to my phone notice judgment include cats coaching call if helpful perfect sounds great okay save time next week yeah I'll see you then thank you

Channel: NEA BPD

Views: 124,068

Keywords: NEA.BPD

Id: nFwAiO22g4Y

Length: 31min 47sec (1907 seconds)

Published: Mon Dec 10 2012