Marsha Linehan session 1 part 3

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but this treatment might work how to give it a chance you think you can think so since you need to write them down do you think he helps to write it down okay mm-hmm okay okay all right so that's the end of that session [Applause] so we thought what we do before we had question answers we would just fast forward this to about how far maybe ten fifty to a couple of months and what happens is that we she's a person who well you know before we do that why don't we take questions on this okay because we don't have that much time okay the thing about this session that was ordinarily I would have a longer session in first session so I would do more a little bit more work on what her problem was and ordinarily I would have also just I wouldn't in this session because of the suicidal problem but in the next session I would go through with her why had her previous therapist kicked her out what led to that and is she going to do the same things to me but in this particular session what we do in the first session is generally work with the client who's suicidal on making sure that we get an actual commitment to stay alive for a certain period of time and generally I would if not I stopped the session because of the time in here but I would have actually done more problem solving and troubleshooting on making sure that she was going to get through the week although she doesn't seem terribly suicidal right now and more than likely if she just attempted suicide a few weeks ago it's unlikely she's going to attempt again anytime soon because the the way it usually goes with a person with borderline personality disorder so it takes a while for anything to build back up again so you have sort of a honeymoon at the beginning so I would have thought I would thought and I'm on a honeymoon with her now for a while but not for very long possibly I'm not sure how much this looks like our treatment actually it's difficult we never role played before in our lives so but but you were very good client so I'm wondering if they're just questions about this comments on it questions yes I agree to the one month yeah no I got six months six months was trying one month with for sure that would be more than I could have possibly hoped for by getting a one month I'm sure of that I figured I was way ahead of the game and the depth the the commitment strategy there was during the face a year and then foot-in-the-door was six months we came down to six months and then I moved up to how long will you be sure of because all she was saying was I'll try so I didn't want to leave trying I didn't want to get trying so then I went up to well give me amount of time that you can be sure of that you won't do it an absolute which is a much different commitment and so then I got a month so I figured okay I mean I could have kept going and tried for more but that's really perfectly fine as long as I've got her alive next week that's really all I need and so I can use this for a while but so a month sure is much higher than six months maybe so that's really how that when I was going up and down yes I would have someone on call we make the commitment to call the therapist because the therapist and DBT the primary therapy is the only person they can call if they they can't really call any other therapists on the team and so if I'm not available someone else would be on call or she can wait until I get back to her but even if I'm sick I mean I'll get the page I'll have a page on for a week I don't not have patients so I'll know if I got a patch if I can't take it someone else will but I'm not expecting her to have trouble and there's from that session I would not expect any trouble in the next way she's - she's probably being apparently competent in the session but on the other hand the real ace is that she just did it and she's not saying she wished she died and she's still planning it she doesn't have tylenol but she did have the razor blades and so I got those in fact that she gave him to me there's not much more I could do with it this session yes yeah you blended back to her employer life scenes of the that problem she did sort of know I was doing some devil's advocate but it wasn't and what was really going on Ashley was a tape of a session what's going through my mind it's very difficult to do a role play when you've got a tape of something so similar in it so I gave a response that was more appropriate for the tape than it was for the actual role play here because on the tape that had work and so then I realized that I had to get out of this tape of a session and into the roleplay it was in and so that would be a devil's advocate and a devil's advocate would be why do you want to change and really throwing it out well why not kill yourself I mean you know and I thought of saying to her well you know if you decide not to kill yourself why would you decide that when you rather be in a therapy where you could kill yourself but with her I was pretty sure if I said that it would have you know she might have gone along with the program and said ok I will or she would have just said what she'd already said which was look I'm here I want to work with you I you're my one last chance and since I already knew all that to get her to say it again and she was sort of there you know client one note like each time it was you're the best and I missed my last chance and done it at that yes the word was the bomb but I really have written it for the 19 years to actually what she understands by having mannequins whether it really means anything to you Wow during myself as much as I concluded to patiently Eli I think because she kept going on and on about it and obviously took it much more seriously than like just say the words I won't kill myself okay or sign thing or whatever I mean it felt more serious to make like it was actually a job wonder whether this wall was actually said whether you really felt that she was signing a verbal commitment but we're not this has nothing to do with signing a commitment it has to do and we would never do a contract it has to do with strengthening committed behaviors and it has to do with eliciting of behavior reinforcing the behavior pushing the behavior and trying to strengthen it not with the idea that one has a commitment that you then carry with you after this it's more this notion of creating committed behavior creating the act of making commitments and verbal public committees commitments increase the probability that you'll do something and then the next week as you see I started it with okay you committed not to kill yourself and come in and here you did it that's really good it was hard you did it so I've now said okay you can make a commitment and do it and good thing you know I'll say good now next week I'll say the same thing and so one thing I'll start trying to do because all of us have to be able to be able to make a verbal commitment and then have behavior match it and so I mean that's how most of us get ourselves to do things that we don't want to do you know it's not hard at all to get yourself to do what you want to do it's really hard to get yourself to do it you don't want to do so DBT works a lot on committed behavior especially at the beginning but the second she calls me or does anything that sounds like she's going to kill herself I'll then say but I thought you agreed not to do that I mean that'll be the first thing out of my mouth wait a second you agreed not to do that and then rather than talk about whether we're going to kill ourselves - not now we'll talk about whether she's going to keep an agreement or not which becomes quite a different thing to be having a discussion about and it's one of the central problems with this group of people is that they make agreements day in and day out without keeping them yes see oh no I certainly would yeah yeah yeah I get paid less than treatment as usual therapist tip I get paid twice a week well see I get paid more by my therapist and I get paged by patients because my therapist clients all page them it all you get paged you get called a lot by your clients in crisis and you don't get caught so for the first six months of any severely suicidal person you'll either not get called at all or you'll get called a lot and then if you don't get caught it all you've got to make them call you if you get called too much you make them call you less and it takes you around six months to shape up clients not to do things you don't want them to do then you take another highly suicidal client and then you can keep a lot of them in your caseload but you can't take a whole bunch of them at once because at the first six months which I view is the part where you're trying to create behavior in the client that you can live with as a therapist and they're trying to create behavior in you that they can live with as a client so you know new clients page me a lot more yeah sorry if I hadn't been able to get that commitment I'm always asked that I've been asked that all my life you know I am 59 I've been working at this since I was 25 I have never in my life not gotten a commitment so I'll tell you you would get one now I may only get one tomorrow I know I call they call me I called them I may get it tomorrow I mean that's the shortest one I've ever gotten let's tell the next day and then I said okay that's fabulous good we've agreed you're alive till tomorrow I'll call you because ordinarily I would never take commitment to trying I do not consider trying the behavior that I'm trying to get you know I'm not interested particularly in trying behaviors those are not the behaviors I'm working on I'm working on this stay alive behaviors so I would never just accept trying and I've never not gotten it so I'm assuming everyone can get it I don't know if you ever not got I don't think my student I don't think any of us have ever not gotten it right yeah we give one way or another you get it do you want to do we were going to do another one for you for a couple of minutes so later on one so this client is you're gonna do CR right [Music] okay this is the she's the same client but now we find out that one of the reasons her clients therapists don't want her is that she has what we would call 100% of voidance behavior okay so I've already figured out that what goes on is that she'll come into a session and no matter what we're talking about she'll start distracting on to some other topic and that way she distracts usually is by attacking this but she could also attack by getting suicidal and saying she's gonna kill herself or that just made me suicidal okay so we're gonna come in and we're getting ready to start the session and I have her diary card and you'll see some of the questions that we ask on the diary card okay but I've we're gonna walk in we don't want to have me picking it up because that takes a while I'll pick it oh thanks I did get it okay so all right thanks jeepers god you had to really awful days Saturday and Sunday you've got fives on just about everything you've got fives on shame and fives on all right so listen just tell me before we get going let me get this okay so what's your urge to harm now harm yourself let's start with that okay what's your urge to quit therapy mmm what's yours to kill yourself okay urged to violence towards someone else okay okay so listen it's not a why earn-in on Sunday I can't tell did you hurt yourself on Sunday okay could you in the future try to make your why your ends your wise look more like wise and less I can't okay don't you see what is happening here I know but goddamn card well I just want to be sure I'm you're gonna hurt yourself what I just want to be sure that I know when you've hurt yourself okay so all right so you having a bad day yeah all right so and it sounds so we need to talk about this the fact that you hurt yourself and the fact that you have urges do it again and we need to also talk about the fact that you want to quit therapy would you stop doing that kind of interferes it's hard to hear when you do that hey thanks thanks would you mind opening the clock back again thank you okay so listen you have anything you want to talk about nothing else for you mm-hmm what do you want to talk about this self-injury first you want to talk about why you quit therapy first well what do you want to talk about first so am i doing that now yeah how well you got something else you want to talk about I just told you what no one talked about the rules of therapy you mean having to follow all my rules listen heaven okay well that's reasonable let's talk about that anything else okay so you want to quit therapy you harmed yourself by the way would you do where which one I don't know okay how deep I just want to know how much attention we had to put on I mean it was it a deep cut it was yeah did you go to the emergency room okay did you put a butterfly bandage on it I mean did you put the kind though that bring it together if it was really date yeah okay good let me see it I just wanted to see what it looks like so listen you want to talk about that first and what happened about the fact that I have rigid rules that you don't like or the fact that you want to quit there for anyway okay so you want to talk about my Richard yeah Marcia what none of this is working and all these little numbers and odd little papers are not doing anything do you understand me nothing do you want to talk about that first you want to talk about the fact that you hurt yourself [Applause] okay when do you really think that's true nothing's happening look at me is this why you want out work they know my girlfriend knew and she thinks I'm a mental patient listen listen Stacy we're gonna have to talk about that so listen let's focus on how if that happened listen Stacy you're ruining my furniture that's my new furniture well I just got it reupholstered well and you're gonna pull out all this red I can already tell you're doing it don't ruin my furniture thank you all right back to you listen we've got to talk about this because I didn't realize how serious this cot was and it sounds like part of the problem it's just that you're feeling demoralized or angry that it happened again all right so so when did this happen was it on one of these what day was right okay so that was Sunday it's not working norsu it's not looking so let's get back to talking about cutting yourself so my life is falling to pieces and you just want to do your little thing step by step by step got me to explain to you again why we want to do it would that be helpful no okay good why'd you cut yourself one all right were you carrying them with you yeah okay you know it's gonna be easier if you collaborate with me if you work with me don't you think if we can figure out if you end up cutting yourself don't you think that means that whatever problem set it off is serious enough that's really awful for your life that would be useful for us to try to figure out what the problem is totally totally is that what the problem was what what's the day on Sunday borderline I can't do anything I'm not worth anything no one needs to be with me where those thoughts going through your mind on Sunday yeah okay so one before you cut yourself thank you buddy now especially after talking to you okay well let's go back and figure it out let's figure out what the problem is listen Stacy sooner or later we got to figure out a different way to solve problems so why don't let's talk about what happened I told you I cut himself at work mm-hmm so what happened at work there's this guy and he has it like out for me like he knows is he notices like things about me and he like he just picks at me and picks at me and I was supposed to close like and it closed that was account with his customer and I'm slow and confused and I was messing it up and he's like what's wrong baby why did you do it like why would the tiny times like this whole long thing about like how stupid I was in front of the customer in front of everyone and I like he made me feel like about that high and then what you know so of course I reacted and then everything just got out of control so I had to do it okay so here at work it's on Sunday were you okay I said you're at this store yeah all right so how are we feeling that day I mean did you sleep the night before we attire to me mm-hmm so you hadn't slept much okay mm-hmm listen Stace you stay in the chair because we need to work on this working mm-hmm I realized it's difficult but let's try to figure it out cuz one way or another we got to come up with a new way to function at work listen put it back down don't leave let's figure this out okay now let's go back and figure out what the problem was that cutting was solving because cutting is always solving some problem so we need to do so that's what happened at work yeah was that following being criticized okay all right so how are you feeling though before you got criticized what I'm trying to figure out is were you just more vulnerable that day and so it hit you or are you were you having a good day and something serious happened the night before and you know I'm just thinking about how I'm working in the stockroom like I'm nowhere like where I used to be my life is all those thoughts are going through your mind yeah okay you know now did you do anything to try to distract yourself on those thoughts given that as we've discussed those thoughts are sort of the one-way road to being miserable were you practicing your distracting skills did you are you aware of them did you notice them oh yeah mm-hmm but I mean were you aware that you were so you notice the thoughts did you
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Channel: Damien Thellier
Views: 17,147
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Length: 26min 14sec (1574 seconds)
Published: Tue Jul 30 2019
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