Psychiatric Interview: BPD (Borderline Personality Disorder) | Part 3 | Analysis with Dr. Jacob

this is essentially the debrief of the session with charlotte that karen did yes what were some of the things that sort of stood out to you in the interview that you were surprised about when you read the feedback or maybe not surprised about or intrigued by you know i thought it was really interesting because i think that having this forum where you um put on the internet put on youtube a therapy session and then allowed people sort of unfettered opportunity to comment about their own thoughts and feelings i thought that was actually really important because at the end of the day therapy is a very individual endeavor and there is something relevant about the match between a therapist and their patient and what constitutes that match becomes really important in addition people come to therapy because usually they either see that they have a problem they're noticing something or somebody else says hey i'm worried about you i look at that first session as a really important opportunity to sort of give that person the floor without interruption so they can organically tell their story and that's particularly important when i've worked with folks who have a diagnosis of personality disorders and i say plural because it's a question mark sometimes people come in thinking they're struggling with one thing and maybe that's the case but it may not be the full picture and without stepping back and giving that person sort of the floor without intervention um sometimes you may miss something or steer the session in a particular way thus shifting the dialogue and so to me actually that first session is really important like when we've been talking about that session and some of the comments which talked about how you did not validate i did not and so that i and that i was you know i'm like like she didn't you know it's not all about validation and you know validation's gonna get you maybe standing next to each other which is not a small thing but it ain't i don't think it's gonna get you better like i don't think it's the road to recovery i feel like um people with this diagnosis perhaps over value the therapeutic effect that validation can have to the exclusion of challenge and so for me i get frustrated when i just hear validation validation validation yeah i mean i think you and i would both agree that validation is important i mean it's one of these sort of ingredients that when somebody really feels like somebody understands them which can occur through validation it's a window to then look at some of the challenging parts of whatever is emerging in that moment you know one of the things marsha lenahan would say is without validation it's hard to sort of confront and then push for change and there's some real utility in that i think the challenge is that validation can become um the center piece of therapy where people feel really supported and of course that's important in therapy but at the expense of pushing to sort of see change and when people come into treatment life isn't going so well usually so there's an element that they're really saying this is not working for me at some level and therefore they want to see some change the other thing about validation is when you sort of validate i think this is one of the comments actually um and just it's like an empty oh i understand moment it actually can feel really invalidating so part of that like first session is trying to step back to allow that person's story to unfold so you really get a sense of what's going on for them i think there was one part when i actually went back to watch it but right before you put it on youtube i noticed charlotte was talking about her dad and feeling very sad about the events that transpired right before his passing and you know my heartstrings were pulled and i noticed my tendency to sit back and the kind of thing that was going on in my mind was understanding the larger framework of her situation she might have felt really sort of sad and grieving the loss of somebody so important and based on her description of her family there may have been other things going on for her so if i were to rush in and validate i might have inadvertently not allowed for any other emotion that might have organically existed that she might not feel and you know i'm not in charlotte's mind i don't know but might not have felt sort of the freedom whether it was at that point or at some other later point should she pursue other therapy to be feel like it was okay to actually talk about like anger or disappointment so it really can inadvertently sort of shape what what i or some other therapist may be conveying of what's okay what's not okay what's justified what's not rather than letting her story just be her story and really understanding her story from her lens so it really is important to sort of like sort of sit back and give somebody that space you know there was one time also where she mentioned how she was drinking and she blacked out and it felt when i was watching it it felt like you knew something was coming well you know the way she described some of her substance use um it was clear she was really uncertain whether she saw it as really a problem so trying to understand what substances serve for her what function it served how it was integrated in her life right now whether there were problems that either she reported or somebody else who loved her reported sort of gives us both a shared context to better understand i might imagine i wonder what's gone on with substances for her in the past or even in the present um but when somebody is really in that place where they're uncertain they're not really sure that this is a problem for them to kind of push them in a direction becomes like an agenda that i'm imposing rather than again organically something she sees as not in line with the kinds of relationships she wants or the way she might want to respond to thoughts feelings um or other you know obstacles in life i was trying to sort of understand and clarify exactly what role substances played and sort of introduced some what i looked at is a little bit of a contradiction for her that on the one hand she didn't see it as a problem on the other hand she'd black out and not remember things so there was a lot going on that i just really wanted to learn about in a first session and whether that became the centerpiece would in part depend on how she sort of navigated those two sides how she could make sense of both i guess one of the things you're probably looking for when you're doing even a first-time interview or consultation is like where is this where is conflict you know when people come into a first session um i would say there's some conflict there's some conflict whether it's an internal conflict or whether it's between two people you know parents worried about their child friends worried about their close friend a partner worried about their significant other but when that person that you're sitting with doesn't see anything wrong with what they're doing there's no motivation to change it's very hard to be motivated and one of the things that i often see is people will change if there's sort of contingency management which would be like um somebody coming to a residential program because family requires them to they won't financially support them otherwise or the many other reasons that families really impose that requirement that's a motivator somebody is saying to themselves okay i'll do this thing because it's there are some contingencies attached the problem is if that therapy remains sort of managed by these contingencies and it doesn't get sort of internalized there's no internal motivation when you take the external away say that residential treatment um there's very little motivation to continue making changes so when you're sitting with somebody for a first interview it's really important to think about like where is this person's is there any internal friction any internal conflict between like how they're feeling or their values and what they're doing with their lives and it's important to be able to sort of not only pick up on that but then represent it back to the person sometimes people are not even aware of how much conflict there is internally within them the point of a first therapy session isn't to sort of in indulge in that aspect to outline that conflict it's to really assess is there any at the very end of my session with charlotte i started asking a little more about some of the areas where there might be conflict because i thought she both really wants to have stable relationships in her life and then she ends up using substances in a way that disrupts some of that stability so those two things are going to have a hard time going together so it sort of introduces both sides and it offers her an opportunity to really grapple there's some friction there where she now can say to herself is this uncomfortable enough for me to want to do something about it and that's i think a really important thing that therapy can address over the long haul not often in the first session that's just sort of an area to probe and better understand have people surprise you with their coming in and being minimally aware of any kind of conflict if that you know and then they've become much more internally conflicted right or isn't that also called like ego dystonic when something becomes ego dystonic you and i have had conversations about this issue of um when something's dystonic which is a representation of internal friction or internal conflict and that is such an important part of a motivator to change without which if something doesn't bother you like why change it you know there's really you can sort of continue as you are unless somebody else says to you i can't tolerate this therein lies at least some friction or conflict it really offers an important opportunity to then gain some internal motivation and that's part of therapy is to be able to sort of see those contradictions and offer back to a person so they can work through that conflict and feel more aligned with whether it's their values or the way they see themself somebody doesn't see themselves as judgmental for example but they're often very critical of other people or themselves that doesn't sit well when they want to ascribe to this version of themselves and yet what they see unfolding is something really different again that's longer term therapy and that first session allows a framework to better understand but have you seen people come in who are minimally conflicted but end up doing pretty well i have there's a lot of work that has to happen in order for somebody to really see the contradictions or the conflicts so they can become an active participant in this process you don't want to like drag somebody through therapy yeah no you know if i were to meet with somebody and they really were not ready to engage in therapy i might say you know it sounds like there's something you want to change but you're not really quite sure you're invested in addressing some of these problems which is very understandable it's incredibly you know painful at times to address emotions that people often spend a lot of energy avoiding um and what i often say to people is why don't you give this some thought and come back you know i'm available come back when you're interested in working on some of these problems because it's going to be painful therapy i think people have the idea that people feel so much better after therapy and i'm not trying to dis therapy by any means when you're addressing some of these core issues it's actually very painful and can be very distressing so it's kind of like you sometimes feel worse in fact most of the time you feel worse before you feel better and when people are on the fence really ambivalent about whether they want to actually confront some of these long-standing often long-standing issues therapy can be [Music] not that helpful actually if the goal is to really change if that's the goal and that's something that's really important to assess like what's the goal of the therapy would you have said that to charlotte or would you do you think she was you know there was enough conflict you mean where is there enough conflict that it would warrant continued therapy i i actually robbie would have asked her first at the very end of the session what happened was she brought up anger and what it said to me is there's a lot of emotion that she experiences but can barely tolerate and so pushes to the side and she's developed some pretty effective strategies for that moment they're just not really long-term solutions so i probably would have met with her again and then sat down and really talked to her about these areas of her world that seem to be going well because she's done a lot of work and then areas where there's still some unresolved feelings and thoughts and her sort of ways of engaging the world are not really necessarily in line with what she says she wants for herself and i would have sat with her and talked to her about that and asked her if it's something she wanted to work on and if she did i think she actually would be able to make very good use of therapy but if she wasn't ready i would have said you know if these things become a bigger issue for you come back and sometimes people need to have more life experience before they want to take the time and energy and really painstaking effort to address some of these internal problems you know you would mention this thing called like a working alliance inventory and again i think this gets to the conversation around validation and also pain and you know for people who are looking to find a therapist you know and and there was other thing of sort of who's who's right for you the person seeking therapy when so um you know what is a working alliance inventory so we were taught you when you and i were talking about sort of validation and um match there were some comments i think that people made in response to the interview you know when i was younger i looked for this kind of therapist that worked or it didn't work there's really important data out there about what constitutes a match what are you mashed on is it theoretical orientation i think my problems were based and rooted in my childhood do i go to a therapist that really is oriented perhaps in a psychodynamic mind frame you know is it based on other characteristics about the therapist i'm going to see am i looking for somebody who's more supportive versus change-oriented who's going to push me and challenge me so those are all things that people sort of maybe don't are not even aware of but they're that are present when they enter into this kind of relationship the person that i know that's done significant research is um this guy named horvath he developed something called the working alliance inventory and what he describes the alliances being is the affective bond between the patient and the therapist an agreement of the tasks of therapy like what we're going to do here and the goals and those three things are actually really important when aligned in predicting not only the strength of the alliance but then how the alliance then impacts things like the process and outcome of of therapy it's not necessarily the therapist who's the nicest or the most validating or most supportive you know i've been stuck in therapy that i think was not good and it took me way too long to get out yeah which is very understandable yes it's all understandable it's just shitty when you're five years in and you're like wow it's getting worse you know i'll say a little bit about john gunderson who is my mentor and um one of the things that he would say is assuming you're in a change-oriented therapy with somebody who's struggling with borderline that behavioral change should happen within about three months maybe three to six months but i would say about three months where somebody stops cutting or self-harming if you look at mary zanarini's research usually people over the course of two years you really see significant change and so if therapy is continuing for years and years and years especially with this orientation you really need to sort of rethink what's happening in the therapy and it's always helpful to get an independent consult that's one of the things i would say have somebody else weigh in do you mean for the therapist to get an independent consult or for the patient for the process that person's job is to look at the dynamic and the treatment from a sort of neutral standpoint with the patient's best interest at heart so if the patient's having a really hard time and feeling maybe angry at the therapist is that anger a result of confronting some long-standing issues that that person doesn't want to think about that actually may be an important part of the process to that the person has to work through which is very different than either feeling like the therapy is not moving it's unchanged it's painful without any kind of light at the end of the tunnel you don't see where it's going really [Music] that's a different story the response by a consultant maybe change the kind of you know dialogue that's happening whether that's a theoretical orientation change the therapist take a break have somebody intervene i mean there are a lot of different options that one can entertain but staying in a therapy where you don't see change for years and years is a tragedy it really is a tragedy and getting a consultation i find always unbelievably helpful the the patient's best interest is the purpose of a therapeutic process you know there's plenty of therapists out there that are not you know that i don't trust you know that the patient is their best interest over their own need to feel that they are doing a good job or that they haven't failed one of the things you did beautifully was you interviewed john a couple of years ago and i think one of the things you asked him was what makes a good therapist for people who struggle with bpd what he describes is somebody who has sort of enough internal sort of fortitude that it's not so much about them in the process of helping somebody struggle with some of these internal long-standing deep-seated pains it's not rainbows and roses and often as somebody who's really invested in the process with somebody you're in this very intense relationship where when you confront some of these issues or maybe you're the person putting some of those issues on the table it's not often met with appreciation and love um and it can be very hard for not only that person to look at but the therapist to bring up and if you're overly concerned with being liked it makes it even harder to bring up what you know is going to be a hard topic it would be a lot easier for me to ignore some things about a process that i might see quite relevant that the person needs to address or might benefit from addressing it would probably make my life a lot easier it doesn't necessarily help somebody confront things they'd so much prefer to avoid we all have tactics that we avoid everybody that's not that's not a pathology it's being human something's too painful hard to think about but when so many aspects of life are painful and you're somebody who's super sensitive to your own emotions people develop phenomenally skillful ways to not think about something part of the therapist's job is to actually be in it with them to help them think about those very things that are tough which by definition does not make you the most popular person in the room and that's something i've signed up for as part of doing this what i can tell you is that having seen people go through a process that's pretty transformative um the reason i do this is to sort of see that person get their life reclaim their life in a way that they really want to see their life reclaimed um and so it's worth it at the end of the day even though the pain is i would say significant for both parties at times in terms of the pain that you the therapist sort of endure as you're walking through this process with a client you know how do you like keep yourself um alive i mean that's so that is a that's a big question um and having done this for so many years um i think it's twofold one is i there's really no other reason i would want to do this work than to participate in a process where somebody has felt unable to realize aspects of their life that are significant and um to be able to walk with them in a process where they can do that it's kind of like when you have a child there's a lot of pain in having the child and then there's the sort of aftermath of seeing the joys of that experience and i feel like working with the intensity of folks that i work with you get those really difficult moments you also get those really joyful experiences that you can share together and sort of makes it really worth it it's also from this is from my perspective couldn't be more important to have loved ones of one's own who are just sort of present and sort of stably there in one's own life

Channel: BorderlinerNotes

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Id: EQKj0fS2mAA

Length: 25min 26sec (1526 seconds)

Published: Tue Mar 16 2021