WEBVTT 1 00:00:09.996 --> 00:00:12.588 - Good evening all of you. 2 00:00:12.588 --> 00:00:15.946 It is my pleasure to welcome all of you to the 3 00:00:15.946 --> 00:00:20.113 E. Diane Davis Memorial Lecture and the annual conference 4 00:00:21.061 --> 00:00:23.821 here at the School for Social Work. 5 00:00:23.821 --> 00:00:27.488 As I say to you every year annual conference 6 00:00:28.402 --> 00:00:32.502 is an incredibly important time for our field faculty, 7 00:00:32.502 --> 00:00:36.362 agency based supervisors, directors of training 8 00:00:36.362 --> 00:00:40.172 and students to come together to address the 9 00:00:40.172 --> 00:00:43.172 critically important issues facing social work 10 00:00:43.172 --> 00:00:45.678 practice and field education. 11 00:00:45.678 --> 00:00:49.586 And to plan for the training year ahead. 12 00:00:49.586 --> 00:00:51.975 We truly could not do this work without you 13 00:00:51.975 --> 00:00:54.422 and we're incredibly grateful for all that you offer 14 00:00:54.422 --> 00:00:56.755 our students and the school. 15 00:00:58.705 --> 00:01:02.672 I'd like to share just a bit with you about E. Diane Davis, 16 00:01:02.672 --> 00:01:06.284 in whose memory this lecture is given. 17 00:01:06.284 --> 00:01:10.367 Diane was a therapist, supervisor, administrator, 18 00:01:11.778 --> 00:01:15.778 consultant, teacher, advocate, mentor and friend 19 00:01:16.968 --> 00:01:19.894 of the Smith College School for Social Work, 20 00:01:19.894 --> 00:01:22.987 where she taught over the course of a decade 21 00:01:22.987 --> 00:01:26.665 a number of courses in our continuing ed program. 22 00:01:26.665 --> 00:01:29.653 Including a particularly popular course which 23 00:01:29.653 --> 00:01:32.914 she developed entitled the Developmental Origins 24 00:01:32.914 --> 00:01:34.497 of Psychopathology. 25 00:01:35.735 --> 00:01:38.598 Her connection with Smith College underlined her commitment 26 00:01:38.598 --> 00:01:42.192 to using a psycho-dynamic frame in understanding 27 00:01:42.192 --> 00:01:46.359 human behavior and she gave a great deal to the school. 28 00:01:47.574 --> 00:01:51.241 Diane died at the incredible early age of 46 29 00:01:52.234 --> 00:01:56.711 but in the years she had she gave an incredible amount 30 00:01:56.711 --> 00:01:58.780 and touched not only the professional lives 31 00:01:58.780 --> 00:02:01.350 but the personal lives of many. 32 00:02:01.350 --> 00:02:03.017 She's deeply missed. 33 00:02:04.589 --> 00:02:07.421 Let me now turn to the pleasure of introducing to you 34 00:02:07.421 --> 00:02:11.854 our keynote speaker for this evening, Dr. Charles Swenson. 35 00:02:11.854 --> 00:02:15.831 Dr. Swenson is an internationally known psychiatrist 36 00:02:15.831 --> 00:02:18.715 and an associate professor of clinical psychiatry 37 00:02:18.715 --> 00:02:21.777 at the University of Massachusetts Medical Center 38 00:02:21.777 --> 00:02:22.860 in Worcester. 39 00:02:23.701 --> 00:02:26.481 Dr. Swenson graduated from Harvard College 40 00:02:26.481 --> 00:02:28.988 and Yale University Medical School 41 00:02:28.988 --> 00:02:32.019 and then joined the faculty of Cornell University 42 00:02:32.019 --> 00:02:34.019 Medical College in 1982, 43 00:02:34.903 --> 00:02:37.933 where he directed a long term psychoanalytically 44 00:02:37.933 --> 00:02:41.555 oriented inpatient program for clients diagnosed with 45 00:02:41.555 --> 00:02:43.388 personality disorders. 46 00:02:45.078 --> 00:02:47.858 While at Cornell he served as a DBT trainer 47 00:02:47.858 --> 00:02:50.136 and consultant throughout the United States, 48 00:02:50.136 --> 00:02:54.294 Canada and Europe, coordinating state wide implementation 49 00:02:54.294 --> 00:02:59.080 of DBT in the public sectors at Illinois, Connecticut, 50 00:02:59.080 --> 00:03:03.824 Massachusetts and the Canadian province of New Brunswick. 51 00:03:03.824 --> 00:03:06.401 And was twice voted teacher of the year by the 52 00:03:06.401 --> 00:03:09.277 psychiatric residents at Cornell. 53 00:03:09.277 --> 00:03:12.579 Since 1987 Dr. Swenson has been involved in the 54 00:03:12.579 --> 00:03:16.496 development, direction or oversight of over 500 55 00:03:17.343 --> 00:03:21.795 inpatient, outpatient, residential and day treatment 56 00:03:21.795 --> 00:03:24.328 programs for clients diagnosed with 57 00:03:24.328 --> 00:03:26.915 Borderline Personality Disorders. 58 00:03:26.915 --> 00:03:29.439 He served for a number of years as the Area 59 00:03:29.439 --> 00:03:32.072 Medical Director for the Western Massachusetts area 60 00:03:32.072 --> 00:03:34.329 of the Department of Mental Health, 61 00:03:34.329 --> 00:03:37.464 overseeing clinical care in Western and Central Mass 62 00:03:37.464 --> 00:03:41.058 for the Department of Mental Health. 63 00:03:41.058 --> 00:03:43.984 Dr. Swenson has published widely on the treatment 64 00:03:43.984 --> 00:03:46.806 of borderline clients and has a new book called 65 00:03:46.806 --> 00:03:48.937 DBT Principles in Action, 66 00:03:48.937 --> 00:03:51.132 which was published just last week. 67 00:03:51.132 --> 00:03:53.786 We're very lucky to have gotten some copies of his 68 00:03:53.786 --> 00:03:56.795 brand new book and Dr. Swenson has graciously offered 69 00:03:56.795 --> 00:03:59.637 to stay after to answer your questions and sign 70 00:03:59.637 --> 00:04:03.804 some books if people are interested in purchasing them. 71 00:04:04.674 --> 00:04:07.941 Dr. Swenson is a highly regarded clinician, 72 00:04:07.941 --> 00:04:12.488 an accomplished writer and an inspiring teacher. 73 00:04:12.488 --> 00:04:15.309 I also know that he is known to write and perform 74 00:04:15.309 --> 00:04:18.193 songs about DBT, even he says, 75 00:04:18.193 --> 00:04:19.781 when they're not requested. 76 00:04:19.781 --> 00:04:23.792 So I'm eager to see what the rest of the evening holds. 77 00:04:23.792 --> 00:04:26.822 Please join me in welcoming Dr. Charles Swenson. 78 00:04:26.822 --> 00:04:29.822 (audience applauds) 79 00:04:40.657 --> 00:04:41.824 - Alright, hi. 80 00:04:43.520 --> 00:04:44.353 Welcome. 81 00:04:45.505 --> 00:04:46.922 Yeah I'll have to 82 00:04:49.144 --> 00:04:52.122 see if the conditions are right for a song later. 83 00:04:52.122 --> 00:04:53.146 (audience laughter) 84 00:04:53.146 --> 00:04:56.795 My big challenge is to get going, I have one hour 85 00:04:56.795 --> 00:05:00.045 to tell you everything, which is a lot. 86 00:05:02.751 --> 00:05:04.834 I am grateful to be here. 87 00:05:06.414 --> 00:05:09.758 I've done a number of things with the Social Work School, 88 00:05:09.758 --> 00:05:12.099 some summer teaching and this year I'll be teaching 89 00:05:12.099 --> 00:05:16.759 in their masters program a little bit about DBT. 90 00:05:16.759 --> 00:05:20.418 So I'm grateful that I have this opportunity to come 91 00:05:20.418 --> 00:05:24.976 and I was miked up for an interview this afternoon, 92 00:05:24.976 --> 00:05:27.693 they're gonna put that on their website. 93 00:05:27.693 --> 00:05:30.730 And I'm gonna put it on a website that I just started 94 00:05:30.730 --> 00:05:33.397 two days ago, charlieswenson.com 95 00:05:34.470 --> 00:05:35.724 if you want to find that. 96 00:05:35.724 --> 00:05:39.131 And I'm grateful to them for inviting me to teach 97 00:05:39.131 --> 00:05:41.848 in the summer, it's been a long haul, 98 00:05:41.848 --> 00:05:44.021 I've been living in this town for 19 years, 99 00:05:44.021 --> 00:05:46.320 I've been pretty reasonably well known in the DBT world 100 00:05:46.320 --> 00:05:48.953 and I've always wondered why the Social Work School 101 00:05:48.953 --> 00:05:53.258 didn't ask someone who lives down the street to teach DBT. 102 00:05:53.258 --> 00:05:55.432 But it's because they weren't ready yet. 103 00:05:55.432 --> 00:05:57.751 You know and there's a time for everything and this year 104 00:05:57.751 --> 00:06:00.573 I'm being asked to do this so it's pretty cool. 105 00:06:00.573 --> 00:06:01.994 I'm pretty happy about that. 106 00:06:01.994 --> 00:06:05.379 And also for them to be willing to do a kind of 107 00:06:05.379 --> 00:06:06.462 a book event. 108 00:06:07.636 --> 00:06:10.896 So after we finish tonight I'll just hang around 109 00:06:10.896 --> 00:06:14.646 and sign books and or talk and or sing songs, 110 00:06:16.893 --> 00:06:18.453 whatever it will be. 111 00:06:18.453 --> 00:06:21.024 And so it's nice to be here and I want to thank 112 00:06:21.024 --> 00:06:25.024 all of you for coming out on a hot Friday night. 113 00:06:26.416 --> 00:06:27.249 Okay. 114 00:06:29.404 --> 00:06:32.267 Could we get to the first, whatever it is, the 115 00:06:32.267 --> 00:06:33.934 second, first slide. 116 00:06:34.913 --> 00:06:37.734 Let me tell you where this comes from, 117 00:06:37.734 --> 00:06:41.538 I've been doing DBT since I learned about it in 1987, 118 00:06:41.538 --> 00:06:44.705 1988 and started developing it in 1989 119 00:06:45.550 --> 00:06:48.831 and since then have been practicing DBT, 120 00:06:48.831 --> 00:06:51.297 supervising it, consulting about it and doing 121 00:06:51.297 --> 00:06:54.766 a lot of implementations and trainings. 122 00:06:54.766 --> 00:06:57.914 So I've adapted DBT to lots of situations 123 00:06:57.914 --> 00:07:01.954 and what you learn when you adapt the same thing, 124 00:07:01.954 --> 00:07:05.235 the same basic thing to so many situations 125 00:07:05.235 --> 00:07:07.972 is that you learn it pretty well. 126 00:07:07.972 --> 00:07:09.853 You learn the principles of it because you have to be 127 00:07:09.853 --> 00:07:12.549 flexible, so you learn the difference between the 128 00:07:12.549 --> 00:07:15.966 trappings of it and the principles of it. 129 00:07:17.272 --> 00:07:19.237 The other thing that got me going in this direction 130 00:07:19.237 --> 00:07:21.682 to look at the principles and take them so seriously 131 00:07:21.682 --> 00:07:24.148 is that this is a treatment model, 132 00:07:24.148 --> 00:07:26.279 whether you know this or not about it. 133 00:07:26.279 --> 00:07:27.705 Some of you are probably very informed 134 00:07:27.705 --> 00:07:29.113 and some of you not. 135 00:07:29.113 --> 00:07:32.547 There's more than 85 treatment strategies, 136 00:07:32.547 --> 00:07:35.305 there's more than a hundred skills, 137 00:07:35.305 --> 00:07:37.479 there's many protocols, 138 00:07:37.479 --> 00:07:40.029 such as the suicidal crisis protocol 139 00:07:40.029 --> 00:07:42.202 if somebody's in a suicidal crisis. 140 00:07:42.202 --> 00:07:44.804 And just how to do this and how to do that protocols. 141 00:07:44.804 --> 00:07:48.273 In other words it's like a very large cookbook 142 00:07:48.273 --> 00:07:51.324 of strategies and skills and all kinds of explanations 143 00:07:51.324 --> 00:07:53.241 about when to use them. 144 00:07:54.647 --> 00:07:56.528 And you're treating people that are really 145 00:07:56.528 --> 00:07:59.182 difficult to treat, borderline personality disorder 146 00:07:59.182 --> 00:08:03.424 and other people with severe chronic dis-regulation 147 00:08:03.424 --> 00:08:04.424 of emotions. 148 00:08:05.263 --> 00:08:08.085 So to put a really complex treatment with so many 149 00:08:08.085 --> 00:08:12.252 alternatives in place, in minute number three and a half 150 00:08:13.351 --> 00:08:17.564 of a session when some surprising thing comes up 151 00:08:17.564 --> 00:08:19.424 and you find yourself thinking, 152 00:08:19.424 --> 00:08:24.126 hmmm which of the 85 plus strategies should I use now? 153 00:08:24.126 --> 00:08:26.381 You know it's done already, you're already done, 154 00:08:26.381 --> 00:08:28.868 you're already cooked, I mean like its over. 155 00:08:28.868 --> 00:08:32.463 And same with what skills should I teach? 156 00:08:32.463 --> 00:08:36.475 Let's see and it's done so I realize that it's 157 00:08:36.475 --> 00:08:38.649 one of the challenging things about this highly 158 00:08:38.649 --> 00:08:40.780 evidence based treatment, 159 00:08:40.780 --> 00:08:44.270 supported by more than 20 randomized control trials 160 00:08:44.270 --> 00:08:48.095 which is pretty good for a psychotherapy. 161 00:08:48.095 --> 00:08:50.916 This problem that even though there's evidence for the 162 00:08:50.916 --> 00:08:53.311 treatment as a whole there's no evidence for what 163 00:08:53.311 --> 00:08:55.394 you do in any one minute. 164 00:08:56.655 --> 00:08:59.351 There's no evidence when you do one of the standard 165 00:08:59.351 --> 00:09:02.383 things in DBT which is to review a diary card with the 166 00:09:02.383 --> 00:09:07.138 patient about their week, a self monitoring instrument. 167 00:09:07.138 --> 00:09:09.227 There's nothing that tells you which of the one million 168 00:09:09.227 --> 00:09:10.727 ways to review it. 169 00:09:11.923 --> 00:09:13.825 There's a lot of suggestions but actually it might make 170 00:09:13.825 --> 00:09:17.641 a ton of difference whether you review it with compassion, 171 00:09:17.641 --> 00:09:21.403 sympathy, whether you review it in a pushy way 172 00:09:21.403 --> 00:09:24.391 that's kind of like factual and objective. 173 00:09:24.391 --> 00:09:26.962 Everything in between or whether you don't even review 174 00:09:26.962 --> 00:09:29.700 it at all on a given week, you know it's sort of like 175 00:09:29.700 --> 00:09:30.736 how do you know? 176 00:09:30.736 --> 00:09:33.808 So you realize there's this paradox when you have 177 00:09:33.808 --> 00:09:37.006 evidence based treatments that are driven by manuals. 178 00:09:37.006 --> 00:09:39.367 That there's evidence for the manualized treatment 179 00:09:39.367 --> 00:09:40.878 but there's no evidence for what to do at 180 00:09:40.878 --> 00:09:42.295 any given moment. 181 00:09:43.156 --> 00:09:45.518 Or how to do it because there's so many ways to do 182 00:09:45.518 --> 00:09:48.394 things if you're a psychotherapist, right. 183 00:09:48.394 --> 00:09:50.797 I realized, wow so what do you do? 184 00:09:50.797 --> 00:09:52.594 How do you do the strategies? 185 00:09:52.594 --> 00:09:55.264 And what about in between the strategies 186 00:09:55.264 --> 00:09:58.358 because even if you have 85 strategies 187 00:09:58.358 --> 00:10:00.615 if you really add it up there's probably way more time 188 00:10:00.615 --> 00:10:02.865 in between using strategies 189 00:10:03.839 --> 00:10:05.720 then when you're actually saying something 190 00:10:05.720 --> 00:10:07.120 or using an intervention. 191 00:10:07.120 --> 00:10:09.984 What do you do during the in between times? 192 00:10:09.984 --> 00:10:12.387 I realize it's really not so easy to think of that. 193 00:10:12.387 --> 00:10:14.707 Then I realized, I remembered that my first learning 194 00:10:14.707 --> 00:10:17.707 from Marsha Linehan in the late 80's 195 00:10:19.158 --> 00:10:23.066 was that this is a principle based treatment 196 00:10:23.066 --> 00:10:24.592 with protocols. 197 00:10:24.592 --> 00:10:27.162 Protocols include skills, strategies 198 00:10:27.162 --> 00:10:31.028 and the kind of protocols I mentioned. 199 00:10:31.028 --> 00:10:33.208 Wow it's the principles you know, 200 00:10:33.208 --> 00:10:36.677 like in between the strategies the nuances 201 00:10:36.677 --> 00:10:40.502 of how to do the strategies, it's very helpful to know 202 00:10:40.502 --> 00:10:42.215 the principles. 203 00:10:42.215 --> 00:10:43.929 What are the principles? 204 00:10:43.929 --> 00:10:45.559 And you know I went to ton of training, 205 00:10:45.559 --> 00:10:48.401 I did a ton of training and we would usually teach 206 00:10:48.401 --> 00:10:52.984 the principles on Friday morning out of a five day workshop. 207 00:10:52.984 --> 00:10:56.453 I was really good at teaching the zen principles for DBT, 208 00:10:56.453 --> 00:10:58.669 which is really weird to be good at teaching zen 209 00:10:58.669 --> 00:11:01.636 since it's something you can't teach. 210 00:11:01.636 --> 00:11:05.317 And so you realize wow, I'm teaching these things 211 00:11:05.317 --> 00:11:09.845 in an hour and behavioral principles of behaviorism, 212 00:11:09.845 --> 00:11:11.369 wow do we really teach those? 213 00:11:11.369 --> 00:11:15.089 So I started to review and over the past four years 214 00:11:15.089 --> 00:11:18.265 I decided to really get clear about the principles 215 00:11:18.265 --> 00:11:20.905 that underlies a treatment. 216 00:11:20.905 --> 00:11:24.019 The principles out of which the strategies flow, 217 00:11:24.019 --> 00:11:26.652 the principles out of which the skills come 218 00:11:26.652 --> 00:11:28.637 and the principles that guide the therapist 219 00:11:28.637 --> 00:11:30.748 throughout the treatment and I thought, 220 00:11:30.748 --> 00:11:35.531 maybe if there aren't so many things to think about, 221 00:11:35.531 --> 00:11:38.520 you can make more decisive and efficient decisions 222 00:11:38.520 --> 00:11:42.407 in the middle of a tough situation to navigate. 223 00:11:42.407 --> 00:11:43.240 You know? 224 00:11:43.240 --> 00:11:45.805 And it turns out, really, there's only a choice 225 00:11:45.805 --> 00:11:47.958 of three directions to go. 226 00:11:47.958 --> 00:11:50.194 At any given moment in DBT, if you know what 227 00:11:50.194 --> 00:11:52.681 the principles are cause they're associated 228 00:11:52.681 --> 00:11:54.431 with three paradigms. 229 00:11:55.521 --> 00:11:57.903 You either go in the direction of pushing to change 230 00:11:57.903 --> 00:11:59.653 the patients behavior 231 00:12:00.766 --> 00:12:02.480 or in the direction of accepting the patient 232 00:12:02.480 --> 00:12:04.647 in the moment as they are. 233 00:12:05.866 --> 00:12:08.227 Or you go in the direction of dialectics 234 00:12:08.227 --> 00:12:12.121 which is more of an improvisation approach 235 00:12:12.121 --> 00:12:14.934 that has certain ingredients to it but it includes 236 00:12:14.934 --> 00:12:18.934 trying to synthesize the opposition in the room, 237 00:12:19.914 --> 00:12:20.747 somehow. 238 00:12:22.275 --> 00:12:24.031 And I thought, oh okay I just have to choose 239 00:12:24.031 --> 00:12:26.120 between acceptance, change, or dialectics, 240 00:12:26.120 --> 00:12:28.169 and you know I did that for a long time 241 00:12:28.169 --> 00:12:30.028 and I did in training, I did it in treatment, 242 00:12:30.028 --> 00:12:32.776 I find that I can actually do that 243 00:12:32.776 --> 00:12:35.200 and then if you already know these strategies 244 00:12:35.200 --> 00:12:38.423 when you do acceptance you start doing acceptance 245 00:12:38.423 --> 00:12:39.322 strategies. 246 00:12:39.322 --> 00:12:41.182 You don't even have to think of the strategies 247 00:12:41.182 --> 00:12:42.958 if you've already learned the strategy 248 00:12:42.958 --> 00:12:45.264 you just have to think acceptance. 249 00:12:45.264 --> 00:12:47.694 And then you're guided by your intuition 250 00:12:47.694 --> 00:12:50.611 along with you sort of over learned 251 00:12:52.701 --> 00:12:55.188 repertoire of strategies. 252 00:12:55.188 --> 00:12:57.040 So, what I want to share with you, what I shared 253 00:12:57.040 --> 00:12:59.151 in this book that I wrote which is called 254 00:12:59.151 --> 00:13:02.235 DBT Principles in Action: Acceptance, Change, 255 00:13:02.235 --> 00:13:05.056 and Dialectics, I want to share with you 256 00:13:05.056 --> 00:13:07.675 these three paradigms and the principles 257 00:13:07.675 --> 00:13:10.789 that I've articulated as being associated with each 258 00:13:10.789 --> 00:13:12.628 and let me tell you that I've articulated 259 00:13:12.628 --> 00:13:14.849 them means nothing about me, I mean I'm just sort 260 00:13:14.849 --> 00:13:17.253 of like borrowing from everybody else. 261 00:13:17.253 --> 00:13:21.161 And trying to extract what I think are really the most 262 00:13:21.161 --> 00:13:24.337 helpful way to put what the principle's are 263 00:13:24.337 --> 00:13:26.135 and I come up with five principles for each 264 00:13:26.135 --> 00:13:30.252 of the three paradigms and they're listed up here. 265 00:13:30.252 --> 00:13:32.049 One other thing about the way I've listed 266 00:13:32.049 --> 00:13:33.466 these principles. 267 00:13:34.626 --> 00:13:38.283 Not one of them is a DBT strategy. 268 00:13:38.283 --> 00:13:41.445 The names I've chosen for these principles 269 00:13:41.445 --> 00:13:44.956 are ordinary words, not all ordinary, 270 00:13:44.956 --> 00:13:48.613 but they're not localized within a therapy 271 00:13:48.613 --> 00:13:50.933 they're not localized within DBT, cognitive 272 00:13:50.933 --> 00:13:52.730 behavioral therapy, or anything else, 273 00:13:52.730 --> 00:13:56.241 they actually, I really reached for this 274 00:13:56.241 --> 00:13:58.603 because I wanted to come up with a framework 275 00:13:58.603 --> 00:14:01.570 of principles to identify that would not only 276 00:14:01.570 --> 00:14:02.653 speak to DBT. 277 00:14:05.875 --> 00:14:08.195 I've been so impressed with what Linehan did 278 00:14:08.195 --> 00:14:12.112 with her own personal suicidal life experience. 279 00:14:14.235 --> 00:14:16.680 It's such a moving story and I've been so impressed 280 00:14:16.680 --> 00:14:19.585 with what she did to turn it into a complex 281 00:14:19.585 --> 00:14:22.002 and evidence based treatment. 282 00:14:25.804 --> 00:14:28.019 I've realized that you might instead of just thinking 283 00:14:28.019 --> 00:14:31.635 of this as DBT if you really extract the principles, 284 00:14:31.635 --> 00:14:34.289 you might think of this as a set of principles 285 00:14:34.289 --> 00:14:36.289 for getting out of hell. 286 00:14:37.591 --> 00:14:39.973 And hell comes in so many forms. 287 00:14:39.973 --> 00:14:41.896 You might think in daily life that it's 288 00:14:41.896 --> 00:14:44.201 a set of principles that will help you when you get 289 00:14:44.201 --> 00:14:48.130 to dead ends in your life, raising kids, 290 00:14:48.130 --> 00:14:51.390 being in a relationship, trying to push yourself 291 00:14:51.390 --> 00:14:54.462 to the next level in an athletic performance, 292 00:14:54.462 --> 00:14:57.074 or an artistic performance. 293 00:14:57.074 --> 00:14:58.830 Trying to get out of the hell of just being 294 00:14:58.830 --> 00:15:01.714 alone cause you can't find anyone to be with. 295 00:15:01.714 --> 00:15:03.559 Trying to get out of the hell or deal with the 296 00:15:03.559 --> 00:15:05.670 dead end of being in a medical condition 297 00:15:05.670 --> 00:15:07.843 that's not getting better and is scaring 298 00:15:07.843 --> 00:15:09.367 the life out of you. 299 00:15:09.367 --> 00:15:11.206 All of these things, the hell of being 300 00:15:11.206 --> 00:15:14.541 a caregiver for somebody who's demented, 301 00:15:14.541 --> 00:15:17.028 who you've loved all your life, 302 00:15:17.028 --> 00:15:20.142 and it's another dead end, and it's really painful. 303 00:15:20.142 --> 00:15:22.113 And I've thought about these various situations 304 00:15:22.113 --> 00:15:23.492 and realized, you know what? 305 00:15:23.492 --> 00:15:25.609 These are pretty good principles, for a lot of these, 306 00:15:25.609 --> 00:15:26.709 I don't know how good I'm gonna I'm gonna be 307 00:15:26.709 --> 00:15:30.351 exploring this next, but I wanted to capture, 308 00:15:30.351 --> 00:15:33.172 not just that this is how you do DBT 309 00:15:33.172 --> 00:15:35.597 but also this is how maybe you face the dead ends 310 00:15:35.597 --> 00:15:38.048 in your life and also it might transfer over 311 00:15:38.048 --> 00:15:40.995 to other types of psychotherapy. 312 00:15:40.995 --> 00:15:42.694 So that my other types that I've learned, 313 00:15:42.694 --> 00:15:45.306 I started out in psychoanalytic training, 314 00:15:45.306 --> 00:15:47.145 learn psychoanalytic approach and then worked 315 00:15:47.145 --> 00:15:49.757 with Otto Kernberg for years in a psychoanalytic 316 00:15:49.757 --> 00:15:51.964 approach to borderline patients. 317 00:15:51.964 --> 00:15:53.887 I've been interested in family treatments 318 00:15:53.887 --> 00:15:56.938 and I've been interested and wrote an article about 319 00:15:56.938 --> 00:16:00.386 mentalization based therapy which I know less about 320 00:16:00.386 --> 00:16:03.659 but enough to write an article. 321 00:16:03.659 --> 00:16:06.669 If you're good at writing articles you can do this. 322 00:16:06.669 --> 00:16:10.639 But actually, now I get to know more and more about it 323 00:16:10.639 --> 00:16:13.592 but sort of like everyone of these things actually 324 00:16:13.592 --> 00:16:16.330 requires reference to all of these principles 325 00:16:16.330 --> 00:16:18.733 so I've been getting more interested in, you know, 326 00:16:18.733 --> 00:16:20.907 is this useful or is it not, 327 00:16:20.907 --> 00:16:24.042 if I write something for people to get out 328 00:16:24.042 --> 00:16:26.487 of dead ends is this just gonna be book number 329 00:16:26.487 --> 00:16:30.070 7,459 at an airport bookshop that tells you 330 00:16:31.398 --> 00:16:33.341 how to cope with you life? 331 00:16:33.341 --> 00:16:35.828 I mean or is there actually something unique because it 332 00:16:35.828 --> 00:16:37.680 comes from an evidence based treatment from a really 333 00:16:37.680 --> 00:16:41.985 smart woman who put together something that's 334 00:16:41.985 --> 00:16:44.785 for people to get out of hell and it really works. 335 00:16:44.785 --> 00:16:48.449 So, I wanna tell you about these, so lemme tell ya, 336 00:16:48.449 --> 00:16:50.643 what I'm gonna do just to forecast this now, 337 00:16:50.643 --> 00:16:53.945 I'm gonna tell you as concisely as I can, 338 00:16:53.945 --> 00:16:55.993 which is tough for me, that's the hardest thing 339 00:16:55.993 --> 00:16:58.773 about this whole talk for me tonight, is to try 340 00:16:58.773 --> 00:17:01.636 to do it in an hour, so I'm really gonna try 341 00:17:01.636 --> 00:17:03.983 to be concise, I'm gonna ask you not to ask any 342 00:17:03.983 --> 00:17:06.476 questions til the end, I'm gonna be trying to leave 343 00:17:06.476 --> 00:17:08.817 questions at the end, time for questions, 344 00:17:08.817 --> 00:17:10.286 and I wanna tell you about each of the three 345 00:17:10.286 --> 00:17:13.086 paradigms, each of the 15 principles briefly 346 00:17:13.086 --> 00:17:16.430 and then demonstrate, just a brief sampling 347 00:17:16.430 --> 00:17:20.631 of what it might look like by doing a brief, few minute 348 00:17:20.631 --> 00:17:23.881 role play after each set of principles. 349 00:17:25.611 --> 00:17:26.444 Okay. 350 00:17:26.444 --> 00:17:28.944 So let's go to the next slide. 351 00:17:31.663 --> 00:17:33.502 And this one I'll go through quickly because actually 352 00:17:33.502 --> 00:17:36.678 this slide is now broken out in the next five slides, 353 00:17:36.678 --> 00:17:40.587 this is just so you can see them for a minute. 354 00:17:40.587 --> 00:17:43.512 This set of principles is derived from cognitive 355 00:17:43.512 --> 00:17:46.146 behavioral therapy, which is really the original 356 00:17:46.146 --> 00:17:47.479 backbone of DBT. 357 00:17:48.403 --> 00:17:50.785 It's how do you solve problems behaviorally. 358 00:17:50.785 --> 00:17:53.035 How do you push for change. 359 00:17:54.066 --> 00:17:54.899 Alright? 360 00:17:56.741 --> 00:18:00.336 And what I've done in those parentheses, 361 00:18:00.336 --> 00:18:03.769 these are terms that belong to DBT, 362 00:18:03.769 --> 00:18:07.328 where you find these things, like direction, 363 00:18:07.328 --> 00:18:09.773 pushing for a certain specific direction 364 00:18:09.773 --> 00:18:13.190 in DBT is specified as treatment targets, 365 00:18:14.384 --> 00:18:17.581 there's primary targets, there's secondary targets 366 00:18:17.581 --> 00:18:21.301 and I'll look back at this at the next slide, 367 00:18:21.301 --> 00:18:24.582 and then there's force which is not a psychotherapy 368 00:18:24.582 --> 00:18:27.027 term it's more of a physics term but it's really 369 00:18:27.027 --> 00:18:29.130 captures that idea that if you're gonna go 370 00:18:29.130 --> 00:18:31.052 in a certain direction and if it really matters 371 00:18:31.052 --> 00:18:33.775 to you, you have to cultivate sufficient force 372 00:18:33.775 --> 00:18:34.858 to get there. 373 00:18:36.743 --> 00:18:40.484 You have to give it all, whatever it'll take 374 00:18:40.484 --> 00:18:44.496 and in DBT that's gonna be called commitment, 375 00:18:44.496 --> 00:18:46.816 commitment strategies and generating 376 00:18:46.816 --> 00:18:49.575 an attachment because a lot of time the only reason 377 00:18:49.575 --> 00:18:53.023 a patient does something in the first era of therapy 378 00:18:53.023 --> 00:18:56.659 is because they get attached to you or someone else. 379 00:18:56.659 --> 00:18:59.313 And then there's persistence which in DBT is represented 380 00:18:59.313 --> 00:19:03.445 by the fact that every night the patient monitors 381 00:19:03.445 --> 00:19:07.602 their progress on their target behaviors, 382 00:19:07.602 --> 00:19:10.548 their emotions, their skills, the things you're trying 383 00:19:10.548 --> 00:19:13.390 to do something about and every week brings that 384 00:19:13.390 --> 00:19:15.856 card in and reviews it with a therapist 385 00:19:15.856 --> 00:19:18.030 and one of the functions for that is to help 386 00:19:18.030 --> 00:19:20.280 both parties stay on track. 387 00:19:21.963 --> 00:19:23.865 It has lots of functions but a very important 388 00:19:23.865 --> 00:19:25.620 one is persistence. 389 00:19:25.620 --> 00:19:28.671 It's like you putting stars on your calendar 390 00:19:28.671 --> 00:19:30.977 because you did exercise again today or something 391 00:19:30.977 --> 00:19:31.810 like that. 392 00:19:32.732 --> 00:19:36.482 Then there's intelligence, which is a larger, 393 00:19:37.978 --> 00:19:41.948 important framework or principle within behavioral 394 00:19:41.948 --> 00:19:45.104 change that I'll get back to and in DBT it consists 395 00:19:45.104 --> 00:19:47.800 of three things, for those of you who know the treatment 396 00:19:47.800 --> 00:19:52.063 it's behavioral analysis which is a way of assessing 397 00:19:52.063 --> 00:19:56.932 the obstacles, case conceptualization which is a way 398 00:19:56.932 --> 00:20:01.718 to formulate the obstacles driven by the theory, 399 00:20:01.718 --> 00:20:05.474 the underlying theory, and treatment planning 400 00:20:05.474 --> 00:20:09.003 which is where you go from your case conceptualization 401 00:20:09.003 --> 00:20:11.010 in order to change the behavior. 402 00:20:11.010 --> 00:20:14.479 So this is kind of the intelligent part of DBT 403 00:20:14.479 --> 00:20:15.660 and you have to know all of these things 404 00:20:15.660 --> 00:20:18.487 and how they actually sort of, 405 00:20:18.487 --> 00:20:22.332 almost imperceptibly weave into each other. 406 00:20:22.332 --> 00:20:24.443 And finally you have to know the techniques, 407 00:20:24.443 --> 00:20:26.366 I mean you have to know how to do the strategies 408 00:20:26.366 --> 00:20:28.498 and stuff, so there's protocol, strategies know 409 00:20:28.498 --> 00:20:30.295 what the skills are. 410 00:20:30.295 --> 00:20:31.883 Next slide. 411 00:20:31.883 --> 00:20:34.800 So lets look at the direction part. 412 00:20:38.660 --> 00:20:43.175 So the agenda, this is where each of these things is, 413 00:20:43.175 --> 00:20:45.912 I mean I feel, I looked at this, I sat in the bathroom 414 00:20:45.912 --> 00:20:47.793 before I came out here tonight and I thought, 415 00:20:47.793 --> 00:20:49.012 I looked at these and I thought, 416 00:20:49.012 --> 00:20:51.812 Jesus Christ this is nothing I should just go home, 417 00:20:51.812 --> 00:20:53.902 I mean because they look so obvious 418 00:20:53.902 --> 00:20:56.786 but actually they're probably not, I just think they 419 00:20:56.786 --> 00:20:59.590 are because I've looked at 'em for four years. 420 00:20:59.590 --> 00:21:01.513 But you know this is really important, I mean, 421 00:21:01.513 --> 00:21:05.463 I find as a supervisor with people in DBT 422 00:21:05.463 --> 00:21:08.033 and other models of treatment that one of the main 423 00:21:08.033 --> 00:21:10.583 ways that therapists don't do very good job 424 00:21:10.583 --> 00:21:13.676 is they actually aren't very clear about their direction. 425 00:21:13.676 --> 00:21:14.972 They don't know what they're doing, 426 00:21:14.972 --> 00:21:16.539 they know what they're doing maybe but they don't 427 00:21:16.539 --> 00:21:20.223 know what they're trying to accomplish and so in DBT 428 00:21:20.223 --> 00:21:22.125 it's something that's very directional, 429 00:21:22.125 --> 00:21:24.131 it's very sequential, it's sort of linear, 430 00:21:24.131 --> 00:21:26.075 it's sort of like this. 431 00:21:26.075 --> 00:21:28.207 It's like we're getting from here to here. 432 00:21:28.207 --> 00:21:30.422 We're getting from cutting yourself to not cutting 433 00:21:30.422 --> 00:21:32.836 yourself which then will get you to where you 434 00:21:32.836 --> 00:21:35.740 can experience your anger and your shame 435 00:21:35.740 --> 00:21:37.809 without cutting yourself, now we'll get from 436 00:21:37.809 --> 00:21:40.380 having anger and shame that you can't manage 437 00:21:40.380 --> 00:21:43.285 to getting it down with more skillful techniques 438 00:21:43.285 --> 00:21:45.605 and now we gotta get to where we're gonna go over 439 00:21:45.605 --> 00:21:48.154 the trauma from your life that's really driving 440 00:21:48.154 --> 00:21:50.808 all of this and we're gonna have to get from where 441 00:21:50.808 --> 00:21:53.776 you experience traumatic cues in a way that's overwhelming 442 00:21:53.776 --> 00:21:56.409 and anguishing and we're gonna get to where you can 443 00:21:56.409 --> 00:21:58.652 experience traumatic cues 444 00:21:58.652 --> 00:22:00.652 without so much anguish. 445 00:22:01.598 --> 00:22:03.834 Alright, so there's step after step, 446 00:22:03.834 --> 00:22:05.903 but every step is directional and it's getting 447 00:22:05.903 --> 00:22:08.326 from here to here and that's important 448 00:22:08.326 --> 00:22:09.726 because the other two sets of principles 449 00:22:09.726 --> 00:22:12.380 have nothing to do with a sense of direction, 450 00:22:12.380 --> 00:22:14.022 this is the direction. 451 00:22:14.022 --> 00:22:17.991 This is the direction and getting to where you're 452 00:22:17.991 --> 00:22:21.251 going is the measure for whether the treatment works. 453 00:22:21.251 --> 00:22:24.407 It's the only one of the 15 principles that, 454 00:22:24.407 --> 00:22:26.490 in the long run, matters. 455 00:22:27.437 --> 00:22:30.112 But all the other 14 help you get there. 456 00:22:30.112 --> 00:22:33.581 So but you gotta have a direction and if your direction is, 457 00:22:33.581 --> 00:22:36.910 well I'm gonna work on my self cutting. 458 00:22:36.910 --> 00:22:39.993 That's not what I mean, that's vague. 459 00:22:40.902 --> 00:22:43.159 I'm gonna stop self cutting, alright when that's getting 460 00:22:43.159 --> 00:22:43.992 better. 461 00:22:45.318 --> 00:22:49.485 How bout stopping it starting this minute for one year. 462 00:22:50.960 --> 00:22:53.280 Oh well I can't do that, oh now you know that you've 463 00:22:53.280 --> 00:22:56.225 got a direction, I mean because now you've encountered 464 00:22:56.225 --> 00:22:58.147 trouble because it's actually gonna be hard, 465 00:22:58.147 --> 00:23:00.760 but if you don't have a specific direction, 466 00:23:00.760 --> 00:23:03.963 you don't get as far and there's research 467 00:23:03.963 --> 00:23:07.767 in psychotherapy research saying that what you target 468 00:23:07.767 --> 00:23:09.397 is what changes. 469 00:23:09.397 --> 00:23:11.529 Or what changes is what you target. 470 00:23:11.529 --> 00:23:14.007 If you don't target substance abuse it usually 471 00:23:14.007 --> 00:23:16.536 doesn't accidentally change while you're targeting 472 00:23:16.536 --> 00:23:18.402 something else. 473 00:23:18.402 --> 00:23:20.247 If you don't target an eating disorder it doesn't 474 00:23:20.247 --> 00:23:23.048 usually accidentally change until you name it 475 00:23:23.048 --> 00:23:25.451 and target it along with whatever else you're 476 00:23:25.451 --> 00:23:28.461 targeting, so this idea of having a direction 477 00:23:28.461 --> 00:23:31.658 and having it be specific and having it be public 478 00:23:31.658 --> 00:23:34.208 between the patient and the therapist and aiming 479 00:23:34.208 --> 00:23:36.569 for it and monitoring your progress towards it 480 00:23:36.569 --> 00:23:40.247 is something that in this model you want to be 481 00:23:40.247 --> 00:23:42.850 very deliberate about so that if I stopped 482 00:23:42.850 --> 00:23:44.335 a therapist in the middle of a session 483 00:23:44.335 --> 00:23:48.327 at any moment, and if I said to the therapist, 484 00:23:48.327 --> 00:23:52.130 let's stop right there, what are you targeting? 485 00:23:52.130 --> 00:23:53.627 What's your direction right now, what are you 486 00:23:53.627 --> 00:23:54.460 trying to do? 487 00:23:54.460 --> 00:23:58.043 And they say, "Well I was trying to target, 488 00:24:00.237 --> 00:24:02.828 "the self cutting of the patient but actually 489 00:24:02.828 --> 00:24:04.834 "she really didn't want to so now we're kinda 490 00:24:04.834 --> 00:24:07.834 "targeting her underlying feelings." 491 00:24:10.414 --> 00:24:13.340 But the person says, "I'm trying to target the overwhelming 492 00:24:13.340 --> 00:24:15.451 "anger she feels because that seems to be 493 00:24:15.451 --> 00:24:17.624 "the driving force for her self cutting." 494 00:24:17.624 --> 00:24:18.983 Alright I'll take that. 495 00:24:18.983 --> 00:24:22.993 You know that's a target towards the target. 496 00:24:22.993 --> 00:24:26.191 Their best targets, I think in DBT and I think in life 497 00:24:26.191 --> 00:24:29.024 in my sort of more grandiose self, 498 00:24:31.248 --> 00:24:34.153 should be clear and specific I just have done so much 499 00:24:34.153 --> 00:24:37.622 work with people that I say, okay what's the target? 500 00:24:37.622 --> 00:24:39.279 And we're already in trouble when they tell me 501 00:24:39.279 --> 00:24:42.581 what the target is, I wanna get a very, very specific 502 00:24:42.581 --> 00:24:46.343 target and it just helps you get places. 503 00:24:46.343 --> 00:24:49.332 It should be compelling to the person not just to you 504 00:24:49.332 --> 00:24:52.180 not just to the therapist and not just in the model. 505 00:24:52.180 --> 00:24:54.186 Stopping cutting for most people is not a very 506 00:24:54.186 --> 00:24:56.324 compelling target. 507 00:24:56.324 --> 00:24:58.838 Unless you link it to something else 508 00:24:58.838 --> 00:25:00.698 that results from stopping cutting. 509 00:25:00.698 --> 00:25:02.180 So you really have to figure out how to make 510 00:25:02.180 --> 00:25:04.291 a target compelling. 511 00:25:04.291 --> 00:25:06.840 You want it to be realistic so it's just not crazy 512 00:25:06.840 --> 00:25:08.554 and won't work. 513 00:25:08.554 --> 00:25:10.351 The person centered meaning it comes from 514 00:25:10.351 --> 00:25:12.086 the patient not from what you think the patient 515 00:25:12.086 --> 00:25:12.919 should do. 516 00:25:14.000 --> 00:25:16.550 Patient in my day program back in White Plains, 517 00:25:16.550 --> 00:25:19.050 New York, our DBT day program, 518 00:25:20.625 --> 00:25:24.073 that sat down at her girls group, 519 00:25:24.073 --> 00:25:26.015 with her fellow patients and her three female 520 00:25:26.015 --> 00:25:28.257 staff members, all of whom are really good at 521 00:25:28.257 --> 00:25:30.744 what they do, all of whom work really hard, 522 00:25:30.744 --> 00:25:34.318 all of whom also have lives that they have to keep up, 523 00:25:34.318 --> 00:25:36.901 working moms in a couple cases. 524 00:25:37.787 --> 00:25:40.838 And the patients they said, "So Kathy what would be 525 00:25:40.838 --> 00:25:42.292 "your goals?" 526 00:25:42.292 --> 00:25:45.789 She said, "Well I'd like to meet a very rich man 527 00:25:45.789 --> 00:25:48.088 "and marry him and take care of his house 528 00:25:48.088 --> 00:25:52.255 "and give parties, I'd love that, that would be great." 529 00:25:53.918 --> 00:25:55.841 And from what I heard from Kathy, 530 00:25:55.841 --> 00:25:58.474 I was her individual therapist, Kathy said 531 00:25:58.474 --> 00:25:59.860 then all the three women just sat there 532 00:25:59.860 --> 00:26:02.911 and looked at her for an extra few seconds 533 00:26:02.911 --> 00:26:06.903 then one of them said, "Well that's an interesting goal." 534 00:26:06.903 --> 00:26:08.909 And you could just tell all of them were like, 535 00:26:08.909 --> 00:26:11.709 but then somebody else said, "But in the meantime 536 00:26:11.709 --> 00:26:13.235 "don't you think we should work towards you 537 00:26:13.235 --> 00:26:15.017 "getting a job?" 538 00:26:15.017 --> 00:26:16.731 You know probably working towards getting a job 539 00:26:16.731 --> 00:26:18.946 was not gonna get her towards her goal as fast 540 00:26:18.946 --> 00:26:21.726 as actually working towards finding a rich man, 541 00:26:21.726 --> 00:26:24.004 I mean unless she changed her goal. 542 00:26:24.004 --> 00:26:26.177 So we were really trying, I mean but this 543 00:26:26.177 --> 00:26:28.392 was challenging, you know, people don't always 544 00:26:28.392 --> 00:26:31.172 target what you want them to target. 545 00:26:31.172 --> 00:26:33.178 And being collaborative so the target is shared 546 00:26:33.178 --> 00:26:34.570 between the two. 547 00:26:34.570 --> 00:26:36.305 Next slide. 548 00:26:36.305 --> 00:26:39.472 Now you need enough force to get going 549 00:26:40.692 --> 00:26:43.859 with your target and you can see here, 550 00:26:44.948 --> 00:26:48.382 you know, there's a lot of things I think that 551 00:26:48.382 --> 00:26:51.049 generate force in psychotherapy. 552 00:26:53.188 --> 00:26:55.220 Having a strong enough attachment, 553 00:26:55.220 --> 00:26:57.943 I think probably most people here are psychotherapists 554 00:26:57.943 --> 00:26:59.690 and you know if you have a very strong connection with 555 00:26:59.690 --> 00:27:02.941 a patient you can accomplish more behavioral progress 556 00:27:02.941 --> 00:27:07.930 in five minutes than in an hour if you don't have that. 557 00:27:07.930 --> 00:27:10.226 The effect of contingencies really laying out 558 00:27:10.226 --> 00:27:11.973 why would you do this or why would you wanna 559 00:27:11.973 --> 00:27:14.306 do this, is really critical. 560 00:27:15.848 --> 00:27:19.343 And structuring life to support whatever the targets are, 561 00:27:19.343 --> 00:27:23.937 you know if you're a teenager and you're targeting 562 00:27:23.937 --> 00:27:26.825 becoming more assertive, with a teenager that has 563 00:27:26.825 --> 00:27:29.365 been stepped on by everybody and doesn't speak 564 00:27:29.365 --> 00:27:33.532 up for herself in a family that's been kind of invalidating, 565 00:27:35.318 --> 00:27:37.654 you know and you have an environment that when she 566 00:27:37.654 --> 00:27:40.275 speaks up she gets smacked around or told 567 00:27:40.275 --> 00:27:43.445 that she's an idiot, is not gonna work. 568 00:27:43.445 --> 00:27:45.233 So you have to work on the family environment with 569 00:27:45.233 --> 00:27:48.074 that person, same with people who are in schools 570 00:27:48.074 --> 00:27:50.898 and people who have a certain friend who is going 571 00:27:50.898 --> 00:27:54.189 in the opposite direction of their treatment targets. 572 00:27:54.189 --> 00:27:57.420 And then in DBT there's six to seven commitment 573 00:27:57.420 --> 00:27:59.838 strategies that are very specific that you use to 574 00:27:59.838 --> 00:28:03.231 try to generate a stronger commitment. 575 00:28:03.231 --> 00:28:07.148 I had a patient that I spelled out the targets. 576 00:28:08.554 --> 00:28:11.460 She wanted to stop cutting herself, 577 00:28:11.460 --> 00:28:14.975 she was 16, she wanted to stop cutting herself 578 00:28:14.975 --> 00:28:16.417 and that's why she came into therapy, 579 00:28:16.417 --> 00:28:18.167 she also drank a lot. 580 00:28:19.506 --> 00:28:21.964 Drank a lot to the point where it was obvious to anyone 581 00:28:21.964 --> 00:28:25.357 but her that this was a big problem. 582 00:28:25.357 --> 00:28:27.612 Cause while she drank on the weekends she would end 583 00:28:27.612 --> 00:28:32.123 up at parties with people much older than her 584 00:28:32.123 --> 00:28:35.414 at a college and she'd wake up in the morning 585 00:28:35.414 --> 00:28:38.218 after blackouts and not know where she was sleeping 586 00:28:38.218 --> 00:28:41.533 and she'd be with some guy that she hated 587 00:28:41.533 --> 00:28:43.240 and her clothes would sometimes be ripped off 588 00:28:43.240 --> 00:28:45.820 and she was sometimes hurt, and she would come in 589 00:28:45.820 --> 00:28:47.811 and say but I don't want to stop drinking, 590 00:28:47.811 --> 00:28:50.879 I just wanna stop cutting myself, I think I'm a freak. 591 00:28:50.879 --> 00:28:54.008 So we spent a fair amount of time arguing, 592 00:28:54.008 --> 00:28:56.466 I guess would be the normal term for it, 593 00:28:56.466 --> 00:28:59.352 negotiating might sound better but we were kinda 594 00:28:59.352 --> 00:29:02.867 arguing about whether her alcohol was a problem 595 00:29:02.867 --> 00:29:05.284 and she just kept saying no and then she tried 596 00:29:05.284 --> 00:29:09.653 to convince me by saying, "But I love alcohol. 597 00:29:09.653 --> 00:29:11.644 "But I love it." 598 00:29:11.644 --> 00:29:13.818 I said, okay you love it, I mean what if you loved 599 00:29:13.818 --> 00:29:16.073 jumping off a cliff, and all these ordinary things 600 00:29:16.073 --> 00:29:20.133 that all of us idiots would say, I mean it's like, 601 00:29:20.133 --> 00:29:22.023 I'd just come up with the same things everybody 602 00:29:22.023 --> 00:29:24.095 comes up with and it doesn't work, you know, 603 00:29:24.095 --> 00:29:26.574 and she just says that, so I agreed since she 604 00:29:26.574 --> 00:29:28.728 had been thrown out of three prior therapies 605 00:29:28.728 --> 00:29:31.979 in the area, all three as it turns out when I called 606 00:29:31.979 --> 00:29:34.376 people was because she wouldn't stop drinking 607 00:29:34.376 --> 00:29:37.322 and they were afraid for her life. 608 00:29:37.322 --> 00:29:40.695 I agreed to work with her on the cutting as our target, 609 00:29:40.695 --> 00:29:43.174 like our 100% target, and that when we got that 610 00:29:43.174 --> 00:29:46.120 under control I'd work on her next target with her 611 00:29:46.120 --> 00:29:49.208 which she defined, and she defined it as 612 00:29:49.208 --> 00:29:51.707 doing stupid things. 613 00:29:51.707 --> 00:29:53.881 Doing stupid things meant she would do these things 614 00:29:53.881 --> 00:29:56.279 like end up in peoples rooms in a black out 615 00:29:56.279 --> 00:29:57.579 and then get hurt. 616 00:29:57.579 --> 00:29:59.245 She didn't want that part to happen she just wanted 617 00:29:59.245 --> 00:30:01.561 to have a good time at the party. 618 00:30:01.561 --> 00:30:03.817 So, she wanted to stop doing stupid things 619 00:30:03.817 --> 00:30:05.650 but not stop drinking. 620 00:30:06.682 --> 00:30:08.571 I told her I didn't know that we could do that 621 00:30:08.571 --> 00:30:10.643 cause I thought that drinking seemed to cause 622 00:30:10.643 --> 00:30:12.736 or create the condition but she said, no she didn't 623 00:30:12.736 --> 00:30:14.098 believe that. 624 00:30:14.098 --> 00:30:16.840 So, I said alright, then I will do that, 625 00:30:16.840 --> 00:30:19.705 if you can stop cutting, which she did instantly, 626 00:30:19.705 --> 00:30:22.631 and didn't do it again cause this was so exciting for her 627 00:30:22.631 --> 00:30:24.785 that we were gonna work on stopping doing stupid things, 628 00:30:24.785 --> 00:30:27.528 but allow her "to keep drinking", 629 00:30:27.528 --> 00:30:30.169 but I told her I would only do it if she would not drink 630 00:30:30.169 --> 00:30:33.054 when she was driving cause that scared me that she 631 00:30:33.054 --> 00:30:35.187 was gonna kill herself or somebody else. 632 00:30:35.187 --> 00:30:36.833 She agreed to that. 633 00:30:36.833 --> 00:30:39.753 And we created a little mini manual on how to stop 634 00:30:39.753 --> 00:30:43.634 doing stupid things when you drink, at parties, 635 00:30:43.634 --> 00:30:45.625 and it was like a two page manual that said 636 00:30:45.625 --> 00:30:47.291 what to do before you go to the party, 637 00:30:47.291 --> 00:30:49.424 what to do during the party, what to do if this happens, 638 00:30:49.424 --> 00:30:52.457 what to do if that happens, very behaviorally oriented, 639 00:30:52.457 --> 00:30:54.875 she really like working on this, and I had told her 640 00:30:54.875 --> 00:30:57.130 that if we did this for three months and it didn't help. 641 00:30:57.130 --> 00:30:59.040 I would quit with her. 642 00:30:59.040 --> 00:31:03.054 Because I would feel I couldn't continue in good conscience. 643 00:31:03.054 --> 00:31:06.610 So we worked on this and she liked this idea, 644 00:31:06.610 --> 00:31:09.860 in fact I told her if this worked we could both 645 00:31:09.860 --> 00:31:13.457 retire on this model by selling it to the world 646 00:31:13.457 --> 00:31:15.552 because so many people would wanna be able 647 00:31:15.552 --> 00:31:17.828 to do this, but she thought this was funny 648 00:31:17.828 --> 00:31:20.632 and we got going, and nothing changed in three months, 649 00:31:20.632 --> 00:31:23.476 three months came by and I said, we have to stop, 650 00:31:23.476 --> 00:31:25.894 and it sort of caught her by surprise, she was upset 651 00:31:25.894 --> 00:31:28.393 about it and then we stopped and she called me back 652 00:31:28.393 --> 00:31:31.393 in about one to two months and said, 653 00:31:32.558 --> 00:31:36.053 "Charlie I think I'm an alcoholic." 654 00:31:36.053 --> 00:31:37.760 I said, okay, why don't you come in and let's 655 00:31:37.760 --> 00:31:41.376 talk about that, and then we targeted her addictions. 656 00:31:41.376 --> 00:31:43.550 Which was not, turned out not just alcohol. 657 00:31:43.550 --> 00:31:46.415 So it's kinda like getting deliberate about your targets, 658 00:31:46.415 --> 00:31:49.381 negotiation your targets and needing to generate the force 659 00:31:49.381 --> 00:31:51.373 and realize if you don't have the force 660 00:31:51.373 --> 00:31:55.123 it's almost pointless to really generate much 661 00:31:56.301 --> 00:31:58.881 problem solving interventions, you actually don't have 662 00:31:58.881 --> 00:31:59.714 a partner. 663 00:32:02.451 --> 00:32:05.275 Next slide, persistence. 664 00:32:05.275 --> 00:32:08.648 So this is sort of, getting persistence over time 665 00:32:08.648 --> 00:32:12.926 of both the direction you have and the force 666 00:32:12.926 --> 00:32:15.579 which really, you know, I don't know about you 667 00:32:15.579 --> 00:32:18.098 in your treatments or your supervisions but I supervise 668 00:32:18.098 --> 00:32:20.943 a lot of people and sometimes I find myself doing it 669 00:32:20.943 --> 00:32:22.792 that I think I was working on one thing 670 00:32:22.792 --> 00:32:25.433 and next thing I know I've drifted off on to 671 00:32:25.433 --> 00:32:27.598 something else and it's sort of like how do we get here 672 00:32:27.598 --> 00:32:30.463 or, and sometimes it's just cause we couldn't make 673 00:32:30.463 --> 00:32:32.028 progress on the first one. 674 00:32:32.028 --> 00:32:35.990 And so we move on and by doing that, it's not 675 00:32:35.990 --> 00:32:40.256 a behavioral model, behaviorists line up the targets, 676 00:32:40.256 --> 00:32:42.390 let's say you have four problems, OCD, 677 00:32:42.390 --> 00:32:46.067 and you have panic disorder, and you have self cutting 678 00:32:46.067 --> 00:32:48.363 and you have something else, you line them up in order 679 00:32:48.363 --> 00:32:51.514 of priority and you tackle the highest priority one 680 00:32:51.514 --> 00:32:52.681 for 100%. 681 00:32:53.860 --> 00:32:55.688 Doesn't mean you never mention the other ones 682 00:32:55.688 --> 00:32:58.492 but you go with the first on for 100% which sometimes 683 00:32:58.492 --> 00:33:02.657 is really difficult cause the others are laying in wait, 684 00:33:02.657 --> 00:33:04.405 they're still happening. 685 00:33:04.405 --> 00:33:06.010 But you don't give up on the first one cause 686 00:33:06.010 --> 00:33:08.459 it takes so much sometimes trial and error 687 00:33:08.459 --> 00:33:10.918 to finally find something that makes the difference 688 00:33:10.918 --> 00:33:13.693 on the first one so that's a behavioral way that 689 00:33:13.693 --> 00:33:15.553 you treat targets which is very different than 690 00:33:15.553 --> 00:33:18.012 psycho dynamically where you can sort of talk about 691 00:33:18.012 --> 00:33:19.901 what ever story's going on and you kinda see 692 00:33:19.901 --> 00:33:22.685 the underpittings of all four, and you're trying 693 00:33:22.685 --> 00:33:24.818 to get at something that's under the surface. 694 00:33:24.818 --> 00:33:27.967 Behavioral, no, we're trying to stop number one. 695 00:33:27.967 --> 00:33:30.792 And then we'll go on to number two. 696 00:33:30.792 --> 00:33:32.823 And the pressure builds sometimes. 697 00:33:32.823 --> 00:33:36.990 So you use this diary card and you use the monitoring. 698 00:33:40.738 --> 00:33:42.973 You know and sometimes I've had college students 699 00:33:42.973 --> 00:33:45.859 in this area that have a great start and I feel like 700 00:33:45.859 --> 00:33:49.942 I'm doing good direction, good force, and we got 701 00:33:49.942 --> 00:33:53.539 persistence going, and it starts in September, 702 00:33:53.539 --> 00:33:55.733 then the patient comes in and she's written down 703 00:33:55.733 --> 00:33:57.704 all of her courses and what her schedule is 704 00:33:57.704 --> 00:33:59.980 and she's very excited cause she feels organized 705 00:33:59.980 --> 00:34:03.494 this time, and her ADHD as far as she's concerned 706 00:34:03.494 --> 00:34:07.416 has gone away and now she's gonna make it, 707 00:34:07.416 --> 00:34:09.874 and then November comes and she starts to write 708 00:34:09.874 --> 00:34:12.739 her professors asking for extensions, 709 00:34:12.739 --> 00:34:14.405 and then you know you're in big trouble. 710 00:34:14.405 --> 00:34:18.408 Like it's drifted and you took your eye off the ball 711 00:34:18.408 --> 00:34:20.648 and I take my eye off the ball cause it's really 712 00:34:20.648 --> 00:34:22.944 hard to keep your eye on the ball with something 713 00:34:22.944 --> 00:34:25.037 that's a student who's figuring out, because they always 714 00:34:25.037 --> 00:34:27.739 have some reason to explain why they can't stay 715 00:34:27.739 --> 00:34:29.663 on something and next thing you know they're in 716 00:34:29.663 --> 00:34:33.158 a hospital in the end of November. 717 00:34:33.158 --> 00:34:36.491 So you've gotta work on the persistence. 718 00:34:40.527 --> 00:34:42.194 Alright, next slide. 719 00:34:44.936 --> 00:34:46.765 The intelligence. 720 00:34:46.765 --> 00:34:50.442 So as it says at the top, you do need direction, 721 00:34:50.442 --> 00:34:53.287 I think, you do need sufficient force which is sometimes 722 00:34:53.287 --> 00:34:56.131 a lot more than what you were thinking. 723 00:34:56.131 --> 00:34:59.030 And you need persistence and to build that into 724 00:34:59.030 --> 00:35:01.286 the relationship or the treatment. 725 00:35:01.286 --> 00:35:04.049 And it's not sufficient because then you still run 726 00:35:04.049 --> 00:35:07.909 in to obstacles, and when you run in to obstacles, 727 00:35:07.909 --> 00:35:09.514 what do you do, then? 728 00:35:09.514 --> 00:35:12.704 You could just double the force, 729 00:35:12.704 --> 00:35:14.350 you could just strengthen the direction 730 00:35:14.350 --> 00:35:15.874 but actually you might still find out, 731 00:35:15.874 --> 00:35:18.660 no that just doesn't do it, just end up in a war 732 00:35:18.660 --> 00:35:20.245 with your patient. 733 00:35:20.245 --> 00:35:22.216 And so you actually have to step back 734 00:35:22.216 --> 00:35:24.126 and both go, hmm. 735 00:35:24.126 --> 00:35:26.787 What is the problem, what are we gonna do here? 736 00:35:26.787 --> 00:35:29.205 And you have to have a model for coping with that, 737 00:35:29.205 --> 00:35:32.009 when I learned object relations theory with Kernberg, 738 00:35:32.009 --> 00:35:34.264 there was a whole way of thinking of how you formulate 739 00:35:34.264 --> 00:35:37.271 this situation that has to do with identifying 740 00:35:37.271 --> 00:35:39.222 underlying object relations, and affects, 741 00:35:39.222 --> 00:35:40.908 and splitting, and so on. 742 00:35:40.908 --> 00:35:44.121 You know with a behavioral model, you have to have 743 00:35:44.121 --> 00:35:46.368 some way to conceptualize what's going on 744 00:35:46.368 --> 00:35:50.247 and the way you start that is what, for those of you 745 00:35:50.247 --> 00:35:53.844 who don't know DBT at all, you do a behavioral analysis, 746 00:35:53.844 --> 00:35:57.277 a link by link analysis of what led up to the problem 747 00:35:57.277 --> 00:36:01.361 behavior, and that becomes your template and everything 748 00:36:01.361 --> 00:36:04.766 comes out on the chain, eventually, if you stick to 749 00:36:04.766 --> 00:36:06.351 the chain. 750 00:36:06.351 --> 00:36:09.768 And doing the chain is so central to DBT, 751 00:36:13.096 --> 00:36:16.835 in more depth ways then I first encountered, 752 00:36:16.835 --> 00:36:19.009 literally everything that I can think of in DBT 753 00:36:19.009 --> 00:36:21.386 is on that chain so if you keep going through 754 00:36:21.386 --> 00:36:24.779 the chain you find everything, you find the invalidating 755 00:36:24.779 --> 00:36:27.014 environment on the chain, you find the person 756 00:36:27.014 --> 00:36:29.434 who has biological vulnerabilities. 757 00:36:29.434 --> 00:36:32.055 You find the trauma on the chain and you find these 758 00:36:32.055 --> 00:36:34.717 lack of skills on the chain, so you just keep going 759 00:36:34.717 --> 00:36:37.176 through the chain and looking for what is 760 00:36:37.176 --> 00:36:38.496 the problem here? 761 00:36:38.496 --> 00:36:41.246 Why cannot we get this to change? 762 00:36:43.027 --> 00:36:45.221 With one patient it was that she just wouldn't 763 00:36:45.221 --> 00:36:47.924 stop substance abuse, she just wouldn't stop, 764 00:36:47.924 --> 00:36:50.626 she just wouldn't stop it and then she would say 765 00:36:50.626 --> 00:36:51.997 she was and then she'd change her mind, 766 00:36:51.997 --> 00:36:53.667 she wouldn't stop it. 767 00:36:53.667 --> 00:36:57.122 So push, push, push, stay with the chain, 768 00:36:57.122 --> 00:36:59.499 stay with the chain. 769 00:36:59.499 --> 00:37:01.470 Hey, you have to show persistence as a therapist 770 00:37:01.470 --> 00:37:04.598 yourself cause this is your target. 771 00:37:04.598 --> 00:37:07.118 And then you find, in this case for instance, 772 00:37:07.118 --> 00:37:10.133 that this person actually couldn't stop 773 00:37:10.133 --> 00:37:13.634 substance abuse, because as she had explained, 774 00:37:13.634 --> 00:37:16.384 she was better when she was high. 775 00:37:18.124 --> 00:37:20.115 Well I said, of course, I mean what do you mean, 776 00:37:20.115 --> 00:37:22.513 I mean of course you're better when you're high, 777 00:37:22.513 --> 00:37:23.366 in many ways. 778 00:37:23.366 --> 00:37:27.218 "No, no, no you're not getting it, my husband 779 00:37:27.218 --> 00:37:30.265 "likes me better when I'm high." 780 00:37:30.265 --> 00:37:32.968 Oh your husband, and so he knows about this? 781 00:37:32.968 --> 00:37:35.304 She says, "No, no, no he doesn't know it's because I'm 782 00:37:35.304 --> 00:37:37.957 "using substance, he thinks it's the normal me. 783 00:37:37.957 --> 00:37:42.124 "So I need to keep doing this with, you know because," 784 00:37:43.890 --> 00:37:46.511 (audience laughing) 785 00:37:46.511 --> 00:37:49.886 If I need water I know where it is. 786 00:37:49.886 --> 00:37:54.458 Yeah, so I said so why don't you bring you husband in? 787 00:37:54.458 --> 00:37:57.404 "Oh no, he can't know that this is why I'm better 788 00:37:57.404 --> 00:37:59.253 "then he won't want to be with me cause of my normal 789 00:37:59.253 --> 00:38:03.459 "self is pretty boring, you know he wouldn't like me." 790 00:38:03.459 --> 00:38:06.344 I said okay, and then I learned that he's a doctor 791 00:38:06.344 --> 00:38:09.635 and he's the one who writes for the medicines 792 00:38:09.635 --> 00:38:12.932 that she's on that get her high, but he thinks it's 793 00:38:12.932 --> 00:38:15.776 doing it because of pain and somehow he's getting 794 00:38:15.776 --> 00:38:18.032 away with doing it cause as I know with my own family 795 00:38:18.032 --> 00:38:20.470 I can't write those kind of medicines for my own family, 796 00:38:20.470 --> 00:38:23.883 unless I say it's for my dog or somebody else, 797 00:38:23.883 --> 00:38:24.716 you know. 798 00:38:25.773 --> 00:38:29.247 So, then you find out by push, push, push, 799 00:38:29.247 --> 00:38:31.320 chain, chain, chain, link, link, link 800 00:38:31.320 --> 00:38:34.245 and then you run into oh that's it, now you know what 801 00:38:34.245 --> 00:38:37.273 to do but you have to have a method and in DBT 802 00:38:37.273 --> 00:38:39.319 that is the method and I use it all the time 803 00:38:39.319 --> 00:38:41.797 and it's finding the missing link, 804 00:38:41.797 --> 00:38:44.967 it's finding the hot link, it's finding the thing 805 00:38:44.967 --> 00:38:46.560 that you never noticed. 806 00:38:46.560 --> 00:38:49.097 With the patient of mine that had severe PTSD 807 00:38:49.097 --> 00:38:52.504 after one year after she had been raped 808 00:38:52.504 --> 00:38:55.837 at Hotel Northampton by her best friend, 809 00:38:57.015 --> 00:39:00.515 who she had gone to hotels with for years. 810 00:39:01.810 --> 00:39:05.977 They went out to a bar which they had always done, 811 00:39:06.930 --> 00:39:10.628 they went into the hotel, they went in the room, 812 00:39:10.628 --> 00:39:12.863 and she was half asleep he got in the bed 813 00:39:12.863 --> 00:39:17.048 and raped her and she, a year later after one thing 814 00:39:17.048 --> 00:39:20.543 after another shut down and she just became more 815 00:39:20.543 --> 00:39:23.428 depressed, more suicidal, more avoidant, she had quit 816 00:39:23.428 --> 00:39:27.817 her really good IT job and she had stayed in her apartment 817 00:39:27.817 --> 00:39:31.149 and she got a lot of locks on the door. 818 00:39:31.149 --> 00:39:32.022 Alright. 819 00:39:32.022 --> 00:39:36.330 So, I'm thinking, oh I know why this happened, 820 00:39:36.330 --> 00:39:41.084 so I go over the link by link analysis of that night 821 00:39:41.084 --> 00:39:44.376 and find out, no, you know what after about five times 822 00:39:44.376 --> 00:39:47.911 through the same story, link by link, 823 00:39:47.911 --> 00:39:50.715 I found a link I didn't know before and it was the 824 00:39:50.715 --> 00:39:53.681 most important link of all and it wasn't the big one 825 00:39:53.681 --> 00:39:55.672 that you would think, that she was penetrated 826 00:39:55.672 --> 00:39:58.673 by him when she's half asleep, and it totally freaked 827 00:39:58.673 --> 00:40:01.294 her out and made her panic, no it actually was something 828 00:40:01.294 --> 00:40:04.794 else, on the way in the door to the hotel, 829 00:40:06.435 --> 00:40:08.365 as she told it the fifth time, 830 00:40:08.365 --> 00:40:09.198 "Oh yeah," 831 00:40:09.198 --> 00:40:11.639 cause I started asking more microscopically, 832 00:40:11.639 --> 00:40:13.752 what happened then? 833 00:40:13.752 --> 00:40:15.580 She said, "Well then as we were going in the door 834 00:40:15.580 --> 00:40:18.854 "there was something weird that happened but it was nothing, 835 00:40:18.854 --> 00:40:20.723 "I went in the door first and he put his hand 836 00:40:20.723 --> 00:40:23.202 "on my back of my neck, like an ordinary person 837 00:40:23.202 --> 00:40:24.775 "would do it's just that he had never done 838 00:40:24.775 --> 00:40:26.278 "that sort of thing. 839 00:40:26.278 --> 00:40:28.229 "And then I went in the room and we close the door 840 00:40:28.229 --> 00:40:29.854 "and that was it. 841 00:40:29.854 --> 00:40:31.236 "And I got in the room and I thought, God that 842 00:40:31.236 --> 00:40:32.236 "was weird." 843 00:40:33.717 --> 00:40:37.395 But then she filed it away and later it was because 844 00:40:37.395 --> 00:40:40.219 she didn't pay attention to that link, 845 00:40:40.219 --> 00:40:42.799 not that she should have but she didn't pay attention 846 00:40:42.799 --> 00:40:46.328 is the reason she felt she's always in danger 847 00:40:46.328 --> 00:40:48.340 because she can no longer interpret the potential 848 00:40:48.340 --> 00:40:50.859 that danger could happen, it wasn't that danger 849 00:40:50.859 --> 00:40:54.153 did happen as much as the fact that she missed the cue 850 00:40:54.153 --> 00:40:58.278 cause she prided herself in singles bars 851 00:40:58.278 --> 00:41:02.037 for years as being a very assertive, very effective, 852 00:41:02.037 --> 00:41:04.495 she could see danger coming a mile a way 853 00:41:04.495 --> 00:41:07.177 and tell people off and so this blew it, you know? 854 00:41:07.177 --> 00:41:09.432 But you don't find this out unless you sort of realize 855 00:41:09.432 --> 00:41:12.643 okay I have a method lemme just use the method 856 00:41:12.643 --> 00:41:15.264 and then keep doing it until you find what the link is. 857 00:41:15.264 --> 00:41:17.925 Which can be really frustrating cause you wanna 858 00:41:17.925 --> 00:41:21.217 move on and you realize you haven't found it. 859 00:41:21.217 --> 00:41:23.310 And the only reason you stick with it is because 860 00:41:23.310 --> 00:41:25.829 that's what the treatment says to do. 861 00:41:25.829 --> 00:41:27.962 And even that I wouldn't stick with sometimes 862 00:41:27.962 --> 00:41:30.371 unless I had a supervisor and I was doing one with 863 00:41:30.371 --> 00:41:32.762 Marsha Linehan as my supervisor. 864 00:41:32.762 --> 00:41:34.681 Came to Marsha and I said, Marsha, I cannot do 865 00:41:34.681 --> 00:41:37.282 one more chain analysis on hair pulling 866 00:41:37.282 --> 00:41:39.700 with this woman, nothing is changing, 867 00:41:39.700 --> 00:41:41.955 she pulls her hair all the time, I mean it's 868 00:41:41.955 --> 00:41:44.048 trichotillomania, it's really, you know, 869 00:41:44.048 --> 00:41:48.680 and I said, I think we need to move onto another target. 870 00:41:48.680 --> 00:41:51.200 And Linehan said then, which I thought was part of 871 00:41:51.200 --> 00:41:54.044 her rigidity at the time and later I came to think 872 00:41:54.044 --> 00:41:56.381 this is why she's so good. 873 00:41:56.381 --> 00:41:58.331 She said, "Well, what can I tell you, Charlie, 874 00:41:58.331 --> 00:42:01.562 "it might be better to move on but it wouldn't be DBT. 875 00:42:01.562 --> 00:42:03.898 "And I'm trying to teach you DBT so if you're doing DBT, 876 00:42:03.898 --> 00:42:07.393 "no you take the highest target, highest priority 877 00:42:07.393 --> 00:42:09.100 target and you do chain analysis." 878 00:42:09.100 --> 00:42:10.766 She said, "you know what the problem is, 879 00:42:10.766 --> 00:42:12.626 "you're missing something. 880 00:42:12.626 --> 00:42:16.164 "You're just missing something, open your eyes." 881 00:42:16.164 --> 00:42:18.704 She said, "It can't be different every time, 882 00:42:18.704 --> 00:42:20.980 it can't be the same every time. 883 00:42:20.980 --> 00:42:23.235 "Nothing's the same for more than one instant 884 00:42:23.235 --> 00:42:27.441 "in reality, at any level, so she's totally different 885 00:42:27.441 --> 00:42:30.366 "every week, and you're totally different. 886 00:42:30.366 --> 00:42:33.475 "Open your eyes, just wait, look, watch." 887 00:42:33.475 --> 00:42:35.426 Pretty soon I did find something. 888 00:42:35.426 --> 00:42:36.523 Probably come back to it. 889 00:42:36.523 --> 00:42:39.977 And then you have a door opens and then you have 890 00:42:39.977 --> 00:42:42.252 to have a way to formulate it and then build it 891 00:42:42.252 --> 00:42:44.752 into your treatment plan to do something about it 892 00:42:44.752 --> 00:42:47.596 with this woman, I really had to start to work with her, 893 00:42:47.596 --> 00:42:50.705 not on her fear of danger happening, but her fear that 894 00:42:50.705 --> 00:42:53.956 she couldn't recognize danger and that led to sort of 895 00:42:53.956 --> 00:42:56.353 a different pathway of working with her. 896 00:42:56.353 --> 00:42:58.710 Next slide, final slide on this. 897 00:42:58.710 --> 00:43:01.940 This is sort of an obvious one, I mean I just thought, 898 00:43:01.940 --> 00:43:04.399 what's the other thing you really need in addition 899 00:43:04.399 --> 00:43:06.309 to these four things, you need to be able to do 900 00:43:06.309 --> 00:43:08.849 the technique, if you're gonna be treating anxiety 901 00:43:08.849 --> 00:43:10.982 disorders you need to be able in behaviorism 902 00:43:10.982 --> 00:43:14.477 to do exposure and response prevention. 903 00:43:14.477 --> 00:43:16.305 You need to be able to do skills training 904 00:43:16.305 --> 00:43:19.333 and skills training and do cognitive restructuring 905 00:43:19.333 --> 00:43:21.486 if you're working on people's cognition, 906 00:43:21.486 --> 00:43:23.599 so it's kinda like you just have to hold yourself 907 00:43:23.599 --> 00:43:26.342 to the fire about learning these things 908 00:43:26.342 --> 00:43:29.634 and then there they are for you when you need them. 909 00:43:29.634 --> 00:43:32.173 Now I wanna do the first role play and I know I'm probably 910 00:43:32.173 --> 00:43:36.756 behind on time but I wanna invite Matthew Munich 911 00:43:36.756 --> 00:43:40.698 who is a supervisor of students in the social work 912 00:43:40.698 --> 00:43:44.660 school, he was a social work student here himself, 913 00:43:44.660 --> 00:43:47.327 I've known Matt since he was 15. 914 00:43:48.236 --> 00:43:51.142 So it's fun to have him do this. 915 00:43:51.142 --> 00:43:54.311 We started playing golf together when he was 15 916 00:43:54.311 --> 00:43:56.810 and his dad and I and he would play. 917 00:43:56.810 --> 00:43:58.192 Come on up. 918 00:43:58.192 --> 00:44:00.406 (crowd laughing) 919 00:44:00.406 --> 00:44:02.865 And he doesn't want me to say any of this stuff. 920 00:44:02.865 --> 00:44:06.121 So anyway, so he's agreed to be a 17 year old 921 00:44:06.121 --> 00:44:08.871 teenage boy in treatment with me. 922 00:44:09.799 --> 00:44:11.587 And here's the problem, cause we're only gonna 923 00:44:11.587 --> 00:44:14.289 go for five or six minutes and I wanna demonstrate 924 00:44:14.289 --> 00:44:18.456 how it might look if I was only doing these things 925 00:44:19.389 --> 00:44:21.807 as opposed to the other principles. 926 00:44:21.807 --> 00:44:23.960 I'm only doing these things which is what Linehan 927 00:44:23.960 --> 00:44:27.049 did at the beginning of trying to develop DBT 928 00:44:27.049 --> 00:44:29.466 and she found it didn't work. 929 00:44:30.471 --> 00:44:34.910 So, here's a situation, in DBT you need to be in 930 00:44:34.910 --> 00:44:38.743 individual therapy and a skills training group 931 00:44:40.153 --> 00:44:43.261 and like many patients, Matt, or actually 932 00:44:43.261 --> 00:44:46.715 he's gonna be Jacob, I learned today, 933 00:44:46.715 --> 00:44:51.267 Jacob doesn't like being in skills training groups. 934 00:44:51.267 --> 00:44:54.261 He just wants to be in individual therapy with me. 935 00:44:54.261 --> 00:44:57.004 We've met a few times, I was supposed to force 936 00:44:57.004 --> 00:44:59.971 him in the group the first week but I kinda let 937 00:44:59.971 --> 00:45:02.510 it go cause I was sympathetic to him and he really 938 00:45:02.510 --> 00:45:04.249 didn't want to go into group, I thought, 939 00:45:04.249 --> 00:45:06.301 we'll ease into it. 940 00:45:06.301 --> 00:45:08.963 Well it turns out it's not happening and now it's many 941 00:45:08.963 --> 00:45:11.250 weeks later and I'm gonna tell him that he has 942 00:45:11.250 --> 00:45:13.972 to be in the group, and that's where we're gonna be. 943 00:45:13.972 --> 00:45:18.178 So obviously, already, the direction here is to get 944 00:45:18.178 --> 00:45:20.799 him to go in the group, it's very specific, 945 00:45:20.799 --> 00:45:22.811 it's sort of either he does or he doesn't, 946 00:45:22.811 --> 00:45:25.881 so you kinda know what your direction is. 947 00:45:25.881 --> 00:45:27.954 Alright, so I haven't really pre-scripted 948 00:45:27.954 --> 00:45:30.656 or him pre-script what's gonna happen but I just, 949 00:45:30.656 --> 00:45:33.947 and there's a little mic right here which might help 950 00:45:33.947 --> 00:45:36.697 but maybe you'll hear him anyway. 951 00:45:39.149 --> 00:45:40.916 Alright Jacob. 952 00:45:40.916 --> 00:45:42.075 Hey. 953 00:45:42.075 --> 00:45:43.408 What's happened? 954 00:45:44.416 --> 00:45:45.249 - Hey. 955 00:45:45.249 --> 00:45:46.082 - You alright? 956 00:45:46.082 --> 00:45:46.915 - Yeah, yep. 957 00:45:46.915 --> 00:45:47.757 - Yeah, good, good. 958 00:45:47.757 --> 00:45:49.728 I missed ya last week, I don't know what happened 959 00:45:49.728 --> 00:45:53.184 last week but you know I left a message for you, 960 00:45:53.184 --> 00:45:54.485 were you gonna, 961 00:45:54.485 --> 00:45:56.471 - I couldn't come in. 962 00:45:56.471 --> 00:45:57.304 - You what? 963 00:45:57.304 --> 00:45:58.226 - I couldn't come in. 964 00:45:58.226 --> 00:45:59.099 - You couldn't come in? 965 00:45:59.099 --> 00:46:00.696 - Yeah no I had other things to do. 966 00:46:00.696 --> 00:46:01.915 - Other things? 967 00:46:01.915 --> 00:46:03.378 Yeah. 968 00:46:03.378 --> 00:46:05.166 More important than me? 969 00:46:05.166 --> 00:46:07.197 Come on, come on man. 970 00:46:07.197 --> 00:46:09.493 There's nothing more important than seeing me. 971 00:46:09.493 --> 00:46:10.358 I swear to God. 972 00:46:10.358 --> 00:46:11.609 What are you doing? 973 00:46:11.609 --> 00:46:13.609 I mean I want you to be, 974 00:46:17.547 --> 00:46:21.192 I want you to be on your game with me, every time. 975 00:46:21.192 --> 00:46:22.216 Right? 976 00:46:22.216 --> 00:46:23.429 Can you do that? - [Jacob] Usually I am. 977 00:46:23.429 --> 00:46:24.262 - What? 978 00:46:24.262 --> 00:46:25.095 - Usually I am. 979 00:46:25.095 --> 00:46:27.150 - You are, you are and I like seeing you and you've 980 00:46:27.150 --> 00:46:29.115 told me you like seeing me, it's only been a few 981 00:46:29.115 --> 00:46:31.560 sessions but, you know we're not gonna stick 982 00:46:31.560 --> 00:46:33.942 with this right now, I wanna come back to it at 983 00:46:33.942 --> 00:46:36.555 some point, and you've only had this happen this one time 984 00:46:36.555 --> 00:46:39.083 I just wanna make sure we're together. 985 00:46:39.083 --> 00:46:40.446 Cause now I'm gonna bring up something that's gonna 986 00:46:40.446 --> 00:46:42.034 be hard for you. 987 00:46:42.034 --> 00:46:44.939 You know how at the beginning of treatment like a month 988 00:46:44.939 --> 00:46:48.116 ago or so I told you that you needed to go, 989 00:46:48.116 --> 00:46:50.979 you needed to be in a group every week for once 990 00:46:50.979 --> 00:46:54.663 in a week you go to group and once you come and see me 991 00:46:54.663 --> 00:46:56.711 cause you gotta learn these skills man, 992 00:46:56.711 --> 00:46:58.822 they make all the difference, they're like, 993 00:46:58.822 --> 00:47:02.989 they're the real thing here and then I help you use them. 994 00:47:04.143 --> 00:47:06.107 So how bout going into group starting next week, 995 00:47:06.107 --> 00:47:06.940 they do have an opening. 996 00:47:06.940 --> 00:47:09.940 - No, no I thought you were kidding. 997 00:47:10.868 --> 00:47:12.582 No come on man, no-- 998 00:47:12.582 --> 00:47:15.654 - Kidding, when did you think I was kidding? 999 00:47:15.654 --> 00:47:16.987 - When you said, 1000 00:47:18.057 --> 00:47:19.457 before. 1001 00:47:19.457 --> 00:47:21.255 - You mean the first time I brought it up? 1002 00:47:21.255 --> 00:47:22.505 - Before, yeah. 1003 00:47:23.512 --> 00:47:24.452 - You thought I was kidding. 1004 00:47:24.452 --> 00:47:25.873 - Yeah. 1005 00:47:25.873 --> 00:47:27.265 - Haha. 1006 00:47:27.265 --> 00:47:29.598 I mean, you don't wanna go-- 1007 00:47:31.089 --> 00:47:33.305 - No I told you I don't like that, that's just really 1008 00:47:33.305 --> 00:47:37.254 uncool of you, that's really harsh, that is really, 1009 00:47:37.254 --> 00:47:38.320 really harsh. 1010 00:47:38.320 --> 00:47:39.229 You're being harsh now. 1011 00:47:39.229 --> 00:47:40.062 - I am? 1012 00:47:40.062 --> 00:47:40.964 - You're being harsh. 1013 00:47:40.964 --> 00:47:42.203 - I am. 1014 00:47:42.203 --> 00:47:43.311 - Yeah, you're being harsh. 1015 00:47:43.311 --> 00:47:44.174 - Let me, 1016 00:47:44.174 --> 00:47:47.142 look, Jacob let me point out something, 1017 00:47:47.142 --> 00:47:49.461 cause you and I have worked together for awhile but this 1018 00:47:49.461 --> 00:47:51.342 is gonna be one of our challenges and we're gonna 1019 00:47:51.342 --> 00:47:53.307 get our relationship even stronger when we get 1020 00:47:53.307 --> 00:47:55.188 through this challenge but let me tell you 1021 00:47:55.188 --> 00:47:59.840 when you say that it hurts or that I'm being uncool 1022 00:47:59.840 --> 00:48:03.246 or unfair to you, you're like leaving aside the fact 1023 00:48:03.246 --> 00:48:05.482 that when you entered this program you knew this is part 1024 00:48:05.482 --> 00:48:07.865 of the program, it's not like I'm an asshole, 1025 00:48:07.865 --> 00:48:10.101 it's like if you wanna call the program an asshole 1026 00:48:10.101 --> 00:48:12.337 and maybe it could do that but it's like 1027 00:48:12.337 --> 00:48:14.508 the program is that way, and we have to do it, 1028 00:48:14.508 --> 00:48:16.389 and I expected you to do it. 1029 00:48:16.389 --> 00:48:18.897 - No, I told you I wasn't good in groups, 1030 00:48:18.897 --> 00:48:22.345 I told you, people don't like me, I don't like other people, 1031 00:48:22.345 --> 00:48:23.327 it just doesn't work. 1032 00:48:23.327 --> 00:48:26.441 It doesn't work, my ears clog up, I don't learn anything, 1033 00:48:26.441 --> 00:48:28.594 I learn things like this. 1034 00:48:28.594 --> 00:48:30.224 I told you that man-- 1035 00:48:30.224 --> 00:48:33.024 - In other words you're like a one on one kind of guy. 1036 00:48:33.024 --> 00:48:33.857 - This is the way I like-- 1037 00:48:33.857 --> 00:48:34.966 - This is the way you learn. 1038 00:48:34.966 --> 00:48:37.306 - This is the way I like it, this is hard enough for me, 1039 00:48:37.306 --> 00:48:40.964 you're pretty good, you're cool, kind of. 1040 00:48:40.964 --> 00:48:42.677 (audience laughing) 1041 00:48:42.677 --> 00:48:45.415 - No I think that's a pretty high praise, 1042 00:48:45.415 --> 00:48:49.908 but whatever it is the fact is that I understand 1043 00:48:49.908 --> 00:48:52.103 you don't want to go into group, you're not the first one, 1044 00:48:52.103 --> 00:48:55.070 the question is how can I help you go in the group 1045 00:48:55.070 --> 00:48:56.951 because you need to go in the group 1046 00:48:56.951 --> 00:48:59.751 because actually, and you might even get something 1047 00:48:59.751 --> 00:49:01.465 out of this going in the group. 1048 00:49:01.465 --> 00:49:02.298 - No. 1049 00:49:02.298 --> 00:49:05.302 - Look, let me be straight with you. 1050 00:49:05.302 --> 00:49:07.747 The reason we do this treatment is because there's 1051 00:49:07.747 --> 00:49:11.592 evidence that it helps teenagers who are doing the stuff 1052 00:49:11.592 --> 00:49:13.996 you're doing, it's like one of the best treatments 1053 00:49:13.996 --> 00:49:15.145 in the world. 1054 00:49:15.145 --> 00:49:18.238 And the only evidence is for when you go to the skills 1055 00:49:18.238 --> 00:49:22.120 group and you see your therapist, so if I just see you 1056 00:49:22.120 --> 00:49:25.085 that might be easier but it's taking the easy way out, 1057 00:49:25.085 --> 00:49:29.252 it's not like doing the thing that's gonna change your life. 1058 00:49:31.166 --> 00:49:32.775 So how bout it? 1059 00:49:32.775 --> 00:49:34.442 Try it, do it, like, 1060 00:49:36.827 --> 00:49:41.133 I do want to know what is it that's so bad? 1061 00:49:41.133 --> 00:49:43.703 But I'd like you first to just say, okay I understand 1062 00:49:43.703 --> 00:49:46.232 Charlie, I gotta do this. 1063 00:49:46.232 --> 00:49:48.641 And then let me work with you, let me help you 1064 00:49:48.641 --> 00:49:51.657 get in there without sacrificing too much, 1065 00:49:51.657 --> 00:49:52.490 you know? 1066 00:49:55.858 --> 00:49:57.091 - I don't know how. 1067 00:49:57.091 --> 00:49:58.721 - You don't know how. 1068 00:49:58.721 --> 00:50:01.145 But you know, to know how you'd need to, 1069 00:50:01.145 --> 00:50:03.874 I would need to help you with that, I need to know 1070 00:50:03.874 --> 00:50:07.030 what is the problem, like when I say go to group 1071 00:50:07.030 --> 00:50:09.266 what is it that sets you off when you think 1072 00:50:09.266 --> 00:50:11.648 I don't work well in groups. 1073 00:50:11.648 --> 00:50:14.407 Earlier you said, people say things to you 1074 00:50:14.407 --> 00:50:16.002 or they treat you a certain way, is that part 1075 00:50:16.002 --> 00:50:16.900 of the problem? 1076 00:50:16.900 --> 00:50:20.808 - It's the way they look, and my face feels so hot. 1077 00:50:20.808 --> 00:50:22.125 Just feels so hot. 1078 00:50:22.125 --> 00:50:24.194 - You're face feels hot. 1079 00:50:24.194 --> 00:50:25.552 Do you know what that's about? 1080 00:50:25.552 --> 00:50:29.356 Is it related to how people look at you? 1081 00:50:29.356 --> 00:50:31.529 - I feel a little bit of it now. 1082 00:50:31.529 --> 00:50:32.362 - You do? 1083 00:50:34.357 --> 00:50:37.345 Is it when you feel you're under a lot of pressure? 1084 00:50:37.345 --> 00:50:40.221 Yeah I feel like I'm putting you under pressure. 1085 00:50:40.221 --> 00:50:41.054 Yeah. 1086 00:50:42.018 --> 00:50:43.606 And I need you to work with me on this 1087 00:50:43.606 --> 00:50:45.320 cause we need you to get to the point where you 1088 00:50:45.320 --> 00:50:46.820 go into the group. 1089 00:50:47.813 --> 00:50:50.676 Okay we're gonna stop right there, thank you Matthew. 1090 00:50:50.676 --> 00:50:51.659 Alright. 1091 00:50:51.659 --> 00:50:53.909 (clapping) 1092 00:50:58.095 --> 00:50:59.262 Alright, whoa. 1093 00:51:00.603 --> 00:51:01.436 Nice job. 1094 00:51:03.320 --> 00:51:04.820 Yeah, so, alright. 1095 00:51:06.747 --> 00:51:09.151 Straight out pushing somebody. 1096 00:51:09.151 --> 00:51:11.805 There's the door let's get you through it, right? 1097 00:51:11.805 --> 00:51:13.205 That's how Linehan started. 1098 00:51:13.205 --> 00:51:16.089 That's the sort of core of DBT, it's very relentless, 1099 00:51:16.089 --> 00:51:19.878 it's very disciplined, and towards the end 1100 00:51:19.878 --> 00:51:21.633 there was a little bit of an opening to start 1101 00:51:21.633 --> 00:51:24.768 to use the intelligence part of my principles 1102 00:51:24.768 --> 00:51:26.590 and say, how do we understand what the problem 1103 00:51:26.590 --> 00:51:29.015 is cause then maybe we can work on it. 1104 00:51:29.015 --> 00:51:30.896 So now let's go to paradigm number two, 1105 00:51:30.896 --> 00:51:31.813 next slide. 1106 00:51:33.382 --> 00:51:35.619 So, you know these are five principles just listing 1107 00:51:35.619 --> 00:51:39.686 them but I wanna now go right on cause I'm already 1108 00:51:39.686 --> 00:51:41.044 gonna run short on time. 1109 00:51:41.044 --> 00:51:42.967 - [Voiceover] You're fine. 1110 00:51:42.967 --> 00:51:44.743 - Well we need time afterwards for, 1111 00:51:44.743 --> 00:51:48.212 but presence, so the first principle, 1112 00:51:48.212 --> 00:51:50.636 and by the way these five principles you might 1113 00:51:50.636 --> 00:51:54.136 say are all could be re-framed as insights 1114 00:51:56.202 --> 00:52:00.883 from a long time of meditation by people who have 1115 00:52:00.883 --> 00:52:02.826 taught meditation and learned meditation 1116 00:52:02.826 --> 00:52:04.400 beginning with the Buddha. 1117 00:52:04.400 --> 00:52:07.054 But these are really all profound principles, 1118 00:52:07.054 --> 00:52:09.437 hard to talk about, hard to get across, 1119 00:52:09.437 --> 00:52:12.133 and they're just this second paradigm. 1120 00:52:12.133 --> 00:52:15.246 They are the things you wanna be doing while you do 1121 00:52:15.246 --> 00:52:17.274 what I just did. 1122 00:52:17.274 --> 00:52:20.952 You want push for change at a context of acceptance. 1123 00:52:20.952 --> 00:52:24.024 That's Linehan's definition of the fundamental dialectic 1124 00:52:24.024 --> 00:52:27.012 of DBT, and what it means to me is that while doing 1125 00:52:27.012 --> 00:52:30.649 those five things relentlessly and in a firm 1126 00:52:30.649 --> 00:52:34.816 and intelligent way, you are also creating a context 1127 00:52:35.999 --> 00:52:37.796 of acceptance. 1128 00:52:37.796 --> 00:52:38.945 And how do you do that? 1129 00:52:38.945 --> 00:52:40.157 These five principles. 1130 00:52:40.157 --> 00:52:43.764 One is presence, while focusing on goals and targets 1131 00:52:43.764 --> 00:52:47.443 out there, the treatment takes place in here, 1132 00:52:47.443 --> 00:52:50.201 in this moment, no matter how much you have your eye 1133 00:52:50.201 --> 00:52:53.169 on the prize, the more important thing to have your 1134 00:52:53.169 --> 00:52:55.955 eye on, that sometimes has to eclipse you eye 1135 00:52:55.955 --> 00:52:58.525 on the prize is this other human being that's sitting 1136 00:52:58.525 --> 00:53:01.388 opposite you and how you're doing and how he's doing 1137 00:53:01.388 --> 00:53:03.290 or how she's doing. 1138 00:53:03.290 --> 00:53:05.380 The therapist establish him or herself 1139 00:53:05.380 --> 00:53:07.532 in the present moment, 1140 00:53:07.532 --> 00:53:11.273 which might done in a number of ways. 1141 00:53:11.273 --> 00:53:14.038 And invites the patient into the present moment, 1142 00:53:14.038 --> 00:53:16.588 a sort of metaphorically that's what I'm doing 1143 00:53:16.588 --> 00:53:19.513 at my best even if I'm gonna challenge the hell 1144 00:53:19.513 --> 00:53:23.066 out of somebody I wanna welcome them into my present 1145 00:53:23.066 --> 00:53:26.897 moment, I wanna stay there, if something very uncomfortable 1146 00:53:26.897 --> 00:53:30.826 happens I wanna stay with it and notice that it's 1147 00:53:30.826 --> 00:53:33.045 really uncomfortable. 1148 00:53:33.045 --> 00:53:35.448 And then I want to move on to the next thing 1149 00:53:35.448 --> 00:53:39.607 and I wanna notice if I've lost my mind, 1150 00:53:39.607 --> 00:53:43.076 if I've lost the present moment, if I've lost contact, 1151 00:53:43.076 --> 00:53:45.772 and sometimes it's just reminding yourself about 1152 00:53:45.772 --> 00:53:47.689 your butt on the chair. 1153 00:53:48.573 --> 00:53:50.537 Oh yeah, I'm still here. 1154 00:53:50.537 --> 00:53:53.170 You know, get back in your body. 1155 00:53:53.170 --> 00:53:55.064 Because when you start doing intense work 1156 00:53:55.064 --> 00:53:57.515 with disregulated people you get out of your body, 1157 00:53:57.515 --> 00:53:59.862 you're in your head, you get defensive, 1158 00:53:59.862 --> 00:54:03.248 you get too thoughtful, and you have to kind of like 1159 00:54:03.248 --> 00:54:06.926 be intuitive and automatic and be there in your body 1160 00:54:06.926 --> 00:54:09.392 so you sometimes have to use anchors to keep 1161 00:54:09.392 --> 00:54:11.273 getting yourself back in there. 1162 00:54:11.273 --> 00:54:15.170 Anchors such as attending to the breath. 1163 00:54:15.170 --> 00:54:17.003 So you're in the middle of a session and you start 1164 00:54:17.003 --> 00:54:19.030 to feel like oh my God I'm losing my mind 1165 00:54:19.030 --> 00:54:21.601 in this session, I'm going around in circles, 1166 00:54:21.601 --> 00:54:24.673 this person is confusing me, you know, sometimes 1167 00:54:24.673 --> 00:54:28.205 the best thing to do is get out of the change paradigm 1168 00:54:28.205 --> 00:54:31.005 and just say, (sighing) 1169 00:54:31.005 --> 00:54:34.370 notice one full breath, like totally, from beginning 1170 00:54:34.370 --> 00:54:36.251 to end and you don't have to announce it to your 1171 00:54:36.251 --> 00:54:39.642 patient, and say by the way, I need a breath here, 1172 00:54:39.642 --> 00:54:41.440 you know, you don't need to do that you can actually 1173 00:54:41.440 --> 00:54:45.264 notice your breath invisibly, I mean a really perceptive 1174 00:54:45.264 --> 00:54:48.796 patient knows you've done it, you know, but you can 1175 00:54:48.796 --> 00:54:51.199 do that or you can make your anchor point, 1176 00:54:51.199 --> 00:54:55.030 as I did once with one patient who was basically 1177 00:54:55.030 --> 00:54:58.353 screaming about, it was in a family session, 1178 00:54:58.353 --> 00:55:01.467 screaming about how her father was always coming down 1179 00:55:01.467 --> 00:55:04.539 on her and giving her no chance at controlling her life 1180 00:55:04.539 --> 00:55:07.444 and I don't really see it because in here he acts like 1181 00:55:07.444 --> 00:55:10.223 a normal human being but at home he acts like a complete 1182 00:55:10.223 --> 00:55:13.609 asshole and he makes her do the dishes every night, 1183 00:55:13.609 --> 00:55:15.517 and this stuff's going on and she's like, 1184 00:55:15.517 --> 00:55:17.377 and I'm thinking oh my God what am I gonna do, 1185 00:55:17.377 --> 00:55:19.153 you know, family therapy's really hard, 1186 00:55:19.153 --> 00:55:21.124 and here's the mom and the dad and she's there 1187 00:55:21.124 --> 00:55:22.874 and she's like going. 1188 00:55:24.029 --> 00:55:27.112 And I thought, Charlie take a breath. 1189 00:55:28.689 --> 00:55:30.361 Took a breath. 1190 00:55:30.361 --> 00:55:31.778 It wasn't enough. 1191 00:55:32.806 --> 00:55:34.394 You know sometimes one breath doesn't do it 1192 00:55:34.394 --> 00:55:37.132 and I started to just look at her face while she was 1193 00:55:37.132 --> 00:55:40.273 still yelling, it was almost like going into a mode 1194 00:55:40.273 --> 00:55:43.241 where you're still there but you're observing in a way 1195 00:55:43.241 --> 00:55:45.665 while you're still there and I looked at her face 1196 00:55:45.665 --> 00:55:49.218 and her face actually looked sad not angry. 1197 00:55:49.218 --> 00:55:51.182 When I actually let myself look at her face 1198 00:55:51.182 --> 00:55:54.693 I had to let go of my fear or my automatic defensiveness 1199 00:55:54.693 --> 00:55:57.828 to somebody who's yelling at me. 1200 00:55:57.828 --> 00:56:00.990 And I just looked at her and I said your face looks sad 1201 00:56:00.990 --> 00:56:02.933 and she burst into tears and said, 1202 00:56:02.933 --> 00:56:04.674 "If you had a father like mine your face would 1203 00:56:04.674 --> 00:56:06.221 "look sad too." 1204 00:56:06.221 --> 00:56:09.523 And suddenly we were at a different place. 1205 00:56:09.523 --> 00:56:13.598 And so sometimes these don't like cure anything 1206 00:56:13.598 --> 00:56:15.604 but they get you a different place, they cut 1207 00:56:15.604 --> 00:56:20.181 the tension in the air by just stopping and observing, 1208 00:56:20.181 --> 00:56:22.020 noticing and making a comment. 1209 00:56:22.020 --> 00:56:24.068 You never know what's gonna come. 1210 00:56:24.068 --> 00:56:26.847 But you might anchor yourself in your observation 1211 00:56:26.847 --> 00:56:29.606 of your patient, in your observation of your breath, 1212 00:56:29.606 --> 00:56:32.532 in your observation of sensations in your body. 1213 00:56:32.532 --> 00:56:35.401 In the sounds in the room or other things. 1214 00:56:35.401 --> 00:56:37.873 And so when you drift from the present, which is the 1215 00:56:37.873 --> 00:56:40.993 hardest thing is knowing you did, 1216 00:56:40.993 --> 00:56:43.186 I mean just like in mindfulness practices, 1217 00:56:43.186 --> 00:56:46.954 you drift and like then you say oops I'm thinking 1218 00:56:46.954 --> 00:56:49.232 about other stuff and you realize you've drifted 1219 00:56:49.232 --> 00:56:50.910 and it could've been an hour, you don't know, 1220 00:56:50.910 --> 00:56:52.197 it might've been 10 second or it might, 1221 00:56:52.197 --> 00:56:54.454 you really don't know but at that moment you've gotta 1222 00:56:54.454 --> 00:56:58.201 like say, alright let's go back, let's observe the breath. 1223 00:56:58.201 --> 00:57:01.295 It's like, let's get back here in my body, in the room 1224 00:57:01.295 --> 00:57:05.462 with my patient, establish my presence, so that we're here. 1225 00:57:06.752 --> 00:57:09.573 It's like loving your patient enough to be there 1226 00:57:09.573 --> 00:57:13.740 for your patient the way you wanna be for your partner. 1227 00:57:16.951 --> 00:57:18.284 Okay next slide. 1228 00:57:19.228 --> 00:57:22.811 Then there's the principal of impermanence. 1229 00:57:27.009 --> 00:57:29.176 And here the idea is that, 1230 00:57:30.457 --> 00:57:33.299 like I said earlier about a different one, 1231 00:57:33.299 --> 00:57:35.201 that things are changing all the time. 1232 00:57:35.201 --> 00:57:36.664 Like nothing ever stays the same. 1233 00:57:36.664 --> 00:57:39.255 When Linehan said to me, "Nothing's the same for 1234 00:57:39.255 --> 00:57:41.136 "more than a second." 1235 00:57:41.136 --> 00:57:43.456 So don't tell me it's the same as last week, 1236 00:57:43.456 --> 00:57:45.663 it's not the same, at all. 1237 00:57:45.663 --> 00:57:47.377 Just looks the same, you think it's the same. 1238 00:57:47.377 --> 00:57:48.965 The fact that you think it's the same 1239 00:57:48.965 --> 00:57:50.449 is a problem. 1240 00:57:50.449 --> 00:57:54.474 So it sort of like, how do you get yourself to be 1241 00:57:54.474 --> 00:57:57.316 aware that actually things are always changing, 1242 00:57:57.316 --> 00:57:59.657 even if stubborn patterns are still there 1243 00:57:59.657 --> 00:58:03.042 and then if you just remind yourself, 1244 00:58:03.042 --> 00:58:06.219 nothing's the same, things actually are changing. 1245 00:58:06.219 --> 00:58:09.186 The walls around us are changing, we can't see it 1246 00:58:09.186 --> 00:58:11.686 but you develop more patience. 1247 00:58:13.232 --> 00:58:14.925 And I remember when Kernberg first taught me 1248 00:58:14.925 --> 00:58:16.910 therapy one of the things he said that was really 1249 00:58:16.910 --> 00:58:19.355 mirrored by what Linehan said, but he had his way 1250 00:58:19.355 --> 00:58:21.842 of saying things and he said, 1251 00:58:21.842 --> 00:58:24.411 "With your borderline patient you're working with, 1252 00:58:24.411 --> 00:58:27.161 "you want to have intense urgency 1253 00:58:29.278 --> 00:58:31.195 "and infinite patience, 1254 00:58:32.726 --> 00:58:34.691 "at the same time." 1255 00:58:34.691 --> 00:58:36.593 And he wasn't teaching me dialectics but it was the 1256 00:58:36.593 --> 00:58:39.566 same idea, you wanted to be there and realize, 1257 00:58:39.566 --> 00:58:42.430 things will change, time will pass. 1258 00:58:42.430 --> 00:58:44.394 Gives you more hope and it helps you participate 1259 00:58:44.394 --> 00:58:48.061 in this moment and makes every moment fresh. 1260 00:58:58.250 --> 00:59:02.333 I had a patient who was suicidal most of the time 1261 00:59:03.306 --> 00:59:07.056 and it was one of these agonizing treatments, 1262 00:59:08.439 --> 00:59:11.490 where she was one of the patients I've had that I thought 1263 00:59:11.490 --> 00:59:13.079 is really gonna do it. 1264 00:59:13.079 --> 00:59:17.096 And it was really scary and she'd come in 1265 00:59:17.096 --> 00:59:20.763 and talk to me and in a very convincing way, 1266 00:59:21.886 --> 00:59:23.496 clearly she was convinced there was no point 1267 00:59:23.496 --> 00:59:26.955 in going on, and she was trying to convince me 1268 00:59:26.955 --> 00:59:30.756 there was no point in going on and that it was over, 1269 00:59:30.756 --> 00:59:32.818 that her body, in fact she would say sometimes 1270 00:59:32.818 --> 00:59:34.901 is actually dead already. 1271 00:59:36.253 --> 00:59:38.098 And it had a psychotic flavor, but there weren't 1272 00:59:38.098 --> 00:59:41.169 other ways in which she was psychotic, but she said, 1273 00:59:41.169 --> 00:59:45.014 "You don't realize, in my body I'm actually already dead. 1274 00:59:45.014 --> 00:59:48.923 "And there's no point in going on, it's just agony. 1275 00:59:48.923 --> 00:59:51.949 "And so I don't know how I'm gonna do it but I can't 1276 00:59:51.949 --> 00:59:53.646 "stand this anymore." 1277 00:59:53.646 --> 00:59:55.815 And I tried to change things and I tried to change 1278 00:59:55.815 --> 00:59:58.457 medications and I had her go to a hospital and come back 1279 00:59:58.457 --> 01:00:01.271 and do all kinds of things and she was still that way 1280 01:00:01.271 --> 01:00:05.503 and I just thought, this is really hard to bear. 1281 01:00:05.503 --> 01:00:10.056 And there was a certain point when I just started to think, 1282 01:00:10.056 --> 01:00:13.622 alright, alright, and I talked to other people, 1283 01:00:13.622 --> 01:00:16.521 try to get a little help with it. 1284 01:00:16.521 --> 01:00:19.937 Nobody was coming up with much and so I just decided, 1285 01:00:19.937 --> 01:00:24.061 okay alright I'm just gonna sit with her and believe 1286 01:00:24.061 --> 01:00:27.061 that this isn't the same every time. 1287 01:00:28.357 --> 01:00:32.738 And just listen, and just be there, and stop trying. 1288 01:00:32.738 --> 01:00:35.402 If I want to acknowledge that it scares me 1289 01:00:35.402 --> 01:00:38.194 I can acknowledge that it scares me to her. 1290 01:00:38.194 --> 01:00:39.912 Acknowledge that I don't know what to do with her 1291 01:00:39.912 --> 01:00:42.490 right now, that I have enormous empathy for her 1292 01:00:42.490 --> 01:00:45.046 but actually I can't think of exactly what we can do 1293 01:00:45.046 --> 01:00:46.958 but then try to give her reasons to keep going 1294 01:00:46.958 --> 01:00:48.762 but it sounded hollow to her. 1295 01:00:48.762 --> 01:00:51.444 And there was a certain point when I just started to 1296 01:00:51.444 --> 01:00:53.111 feel like, you know, 1297 01:00:54.043 --> 01:00:55.676 I just have to be here. 1298 01:00:55.676 --> 01:00:57.888 It's like realizing you're standing at a wall 1299 01:00:57.888 --> 01:01:00.057 and the walls a foot thick and your goal is to get 1300 01:01:00.057 --> 01:01:02.807 to the other side of the wall and there's not a hole in it 1301 01:01:02.807 --> 01:01:04.974 and you can't go around it and you can't go over it 1302 01:01:04.974 --> 01:01:06.155 and you can't go through it. 1303 01:01:06.155 --> 01:01:07.874 And there you are, what do you do? 1304 01:01:07.874 --> 01:01:09.463 Well you stand there. 1305 01:01:09.463 --> 01:01:12.320 You know in this model, impermanence says this wall's 1306 01:01:12.320 --> 01:01:14.339 gonna crumble some day. 1307 01:01:14.339 --> 01:01:17.260 Or a crack's gonna develop if I just keep paying attention, 1308 01:01:17.260 --> 01:01:19.236 I'm just gonna stay with her. 1309 01:01:19.236 --> 01:01:21.577 And I just did and not long after that, 1310 01:01:21.577 --> 01:01:24.754 and I would just hear bad things from her, 1311 01:01:24.754 --> 01:01:28.513 I went away for a week, which scared me, about her, 1312 01:01:28.513 --> 01:01:30.274 and I came back and she came into a session 1313 01:01:30.274 --> 01:01:33.174 with the first affect other than depression 1314 01:01:33.174 --> 01:01:34.763 I'd seen for long, she said, 1315 01:01:34.763 --> 01:01:37.038 "I'm moving to New York." 1316 01:01:37.038 --> 01:01:38.305 What do you mean you're moving to New York, 1317 01:01:38.305 --> 01:01:39.722 you can barely get out of your apartment. 1318 01:01:39.722 --> 01:01:43.309 "No, I've decided I need to go back to where the original 1319 01:01:43.309 --> 01:01:47.476 "problem is, where I was left by so and so and where 1320 01:01:48.701 --> 01:01:51.600 "everything fell apart, years ago. 1321 01:01:51.600 --> 01:01:53.426 "And I just need to go back there and I realized 1322 01:01:53.426 --> 01:01:57.185 "this is what I've figured out so that's what I'm gonna do." 1323 01:01:57.185 --> 01:01:58.667 I said I think think we should talk about, 1324 01:01:58.667 --> 01:02:00.901 "I've already got an apartment." 1325 01:02:00.901 --> 01:02:02.877 Oh, but how are you gonna, 1326 01:02:02.877 --> 01:02:05.089 "I've already got a job. 1327 01:02:05.089 --> 01:02:07.302 "I've got my old job back." 1328 01:02:07.302 --> 01:02:10.347 Oh, wow, you've gone a long ways since I went 1329 01:02:10.347 --> 01:02:12.065 on vacation. 1330 01:02:12.065 --> 01:02:15.287 Yeah, you know, and I don't know what the relationship 1331 01:02:15.287 --> 01:02:18.380 between these things were but I think sometimes you have 1332 01:02:18.380 --> 01:02:21.774 to write relax into the awareness that you don't have 1333 01:02:21.774 --> 01:02:23.664 another thing to try. 1334 01:02:23.664 --> 01:02:27.098 And so you realize impermanence and things will unfold 1335 01:02:27.098 --> 01:02:29.633 and sometimes they do and sometimes they don't work. 1336 01:02:29.633 --> 01:02:31.652 And then if you can think of anything to do, 1337 01:02:31.652 --> 01:02:34.702 by all means do it, but sometimes the valuable thing 1338 01:02:34.702 --> 01:02:36.098 is just to be there. 1339 01:02:36.098 --> 01:02:37.945 Marsha Linehan tells a story, when she was in 1340 01:02:37.945 --> 01:02:40.153 the Institute of Living, 1341 01:02:40.153 --> 01:02:41.890 when she was 19 years old and she was there 1342 01:02:41.890 --> 01:02:44.893 for a year and a half and she just went through 1343 01:02:44.893 --> 01:02:47.019 really a bad time and trying to hurt herself 1344 01:02:47.019 --> 01:02:50.842 and being impossible and being put into the security floor 1345 01:02:50.842 --> 01:02:52.325 over and over and over again 1346 01:02:52.325 --> 01:02:56.408 and then she says that when she came and gave her 1347 01:02:57.434 --> 01:03:00.656 coming out talk in Hartford at the Institute of Living 1348 01:03:00.656 --> 01:03:03.019 about three or four years ago telling her story 1349 01:03:03.019 --> 01:03:04.909 that's written in the New York Times and you can 1350 01:03:04.909 --> 01:03:08.367 watch it on YouTube or whatever, but she describes 1351 01:03:08.367 --> 01:03:11.804 that the thing that got her through the hospitalization 1352 01:03:11.804 --> 01:03:15.391 was two different doctors, one of them was a psychiatrist 1353 01:03:15.391 --> 01:03:17.469 and one was a psychologist, one was her therapist 1354 01:03:17.469 --> 01:03:20.068 one was her medicating doctor and both of them's 1355 01:03:20.068 --> 01:03:22.018 at different times talked to her, 1356 01:03:22.018 --> 01:03:24.875 especially the psychologist she had talked to her one day 1357 01:03:24.875 --> 01:03:27.452 and said, "Marsha I just wanna tell you, 1358 01:03:27.452 --> 01:03:31.039 "we are trying everything we know how to do. 1359 01:03:31.039 --> 01:03:34.154 "I think you must notice, we haven't helped you. 1360 01:03:34.154 --> 01:03:37.290 "And we feel terrible about it and we're just trying, 1361 01:03:37.290 --> 01:03:38.987 "we just want you to know that, you know, 1362 01:03:38.987 --> 01:03:41.672 "because we're looking for a way to do it but we know 1363 01:03:41.672 --> 01:03:43.796 "we haven't helped you." 1364 01:03:43.796 --> 01:03:46.330 She said that was unbelievably helpful. 1365 01:03:46.330 --> 01:03:48.693 That they were just persisting without knowing what to do, 1366 01:03:48.693 --> 01:03:50.411 being transparent about the fact they didn't know 1367 01:03:50.411 --> 01:03:53.075 what to do, made her feel connected for the first time 1368 01:03:53.075 --> 01:03:56.554 in a while, cause of that, so that kinda sense of 1369 01:03:56.554 --> 01:03:59.970 staying with things, things are impermanent, 1370 01:03:59.970 --> 01:04:03.471 they will evolve, doesn't always turn out that good 1371 01:04:03.471 --> 01:04:06.671 but I think, it's what I mean by this principle 1372 01:04:06.671 --> 01:04:09.356 and I think it often is a good way to go. 1373 01:04:09.356 --> 01:04:10.945 Next slide. 1374 01:04:10.945 --> 01:04:13.158 This is non attachment. 1375 01:04:13.158 --> 01:04:15.263 We get attached to what we want, this is just straight 1376 01:04:15.263 --> 01:04:17.191 Buddhist kinda teachings. 1377 01:04:17.191 --> 01:04:19.339 That we get attached to what we want and we try 1378 01:04:19.339 --> 01:04:22.174 to avoid what we don't want and so we get, 1379 01:04:22.174 --> 01:04:24.945 in therapy we get attached to a positive behavioral 1380 01:04:24.945 --> 01:04:27.866 outcome, and if it doesn't come we get really frustrated 1381 01:04:27.866 --> 01:04:30.873 because somehow for God knows why we actually think 1382 01:04:30.873 --> 01:04:33.064 that because we think we want to get there we should 1383 01:04:33.064 --> 01:04:34.460 be there. 1384 01:04:34.460 --> 01:04:37.250 Like it has nothing to do with reality, we just think 1385 01:04:37.250 --> 01:04:39.484 I'm gonna get this patient to not be suicidal, 1386 01:04:39.484 --> 01:04:41.611 they keep being suicidal and it's sort of like 1387 01:04:41.611 --> 01:04:43.887 oh my God, they're still suicidal, alright they're 1388 01:04:43.887 --> 01:04:47.346 still suicidal because that hasn't changed 1389 01:04:47.346 --> 01:04:50.739 but there is this way which once we attach our brain, 1390 01:04:50.739 --> 01:04:54.133 our thoughts, to I've got to do this, 1391 01:04:54.133 --> 01:04:56.450 you know you're at risk of burnout. 1392 01:04:56.450 --> 01:04:58.641 You're at risk of getting disregulated yourself 1393 01:04:58.641 --> 01:05:00.725 and therefore being less helpful to the patient 1394 01:05:00.725 --> 01:05:02.679 so it's a really tricky thing what to do 1395 01:05:02.679 --> 01:05:04.505 cause you don't wanna let go of the patient 1396 01:05:04.505 --> 01:05:06.180 but you have to let go of the belief that you 1397 01:05:06.180 --> 01:05:10.111 can help the patient, sometimes, and just work 1398 01:05:10.111 --> 01:05:11.636 without that belief anymore. 1399 01:05:11.636 --> 01:05:15.051 So sometimes you think the patient should cooperate more 1400 01:05:15.051 --> 01:05:18.875 and it drives you crazy, right, you wanna, 1401 01:05:18.875 --> 01:05:21.173 and you can't get the patient to cooperate 1402 01:05:21.173 --> 01:05:22.891 or comply with things and you just think, 1403 01:05:22.891 --> 01:05:24.824 oh my God if only she complied. 1404 01:05:24.824 --> 01:05:26.306 If only he complied. 1405 01:05:26.306 --> 01:05:28.411 But actually that might not be true. 1406 01:05:28.411 --> 01:05:29.700 But once you get hooked on that, 1407 01:05:29.700 --> 01:05:32.772 so it's sort of whatever we get hooked onto, 1408 01:05:32.772 --> 01:05:36.724 it's realizing that we're attached to something 1409 01:05:36.724 --> 01:05:39.280 that we actually can't control 1410 01:05:39.280 --> 01:05:41.857 and so, you know, practicing non attachment 1411 01:05:41.857 --> 01:05:45.251 we notice these things, we let go as much as we can 1412 01:05:45.251 --> 01:05:48.473 which help us to reduce our burnout and prevent 1413 01:05:48.473 --> 01:05:51.132 a limit with the situation and maybe then begin 1414 01:05:51.132 --> 01:05:53.882 to notice what's really going on. 1415 01:05:57.532 --> 01:05:59.380 It was a moment like that with that teenager 1416 01:05:59.380 --> 01:06:01.297 that had the alcoholism 1417 01:06:02.322 --> 01:06:05.866 but that didn't think it was a problem 1418 01:06:05.866 --> 01:06:08.680 and that I really, you know I went through with her, 1419 01:06:08.680 --> 01:06:10.828 I gotta do something about this. 1420 01:06:10.828 --> 01:06:13.062 And then the more I checked with the other 1421 01:06:13.062 --> 01:06:15.511 doctors she had I realized she's don't this with three 1422 01:06:15.511 --> 01:06:20.279 other people, she's only like 16 and she's done this. 1423 01:06:20.279 --> 01:06:23.028 She's really good at this and its sorta like, 1424 01:06:23.028 --> 01:06:24.611 so I had to let go, 1425 01:06:25.713 --> 01:06:30.353 to some degree of my belief that I should be able, 1426 01:06:30.353 --> 01:06:33.682 the great me, I should be able to figure this out 1427 01:06:33.682 --> 01:06:36.281 and become the omnipotent rescuer. 1428 01:06:36.281 --> 01:06:38.150 And as soon as you're into that category 1429 01:06:38.150 --> 01:06:40.835 you're attached to something you can't control 1430 01:06:40.835 --> 01:06:43.584 and it really can burn you out and can lead 1431 01:06:43.584 --> 01:06:46.001 to clinical, to bad outcomes. 1432 01:06:50.806 --> 01:06:52.094 I may mention this guy again 1433 01:06:52.094 --> 01:06:53.872 but there was a 16 year old boy who had cut 1434 01:06:53.872 --> 01:06:57.717 himself mercilessly for about a year and a half 1435 01:06:57.717 --> 01:06:59.715 and was depressed and had stopped going to school 1436 01:06:59.715 --> 01:07:03.018 and wouldn't leave his room above the garage 1437 01:07:03.018 --> 01:07:04.101 in his house. 1438 01:07:05.123 --> 01:07:05.956 And he, 1439 01:07:08.903 --> 01:07:11.158 when they brought him a tutor he called the police 1440 01:07:11.158 --> 01:07:14.187 and put out a restraining order on the tutor 1441 01:07:14.187 --> 01:07:16.034 and he just didn't want to go he just wanted 1442 01:07:16.034 --> 01:07:18.762 to be in his room and listen to his music 1443 01:07:18.762 --> 01:07:20.738 and the only thing he would come to is his parents 1444 01:07:20.738 --> 01:07:24.067 would bring him to me and it was a distance away. 1445 01:07:24.067 --> 01:07:25.506 And they'd come once a week and I'd do an 1446 01:07:25.506 --> 01:07:27.568 individual therapy session then I'd do a family 1447 01:07:27.568 --> 01:07:31.606 session and teach skills to the mom and dad and the kid. 1448 01:07:31.606 --> 01:07:33.862 And in the individual sessions with me for literally 1449 01:07:33.862 --> 01:07:37.019 three months he almost never spoke. 1450 01:07:37.019 --> 01:07:39.511 And he would stare at the wall sideways, 1451 01:07:39.511 --> 01:07:41.422 his head sideways to me, he had long hair, 1452 01:07:41.422 --> 01:07:43.313 I didn't even see his face, and it would go on 1453 01:07:43.313 --> 01:07:47.277 and on and on and I just, you know I have a lot 1454 01:07:47.277 --> 01:07:49.897 of patience with difficult people, working with people 1455 01:07:49.897 --> 01:07:53.527 but I was losing it and I went into my consultation, 1456 01:07:53.527 --> 01:07:56.148 DBT consultation team, and I said guys, I think this 1457 01:07:56.148 --> 01:07:58.489 kid hates me, he doesn't want to work with me, 1458 01:07:58.489 --> 01:08:00.787 I think I should really stop, this is not getting 1459 01:08:00.787 --> 01:08:03.902 anywhere I just think this could be making him worse, 1460 01:08:03.902 --> 01:08:05.813 blah, blah, blah. 1461 01:08:05.813 --> 01:08:08.365 And one of my team members who runs an adolescent 1462 01:08:08.365 --> 01:08:10.684 residential program, actually around here, 1463 01:08:10.684 --> 01:08:13.348 said, "Oh my God, you are such an idiot, 1464 01:08:13.348 --> 01:08:16.978 "I mean this kid goes nowhere, but he comes an hour 1465 01:08:16.978 --> 01:08:17.978 "to see you. 1466 01:08:19.744 --> 01:08:22.147 "You know, he puts restraining orders against people 1467 01:08:22.147 --> 01:08:25.197 "and he comes and he sits in your office and doesn't talk." 1468 01:08:25.197 --> 01:08:28.999 He says, "This kid loves you, you just gotta think that, 1469 01:08:28.999 --> 01:08:30.498 "you just gotta have the assumption. 1470 01:08:30.498 --> 01:08:31.843 "He loves you to pieces and he just 1471 01:08:31.843 --> 01:08:34.161 "doesn't know what to do about it." 1472 01:08:34.161 --> 01:08:37.552 And I didn't believe that, actually. 1473 01:08:37.552 --> 01:08:41.268 But it did help me let go of thinking I should 1474 01:08:41.268 --> 01:08:44.597 be able to get him to talk and I started thinking, 1475 01:08:44.597 --> 01:08:47.304 well we have a narrow idea of psychotherapy 1476 01:08:47.304 --> 01:08:49.215 it's all talk. 1477 01:08:49.215 --> 01:08:52.373 Alright so we'll just sit together. 1478 01:08:52.373 --> 01:08:54.564 I mean that's what they do a silent retreats, 1479 01:08:54.564 --> 01:08:56.067 right, we'll just sit next to each other, we'll 1480 01:08:56.067 --> 01:08:58.494 just sit, sit and then I'll tell him a story 1481 01:08:58.494 --> 01:09:00.210 now and then and then I eventually told him a story 1482 01:09:00.210 --> 01:09:02.208 that he got very curious about, 1483 01:09:02.208 --> 01:09:05.172 about my own two year old son. 1484 01:09:05.172 --> 01:09:06.995 When he thought that something happened that might 1485 01:09:06.995 --> 01:09:08.969 have hurt my son and he was suddenly very curious 1486 01:09:08.969 --> 01:09:11.654 and all of a sudden he was willing to talk to me 1487 01:09:11.654 --> 01:09:15.241 but it was sort of like I had to let go of trying 1488 01:09:15.241 --> 01:09:17.432 to get him and it made me more comfortable, 1489 01:09:17.432 --> 01:09:19.107 I just thought okay, I'm just gonna sit with this 1490 01:09:19.107 --> 01:09:22.637 guy and yet he would talk with the family meetings. 1491 01:09:22.637 --> 01:09:24.264 Next slide please. 1492 01:09:24.264 --> 01:09:25.264 Inter-being. 1493 01:09:26.885 --> 01:09:29.828 So in addition to being in the present moment entirely, 1494 01:09:29.828 --> 01:09:31.610 like really just being there, 1495 01:09:31.610 --> 01:09:34.123 which some people do more easily that others, 1496 01:09:34.123 --> 01:09:36.873 for me it's fair amount of work to be there, 1497 01:09:36.873 --> 01:09:40.009 I mean seems like I'm probably there but it's 1498 01:09:40.009 --> 01:09:43.188 actually not easy, get in my head and all kinds 1499 01:09:43.188 --> 01:09:46.410 of things but so now you wanna be able to be there, 1500 01:09:46.410 --> 01:09:50.104 you wanna notice the impermanence of everything, 1501 01:09:50.104 --> 01:09:52.574 it sort of helps open up the situation, 1502 01:09:52.574 --> 01:09:54.464 you wanna notice your attachments and be able to 1503 01:09:54.464 --> 01:09:58.030 see if you can just let them go and see things 1504 01:09:58.030 --> 01:10:00.199 as they are and be with things as they are, 1505 01:10:00.199 --> 01:10:02.455 longer than you wish you had to. 1506 01:10:02.455 --> 01:10:06.085 And then there's this idea of inter-being. 1507 01:10:06.085 --> 01:10:08.662 That captures several different Buddhist kind 1508 01:10:08.662 --> 01:10:11.559 of ideas, and the idea of inter-being has to do with 1509 01:10:11.559 --> 01:10:14.180 just that in spite of the fact that conventionally 1510 01:10:14.180 --> 01:10:16.757 we actually think we're unique, we actually think 1511 01:10:16.757 --> 01:10:20.087 we have a self, we actually think that we have thoughts 1512 01:10:20.087 --> 01:10:22.621 that other people don't have. 1513 01:10:22.621 --> 01:10:25.693 We actually think that there's a boundary between us 1514 01:10:25.693 --> 01:10:28.697 and other people in the world and that all that's true, 1515 01:10:28.697 --> 01:10:31.315 it isn't like that's not true, it's jut that's 1516 01:10:31.315 --> 01:10:33.397 what we all agree on, hey let's all agree that there's 1517 01:10:33.397 --> 01:10:38.100 a boundary between us and that we have a unique self, 1518 01:10:38.100 --> 01:10:41.361 and that we are pretty autonomous but we're 1519 01:10:41.361 --> 01:10:44.260 in relationships, conventional thinking. 1520 01:10:44.260 --> 01:10:46.666 Well this is not so conventional thinking. 1521 01:10:46.666 --> 01:10:49.716 It's really thinking, there is no boundary, 1522 01:10:49.716 --> 01:10:53.644 its like again at this situation like looking at waves 1523 01:10:53.644 --> 01:10:55.814 and whatever, what is it the two different models 1524 01:10:55.814 --> 01:10:58.731 of light, waves and something else. 1525 01:10:59.938 --> 01:11:00.771 What? 1526 01:11:00.771 --> 01:11:02.214 - [Voiceover] Particles. 1527 01:11:02.214 --> 01:11:03.047 I couldn't hear it. 1528 01:11:03.047 --> 01:11:05.050 - [Voiceover] Waves and particles. 1529 01:11:05.050 --> 01:11:07.189 Particles, waves and particles, 1530 01:11:07.189 --> 01:11:10.173 yeah you can look at light twice in two different ways, 1531 01:11:10.173 --> 01:11:12.536 so this is looking at the same situation 1532 01:11:12.536 --> 01:11:15.049 and saying, there's actually no boundary, 1533 01:11:15.049 --> 01:11:17.927 I've been talking to you guys for this long 1534 01:11:17.927 --> 01:11:19.882 and every word out of my mouth has been shaped 1535 01:11:19.882 --> 01:11:22.632 in conjunction with noticing you. 1536 01:11:24.712 --> 01:11:29.352 I've probably imitated some of you, in the most subtle way. 1537 01:11:29.352 --> 01:11:31.328 I probably think I'm making stuff up and it probably 1538 01:11:31.328 --> 01:11:33.411 was something that my grandfather would say 1539 01:11:33.411 --> 01:11:35.922 when he used to talk to dairy farmers 1540 01:11:35.922 --> 01:11:39.208 in Seattle Washington like 60 years ago 1541 01:11:39.208 --> 01:11:40.624 when he would give talk. 1542 01:11:40.624 --> 01:11:43.239 I mean, in other words, this idea that there's me 1543 01:11:43.239 --> 01:11:45.774 and there's a boundary and there's you over there 1544 01:11:45.774 --> 01:11:48.437 actually you're shaping every word that comes 1545 01:11:48.437 --> 01:11:52.604 out of me, every gesture and my pace and my tone. 1546 01:11:52.604 --> 01:11:56.139 And I'm shaping everything that's going into your thinking 1547 01:11:56.139 --> 01:11:59.602 to some degree, so the longer we're doing this together, 1548 01:11:59.602 --> 01:12:02.801 the more actually it's just we're just an entity here, 1549 01:12:02.801 --> 01:12:04.543 you know, we're the Starship Enterprise and there's 1550 01:12:04.543 --> 01:12:06.418 actually no difference between, 1551 01:12:06.418 --> 01:12:10.014 we're all just sharing the same air, the same food 1552 01:12:10.014 --> 01:12:12.441 if you went to the same place I did, some of you did, 1553 01:12:12.441 --> 01:12:16.654 the same conversation, the same ideas, and we all have 1554 01:12:16.654 --> 01:12:19.169 to preserve this idea that we're individual and different 1555 01:12:19.169 --> 01:12:21.198 and there's these boundaries but actually another point 1556 01:12:21.198 --> 01:12:24.198 of view is that you are influencing me profoundly 1557 01:12:24.198 --> 01:12:27.404 at every moment and even people that I don't even notice 1558 01:12:27.404 --> 01:12:30.536 are influencing me profoundly and people who aren't 1559 01:12:30.536 --> 01:12:33.228 even here right now are influencing my profoundly 1560 01:12:33.228 --> 01:12:36.647 and any idea that I'm this autonomous being, 1561 01:12:36.647 --> 01:12:38.544 sort of like when I was watching the New York Nix's 1562 01:12:38.544 --> 01:12:40.706 in Madison Square Garden with my best friend 1563 01:12:40.706 --> 01:12:44.853 a lot of years ago and I remember saying one time, 1564 01:12:44.853 --> 01:12:48.412 hey Cindy, we each thought we were pretty expert 1565 01:12:48.412 --> 01:12:50.706 about the strategy of the nix, 1566 01:12:50.706 --> 01:12:52.868 and I said something about the point guard and what 1567 01:12:52.868 --> 01:12:54.927 was going on and the strategy and God he really should 1568 01:12:54.927 --> 01:12:58.015 take him out, all these things, I'm saying this complicated 1569 01:12:58.015 --> 01:13:01.522 thing and I'm thinking God, I didn't pat myself on the back 1570 01:13:01.522 --> 01:13:03.375 but I thought, that was pretty smart, you know, 1571 01:13:03.375 --> 01:13:05.912 and Cindy's listening and nodding and then like 1572 01:13:05.912 --> 01:13:09.066 three minutes later a guy behind me who did not hear 1573 01:13:09.066 --> 01:13:10.983 me said the same thing. 1574 01:13:11.890 --> 01:13:14.559 Like a guy up there with the same level of enthusiasm 1575 01:13:14.559 --> 01:13:17.714 is telling his friend the same thing. 1576 01:13:17.714 --> 01:13:19.434 And I turn to Cindy and I said, did you hear that? 1577 01:13:19.434 --> 01:13:20.267 And she said "Yeah." 1578 01:13:20.267 --> 01:13:22.265 I said, he said just what I said like minutes ago, 1579 01:13:22.265 --> 01:13:26.486 she said, "Charlie we all listen to the same radio shows." 1580 01:13:26.486 --> 01:13:29.309 I go, oh right, you know that's right, I mean I think 1581 01:13:29.309 --> 01:13:33.251 I had an individual thought, I mean there's no such thing. 1582 01:13:33.251 --> 01:13:34.596 There's no such thing. 1583 01:13:34.596 --> 01:13:37.155 The nursing staff in a in-patient hospital thinks 1584 01:13:37.155 --> 01:13:40.177 the patient is manipulating the staff. 1585 01:13:40.177 --> 01:13:44.361 But if you look carefully, microsecond by microsecond, 1586 01:13:44.361 --> 01:13:47.516 it's just as likely that the staff is manipulating 1587 01:13:47.516 --> 01:13:50.207 the patient, in other words the only way to get attention 1588 01:13:50.207 --> 01:13:53.259 is to act that way and the staff is the one that's 1589 01:13:53.259 --> 01:13:55.869 in control of that, so it's sort of like there's no 1590 01:13:55.869 --> 01:13:57.994 such thing as this boundary. 1591 01:13:57.994 --> 01:14:00.531 But there is of course, so the idea of letting yourself 1592 01:14:00.531 --> 01:14:03.862 sort of sink, I have pictured it visually when I do it 1593 01:14:03.862 --> 01:14:07.862 with a patient and I feel like we're so at odds, 1594 01:14:08.708 --> 01:14:10.715 this kid keeps cutting himself, cutting himself, 1595 01:14:10.715 --> 01:14:14.090 cutting himself, if I shift my position I kind of drop 1596 01:14:14.090 --> 01:14:17.884 down into this level of thinking then I start to say, 1597 01:14:17.884 --> 01:14:19.384 we're cutting him. 1598 01:14:20.877 --> 01:14:22.774 He and I are cutting him. 1599 01:14:22.774 --> 01:14:24.230 What are we doing? 1600 01:14:24.230 --> 01:14:27.076 It's like, in other words I'm influencing him every 1601 01:14:27.076 --> 01:14:30.389 second, he's still cutting himself, so are other people 1602 01:14:30.389 --> 01:14:33.311 but it's sort of like, try that on, like just drop 1603 01:14:33.311 --> 01:14:37.127 conventional reality and say okay, why am I cutting him? 1604 01:14:37.127 --> 01:14:39.010 It's just a different kind of question and it might 1605 01:14:39.010 --> 01:14:42.900 be the case or maybe his mother's cutting him. 1606 01:14:42.900 --> 01:14:44.973 Because she's never wanted him to live anyway, 1607 01:14:44.973 --> 01:14:45.922 or something like that. 1608 01:14:45.922 --> 01:14:49.694 So, it just helps to be able to drop into that other level 1609 01:14:49.694 --> 01:14:52.804 and be there and it creates a profound sense of we 1610 01:14:52.804 --> 01:14:55.187 are connected to each other. 1611 01:14:55.187 --> 01:14:56.770 And the next slide. 1612 01:14:57.679 --> 01:14:59.819 The last of these which could otherwise be labeled 1613 01:14:59.819 --> 01:15:02.400 karma if it was just straight Buddhism, 1614 01:15:02.400 --> 01:15:05.709 is the idea that everything that happens, 1615 01:15:05.709 --> 01:15:08.422 every phenomenon that occurs has it's causes 1616 01:15:08.422 --> 01:15:11.077 and conditions and it arises out of those causes 1617 01:15:11.077 --> 01:15:13.113 and conditions, and the question is how could it 1618 01:15:13.113 --> 01:15:14.569 be otherwise. 1619 01:15:14.569 --> 01:15:17.062 Given everything, of course that occurred, I mean 1620 01:15:17.062 --> 01:15:20.202 it just had to and the more you can do that with people, 1621 01:15:20.202 --> 01:15:24.369 the more you can just say, well of course you did that. 1622 01:15:25.739 --> 01:15:28.981 The more you can kinda like accept where they're at. 1623 01:15:28.981 --> 01:15:31.717 There's a kind of deep acceptance that comes from that. 1624 01:15:31.717 --> 01:15:35.820 There was a 16 year old girl who was hospitalized 1625 01:15:35.820 --> 01:15:39.680 back in White Plains when I was working there, 1626 01:15:39.680 --> 01:15:42.393 and then I interviewed her in a case conference 1627 01:15:42.393 --> 01:15:45.746 and what had happened was she lived locally, 1628 01:15:45.746 --> 01:15:48.614 she got up on her house, it was the days when they 1629 01:15:48.614 --> 01:15:52.281 had TV antennas, and she grabbed the antenna 1630 01:15:54.305 --> 01:15:56.599 and she started swinging around the antenna 1631 01:15:56.599 --> 01:15:58.982 on top of her house singing all of those songs 1632 01:15:58.982 --> 01:16:02.997 to Westside Story, really loud, until the neighbors 1633 01:16:02.997 --> 01:16:05.210 next door called the police. 1634 01:16:05.210 --> 01:16:06.997 And the police came and got her off the roof 1635 01:16:06.997 --> 01:16:09.931 and took her to the hospital. 1636 01:16:09.931 --> 01:16:13.063 And I was gonna interview her and I just thought, 1637 01:16:13.063 --> 01:16:15.771 you know what a crazy story, I'll do this link by 1638 01:16:15.771 --> 01:16:18.629 link analysis of how it was and I did but at the same 1639 01:16:18.629 --> 01:16:21.894 time I tried to think, you know, I just tried 1640 01:16:21.894 --> 01:16:24.607 to start my interview by thinking, 1641 01:16:24.607 --> 01:16:27.100 of course this happened. 1642 01:16:27.100 --> 01:16:31.291 So I said something like that with her just as a little 1643 01:16:31.291 --> 01:16:33.122 different way of starting, saying, you know 1644 01:16:33.122 --> 01:16:37.997 I'm assuming that this was of course what you had to do. 1645 01:16:37.997 --> 01:16:40.997 She said, "Well yeah I did." 1646 01:16:40.997 --> 01:16:42.894 I thought, wow I was right. 1647 01:16:42.894 --> 01:16:45.012 I mean but it's sort of like, and then I said 1648 01:16:45.012 --> 01:16:47.240 well tell me about it, like why did you have to do that? 1649 01:16:47.240 --> 01:16:49.402 "Well my parents were having a big argument and they 1650 01:16:49.402 --> 01:16:50.843 "always have big arguments, they were inside 1651 01:16:50.843 --> 01:16:53.137 "and I thought, I hate their argument I did not want 1652 01:16:53.137 --> 01:16:56.321 "to be there so I went outside and I got up 1653 01:16:56.321 --> 01:16:58.490 "on the roof and I just swung around and I felt 1654 01:16:58.490 --> 01:16:59.657 "a lot freer." 1655 01:17:01.292 --> 01:17:04.895 I said, wow, so you're saying it made a lot of sense, 1656 01:17:04.895 --> 01:17:07.520 cause you know to your neighbors it didn't make much sense, 1657 01:17:07.520 --> 01:17:09.461 and I never want you to do it again cause you just risked 1658 01:17:09.461 --> 01:17:10.294 your life. 1659 01:17:11.675 --> 01:17:13.866 But it did make sense I mean is there any other way it 1660 01:17:13.866 --> 01:17:17.190 made sense, she said, "Yeah, got me in the hospital." 1661 01:17:17.190 --> 01:17:18.609 That's a good thing? 1662 01:17:18.609 --> 01:17:21.190 She said, "Yeah, are you kidding? 1663 01:17:21.190 --> 01:17:23.727 "This is the best place for me. 1664 01:17:23.727 --> 01:17:25.977 "My parents need help." 1665 01:17:25.977 --> 01:17:29.447 So there was a whole story and if you assume 1666 01:17:29.447 --> 01:17:32.359 that what you're seeing that's crazy is in some way 1667 01:17:32.359 --> 01:17:34.455 perfect as it is, it had to be that way 1668 01:17:34.455 --> 01:17:37.058 and whether you do it the way I just said or not, 1669 01:17:37.058 --> 01:17:40.587 you kinda come across the causes and conditions. 1670 01:17:40.587 --> 01:17:42.528 And get out of the judgement, so all of these 1671 01:17:42.528 --> 01:17:46.550 have to do with arriving at a place of being deeply 1672 01:17:46.550 --> 01:17:49.095 present and accepting, of the patient, even if you're 1673 01:17:49.095 --> 01:17:52.337 pushing the hell out of them, to get them to be 1674 01:17:52.337 --> 01:17:53.977 in a group. 1675 01:17:53.977 --> 01:17:56.779 Okay, so I wanna do a second role play. 1676 01:17:56.779 --> 01:17:59.404 So here's Jacob again and I'm gonna take these 1677 01:17:59.404 --> 01:18:02.404 principles as my main approach here. 1678 01:18:04.455 --> 01:18:06.933 Oh my gosh it's almost nine, we're not gonna get 1679 01:18:06.933 --> 01:18:09.742 to all three, I knew this would happen, what can I say, 1680 01:18:09.742 --> 01:18:11.825 but if you, oh forget it. 1681 01:18:13.205 --> 01:18:15.738 So, but I think it's good to see. 1682 01:18:15.738 --> 01:18:18.238 So, Jacob, hey, how you doing? 1683 01:18:19.688 --> 01:18:21.130 - Okay. 1684 01:18:21.130 --> 01:18:23.220 - Alright good, that's good. 1685 01:18:23.220 --> 01:18:26.522 I kind of missed you last week, kinda missed you, 1686 01:18:26.522 --> 01:18:28.946 I mean I don't know if you remember cause it's a long 1687 01:18:28.946 --> 01:18:30.446 time, a week, but, 1688 01:18:31.801 --> 01:18:33.431 you weren't here and we were just getting to know 1689 01:18:33.431 --> 01:18:35.715 each other so, yeah, I just want you to know 1690 01:18:35.715 --> 01:18:36.781 I miss you. 1691 01:18:36.781 --> 01:18:37.769 - Yeah, I bunked. 1692 01:18:37.769 --> 01:18:38.668 - What? 1693 01:18:38.668 --> 01:18:39.859 - I bunked. 1694 01:18:39.859 --> 01:18:40.967 I bunked. 1695 01:18:40.967 --> 01:18:43.571 - Okay, alright, alright. 1696 01:18:43.571 --> 01:18:46.162 So, hey there's something we need to talk about 1697 01:18:46.162 --> 01:18:49.289 I've been putting off and it has to do with going 1698 01:18:49.289 --> 01:18:52.325 into the group, the skills group, 1699 01:18:52.325 --> 01:18:55.048 that you knew about a few weeks ago but we haven't 1700 01:18:55.048 --> 01:18:57.264 really brought it up since and I haven't said a thing, 1701 01:18:57.264 --> 01:18:59.213 you haven't said a thing, you and I I guess have been 1702 01:18:59.213 --> 01:19:03.964 kinda joining each other in pretending it doesn't exist 1703 01:19:03.964 --> 01:19:06.212 but there's actually this requirement that 1704 01:19:06.212 --> 01:19:07.947 you're in the group. 1705 01:19:07.947 --> 01:19:10.267 I hate to bring this to your attention. 1706 01:19:10.267 --> 01:19:11.517 - No you don't. 1707 01:19:12.933 --> 01:19:16.675 - Yes actually I do, but you get, you know, 1708 01:19:16.675 --> 01:19:17.553 that's a good point. 1709 01:19:17.553 --> 01:19:19.007 What do mean I don't? 1710 01:19:19.007 --> 01:19:21.075 - You don't hate bringing it to my attention, 1711 01:19:21.075 --> 01:19:23.742 it seems like you're having fun. 1712 01:19:27.282 --> 01:19:30.104 - Here's the thing, you are so sharp, I mean I think 1713 01:19:30.104 --> 01:19:32.800 it's true I don't hate to bring it to your attention, 1714 01:19:32.800 --> 01:19:35.203 I wouldn't say I'm having fun, I didn't-- 1715 01:19:35.203 --> 01:19:36.749 - I don't wanna go. 1716 01:19:36.749 --> 01:19:38.184 - I didn't look forward to the discussion. 1717 01:19:38.184 --> 01:19:39.017 You don't want to go? 1718 01:19:39.017 --> 01:19:40.628 - No I don't want to go, I'm not going. 1719 01:19:40.628 --> 01:19:42.739 I didn't think you were serious. 1720 01:19:42.739 --> 01:19:43.637 - Yeah? 1721 01:19:43.637 --> 01:19:45.121 - No I didn't think you were serious. 1722 01:19:45.121 --> 01:19:45.954 - Okay. 1723 01:19:46.825 --> 01:19:47.732 - I still don't. 1724 01:19:47.732 --> 01:19:49.884 - You still don't. 1725 01:19:49.884 --> 01:19:53.541 I'll be clear, that I am serious but I've let it go 1726 01:19:53.541 --> 01:19:55.949 cause I've kind of enjoyed, and this is true, 1727 01:19:55.949 --> 01:20:00.120 getting to know you and yet this is still hanging over 1728 01:20:00.120 --> 01:20:03.909 my head, that you have to get in there and there's 1729 01:20:03.909 --> 01:20:05.963 actually good reasons for it but I'm more 1730 01:20:05.963 --> 01:20:08.701 concerned right now with that just bringing it up 1731 01:20:08.701 --> 01:20:11.911 you just sort of say you can't go or you're not going 1732 01:20:11.911 --> 01:20:13.401 and I wanna know what that's about. 1733 01:20:13.401 --> 01:20:15.157 - Well is this cause I didn't come, cause I skipped 1734 01:20:15.157 --> 01:20:15.990 last week? 1735 01:20:15.990 --> 01:20:17.420 - No it's not, it has nothing to do with that, 1736 01:20:17.420 --> 01:20:19.761 I was gonna bring it up last week. 1737 01:20:19.761 --> 01:20:22.038 Now, probably you were smart to skip last week 1738 01:20:22.038 --> 01:20:24.580 and you didn't even know it. 1739 01:20:24.580 --> 01:20:27.547 No, the point was I just need to bring it up 1740 01:20:27.547 --> 01:20:31.380 and I want to know what is the problem with it 1741 01:20:32.396 --> 01:20:34.402 cause there's obviously a problem and I believe it's 1742 01:20:34.402 --> 01:20:37.606 probably a real problem you have with the idea, 1743 01:20:37.606 --> 01:20:39.273 what is the problem? 1744 01:20:41.493 --> 01:20:43.666 - I don't like people. 1745 01:20:43.666 --> 01:20:45.666 - You don't like people? 1746 01:20:48.180 --> 01:20:49.817 Okay. 1747 01:20:49.817 --> 01:20:51.234 That's a big one. 1748 01:20:52.178 --> 01:20:55.480 - I mean I really don't like people. 1749 01:20:55.480 --> 01:20:57.528 I don't think you get it. 1750 01:20:57.528 --> 01:21:00.442 - I might not get it yet but I get that you do 1751 01:21:00.442 --> 01:21:03.733 actually come to see me but I don't know how 1752 01:21:03.733 --> 01:21:06.617 you feel about that and that you don't like people, 1753 01:21:06.617 --> 01:21:08.080 we haven't talked much about that. 1754 01:21:08.080 --> 01:21:09.898 What do you mean you don't like people? 1755 01:21:09.898 --> 01:21:13.420 Anything, any people, anything about people? 1756 01:21:13.420 --> 01:21:14.492 Just like to know. 1757 01:21:14.492 --> 01:21:16.484 - I don't think they get me. 1758 01:21:16.484 --> 01:21:17.317 - No. 1759 01:21:17.317 --> 01:21:18.460 - I don't think they like me. 1760 01:21:18.460 --> 01:21:19.293 - Oh. 1761 01:21:19.293 --> 01:21:21.126 - I think it's mutual. 1762 01:21:32.190 --> 01:21:35.363 - And yet people are expecting you to be with people. 1763 01:21:35.363 --> 01:21:36.196 - Who? 1764 01:21:36.196 --> 01:21:39.167 - A lot, well the clinic expects you to be in a group 1765 01:21:39.167 --> 01:21:43.084 and your parents wanted you to be here with me. 1766 01:21:44.623 --> 01:21:46.341 I'm just trying to think what it would be like 1767 01:21:46.341 --> 01:21:49.239 to be in your shoes and not like people as much 1768 01:21:49.239 --> 01:21:51.573 as you don't like people. 1769 01:21:51.573 --> 01:21:54.429 I wanna know all about that, I just don't get it, 1770 01:21:54.429 --> 01:21:58.429 I don't get why, I don't get where it came from. 1771 01:21:59.419 --> 01:22:02.002 - You'd be afraid all the time. 1772 01:22:03.801 --> 01:22:05.176 All the time. 1773 01:22:05.176 --> 01:22:07.560 - You're afraid of other people all the time? 1774 01:22:07.560 --> 01:22:10.393 - All the time, like all the time. 1775 01:22:15.486 --> 01:22:17.467 - How do you get by? 1776 01:22:17.467 --> 01:22:18.526 How do you get by? 1777 01:22:18.526 --> 01:22:20.843 I mean you've had to go to school, 1778 01:22:20.843 --> 01:22:22.784 you have to be with other people sometimes 1779 01:22:22.784 --> 01:22:24.813 or maybe you don't maybe you find a lot of ways 1780 01:22:24.813 --> 01:22:26.056 to not be with people. 1781 01:22:26.056 --> 01:22:28.129 - I bunk out on a lot of things. 1782 01:22:28.129 --> 01:22:30.931 - You do a lot of that, a lot of that. 1783 01:22:30.931 --> 01:22:32.431 Is that a relief when you do it? 1784 01:22:32.431 --> 01:22:36.598 It's just, are you okay when you're with yourself? 1785 01:22:37.924 --> 01:22:38.757 Yeah? 1786 01:22:40.041 --> 01:22:42.269 Alright, we're gonna stop there. 1787 01:22:42.269 --> 01:22:44.686 Oh, very different direction. 1788 01:22:47.056 --> 01:22:48.292 Okay. 1789 01:22:48.292 --> 01:22:49.770 Now. 1790 01:22:49.770 --> 01:22:52.020 (clapping) 1791 01:22:54.917 --> 01:22:57.365 Alright we're gonna, you know, I'm gonna give 1792 01:22:57.365 --> 01:23:02.307 you the one minute version of the third principles 1793 01:23:02.307 --> 01:23:05.224 but we're not gonna do a role play. 1794 01:23:10.755 --> 01:23:13.123 The third set are the dialectical principles 1795 01:23:13.123 --> 01:23:15.241 and they're the ones that involve, they're the most 1796 01:23:15.241 --> 01:23:19.285 challenging, they involve creativity, improvisation, 1797 01:23:19.285 --> 01:23:23.939 going with the moment, all of that, let me just say, 1798 01:23:23.939 --> 01:23:27.336 in an interview with Michael Jordan where somebody 1799 01:23:27.336 --> 01:23:31.020 asked him, "What did you like best about basketball?" 1800 01:23:31.020 --> 01:23:34.388 and he actually looked like he took it seriously. 1801 01:23:34.388 --> 01:23:36.947 He said, "Well, you know the best thing was when 1802 01:23:36.947 --> 01:23:40.087 "I did things that I've never done before, just cause 1803 01:23:40.087 --> 01:23:43.859 "I had to, and then I would think, wow, look what 1804 01:23:43.859 --> 01:23:45.491 "I just did." 1805 01:23:45.491 --> 01:23:47.013 And there's something about that that captures 1806 01:23:47.013 --> 01:23:50.102 the quality of dialectical, that's not where it comes 1807 01:23:50.102 --> 01:23:52.660 from theoretically but that's what it's like 1808 01:23:52.660 --> 01:23:56.072 in therapy, you come up with a metaphor, you come up 1809 01:23:56.072 --> 01:23:58.572 with a move you've never done before, cause it feels like 1810 01:23:58.572 --> 01:24:00.778 the right thing and you know what your direction is 1811 01:24:00.778 --> 01:24:03.205 and you want to get there but you don't know how you're 1812 01:24:03.205 --> 01:24:06.323 gonna do it with this family, 1813 01:24:06.323 --> 01:24:09.301 with this kid, with this adult and so you try 1814 01:24:09.301 --> 01:24:12.080 something, it's within the ethical boundaries 1815 01:24:12.080 --> 01:24:15.663 but it is different and it is a way to cope 1816 01:24:17.440 --> 01:24:22.036 with polarization, basically, it's when you get stuck 1817 01:24:22.036 --> 01:24:24.463 and when you're stuck, there's one thing opposing 1818 01:24:24.463 --> 01:24:27.639 another thing one way or another, it's either 1819 01:24:27.639 --> 01:24:30.176 you opposing the other person, you opposing yourself, 1820 01:24:30.176 --> 01:24:33.551 you opposing something else but there's always a this 1821 01:24:33.551 --> 01:24:35.845 when you then use dialectics and you're trying to get 1822 01:24:35.845 --> 01:24:40.544 from this, to get these two things with the wisdom 1823 01:24:40.544 --> 01:24:44.573 of both sides to join in a different way 1824 01:24:44.573 --> 01:24:47.617 so that you don't have one beat out the other 1825 01:24:47.617 --> 01:24:49.618 but you come up with a new way 1826 01:24:49.618 --> 01:24:52.993 and I'll give you one example before we stop. 1827 01:24:52.993 --> 01:24:55.243 And these principles, are they up there yet? 1828 01:24:55.243 --> 01:24:57.410 No, put the principles up. 1829 01:24:59.177 --> 01:25:02.883 The principle that always involves opposition, 1830 01:25:02.883 --> 01:25:05.794 so there's always a this. 1831 01:25:05.794 --> 01:25:08.309 It always involves moving towards synthesis 1832 01:25:08.309 --> 01:25:11.419 which is finding that validity on both sides, 1833 01:25:11.419 --> 01:25:13.228 honoring the validity on both sides 1834 01:25:13.228 --> 01:25:15.633 and moving to something that encapsulates 1835 01:25:15.633 --> 01:25:18.966 both things and doesn't diss either one. 1836 01:25:20.096 --> 01:25:22.368 So it's very inclusive. 1837 01:25:22.368 --> 01:25:25.059 It involves systemic thinking so you broaden 1838 01:25:25.059 --> 01:25:28.765 your perspective out to the other elements 1839 01:25:28.765 --> 01:25:31.964 of the system in families it's obvious what that is. 1840 01:25:31.964 --> 01:25:34.876 But everybody's in a system so it opens up the door 1841 01:25:34.876 --> 01:25:37.905 for more ways to understand a person. 1842 01:25:37.905 --> 01:25:40.221 If you can intervene with a family member 1843 01:25:40.221 --> 01:25:42.604 and this person changes. 1844 01:25:42.604 --> 01:25:45.074 You can intervene with yourself and this person 1845 01:25:45.074 --> 01:25:48.471 changes, cause you and he are in transaction 1846 01:25:48.471 --> 01:25:51.163 and that's the next one is transaction that 1847 01:25:51.163 --> 01:25:53.280 everything including your own identity 1848 01:25:53.280 --> 01:25:56.082 is in transaction and finally that there's this 1849 01:25:56.082 --> 01:25:59.082 sense that things are always moving in flux, 1850 01:25:59.082 --> 01:26:01.574 everything's in flux, and that actually therapy 1851 01:26:01.574 --> 01:26:06.075 makes sense to try to keep generating movement, 1852 01:26:06.075 --> 01:26:08.413 keep going with movement as much as you can 1853 01:26:08.413 --> 01:26:10.869 unless you just can't and then there are these other 1854 01:26:10.869 --> 01:26:13.670 times in the acceptance paradigm where you just don't 1855 01:26:13.670 --> 01:26:16.369 do anything for awhile, anything very overt. 1856 01:26:16.369 --> 01:26:19.347 So the example I'll just leave you with is on an 1857 01:26:19.347 --> 01:26:24.310 inpatient unit, where we developed DBT in White Plains, 1858 01:26:24.310 --> 01:26:26.406 a 19 year old girl who had been a student at 1859 01:26:26.406 --> 01:26:30.641 Cornell University and had jumped off one of their 1860 01:26:30.641 --> 01:26:35.605 famous gorges to kill herself and she was in a hospital 1861 01:26:35.605 --> 01:26:38.141 and then she was referred to our program 1862 01:26:38.141 --> 01:26:41.230 and in our hospital unit, she was just this really smart, 1863 01:26:41.230 --> 01:26:44.563 capable person but kept hurting herself. 1864 01:26:46.061 --> 01:26:49.745 Trying to hurt herself, break a light bulb, 1865 01:26:49.745 --> 01:26:52.105 stab it into her arm, things like that. 1866 01:26:52.105 --> 01:26:55.789 And one day she came to her therapist, Ed Sheeran 1867 01:26:55.789 --> 01:26:57.622 who was a really smart 1868 01:26:59.715 --> 01:27:03.377 psychologist who had DBT training, a lot of it, 1869 01:27:03.377 --> 01:27:07.171 and she came up to him and said, "Ed I wanna leave today, 1870 01:27:07.171 --> 01:27:08.693 "I'm getting out of the hospital." 1871 01:27:08.693 --> 01:27:11.407 He said, "No, no, you can't leave today, this morning 1872 01:27:11.407 --> 01:27:13.723 "you tried to hurt yourself, so actually I want 1873 01:27:13.723 --> 01:27:17.076 "to get you out too but we can't get you out today." 1874 01:27:17.076 --> 01:27:20.142 "No, I'm leaving today, I'm leaving, I'm just telling 1875 01:27:20.142 --> 01:27:22.267 "you, Ed, I'm just giving you notice I'm leaving. 1876 01:27:22.267 --> 01:27:23.684 "How do I leave?" 1877 01:27:24.797 --> 01:27:27.708 "I'm telling you we can't really let you out today." 1878 01:27:27.708 --> 01:27:28.922 "How do I leave?" 1879 01:27:28.922 --> 01:27:32.319 "Well you could sign what's called a 72 hour notice, 1880 01:27:32.319 --> 01:27:35.834 "and then within 72 hours a judge has to see you 1881 01:27:35.834 --> 01:27:37.819 "and make the decision." 1882 01:27:37.819 --> 01:27:38.652 "Alright, I'm doing that. 1883 01:27:38.652 --> 01:27:40.084 "Where do I go?" 1884 01:27:40.084 --> 01:27:41.301 "The nursing station has those. 1885 01:27:41.301 --> 01:27:44.077 "Why don't you go get a paper and fill it out 1886 01:27:44.077 --> 01:27:45.709 "and then I think you and I should have a session 1887 01:27:45.709 --> 01:27:47.106 "right away." 1888 01:27:47.106 --> 01:27:49.069 "Well why should we have a session right away?" 1889 01:27:49.069 --> 01:27:52.864 And he said, "Because I wanna help you get ready 1890 01:27:52.864 --> 01:27:55.136 "for the hearing cause you're gonna have 1891 01:27:55.136 --> 01:27:58.342 "to present your case, I want you to do it skillfully." 1892 01:27:58.342 --> 01:28:00.217 "I thought you thought I should stay?" 1893 01:28:00.217 --> 01:28:03.842 "No I do think you should stay, but actually 1894 01:28:03.842 --> 01:28:06.827 "I have a higher goal for you which is that you 1895 01:28:06.827 --> 01:28:09.560 "whatever you do skillfully, so you come out of it 1896 01:28:09.560 --> 01:28:11.452 "proud of yourself even if you lose, 1897 01:28:11.452 --> 01:28:13.614 "which you probably will." 1898 01:28:13.614 --> 01:28:17.644 He said very casually, and she said, well she's a little 1899 01:28:17.644 --> 01:28:21.813 thrown by this and she says, "Yeah but I have a really good 1900 01:28:21.813 --> 01:28:22.646 "argument." 1901 01:28:22.646 --> 01:28:24.409 And he said, "But here's the problem, 1902 01:28:24.409 --> 01:28:26.997 "when the judge comes I'm the one who testifies against 1903 01:28:26.997 --> 01:28:29.519 "you and I'm really good at this, so I really want you 1904 01:28:29.519 --> 01:28:33.078 "to get your game up and so let's work on your skills 1905 01:28:33.078 --> 01:28:35.152 "and maybe you'll beat me, who knows, 1906 01:28:35.152 --> 01:28:37.115 you know there could always be a first one." 1907 01:28:37.115 --> 01:28:39.806 And so it was a brilliant maneuver that captured 1908 01:28:39.806 --> 01:28:43.159 the wisdom of both sides, it didn't diss her, 1909 01:28:43.159 --> 01:28:46.247 it didn't diss him, it found a way to put them together 1910 01:28:46.247 --> 01:28:47.446 in a synthesis. 1911 01:28:47.446 --> 01:28:51.372 It incorporated some movement and it didn't necessarily 1912 01:28:51.372 --> 01:28:54.306 encroach systemic thinking or anything but the transaction 1913 01:28:54.306 --> 01:28:57.578 was important, so in other words, when you get to DBT 1914 01:28:57.578 --> 01:28:59.975 there's a set of strategies called dialectical 1915 01:28:59.975 --> 01:29:01.770 and I think they're based on these principles, 1916 01:29:01.770 --> 01:29:04.064 it's eight different strategies for how to do 1917 01:29:04.064 --> 01:29:06.851 what Ed did, in a variety of different ways 1918 01:29:06.851 --> 01:29:10.093 when you're faced with opposition. 1919 01:29:10.093 --> 01:29:10.926 Alright. 1920 01:29:11.814 --> 01:29:15.696 Now, it's passed nine, so at 8:30 we're gonna stop 1921 01:29:15.696 --> 01:29:18.113 and have question and answer. 1922 01:29:19.895 --> 01:29:21.991 I'm sorry that I didn't leave time, 1923 01:29:21.991 --> 01:29:24.851 I just, I knew this would happen, it's what I was 1924 01:29:24.851 --> 01:29:26.190 worried about. 1925 01:29:26.190 --> 01:29:29.300 So, here's the thing, there's a set of, 1926 01:29:29.300 --> 01:29:31.859 so I wanna thank you guys for hanging in there, 1927 01:29:31.859 --> 01:29:33.785 listening to all of this I just have no idea 1928 01:29:33.785 --> 01:29:36.013 how it came across. 1929 01:29:36.013 --> 01:29:39.013 (audience clapping) 1930 01:29:43.734 --> 01:29:46.932 And, you know, now there's these books that Caroline 1931 01:29:46.932 --> 01:29:51.499 has, so the book that I wrote is about this topic 1932 01:29:51.499 --> 01:29:56.425 it's just, it actually gets to the end during the book, 1933 01:29:56.425 --> 01:29:59.065 so if you missed the end here, if you think you did, 1934 01:29:59.065 --> 01:30:01.756 thought actually we did just got fast to the end, 1935 01:30:01.756 --> 01:30:04.624 but anyway, so they're here and I've never done this, 1936 01:30:04.624 --> 01:30:07.117 literally, before, what this is, 1937 01:30:07.117 --> 01:30:09.676 it's called a book signing, but that means somebody 1938 01:30:09.676 --> 01:30:11.661 actually would then buy a book and I would sign 1939 01:30:11.661 --> 01:30:13.132 I'm not just gonna sign books, right? 1940 01:30:13.132 --> 01:30:16.757 - [Woman] No, you have to buy the books. 1941 01:30:16.757 --> 01:30:20.308 - But it's actually awkward situation, so if you wanna 1942 01:30:20.308 --> 01:30:22.529 buy a book then you ask to buy a book. 1943 01:30:22.529 --> 01:30:24.470 - So yeah, what I would suggest, because, 1944 01:30:24.470 --> 01:30:26.059 - And there could be Q and A. 1945 01:30:26.059 --> 01:30:28.309 - Exactly, people who have questions who want to continue 1946 01:30:28.309 --> 01:30:31.861 a conversation with Dr. Swenson, want to buy a book, 1947 01:30:31.861 --> 01:30:34.993 which was just published today, it just came out today, 1948 01:30:34.993 --> 01:30:37.332 but we were able to get some advanced copies, 1949 01:30:37.332 --> 01:30:39.537 so we have them and I would say why don't we close 1950 01:30:39.537 --> 01:30:42.824 the kind of formal part of the lecture, 1951 01:30:42.824 --> 01:30:45.368 everybody who's got questions, conversation, book needs, 1952 01:30:45.368 --> 01:30:47.839 come on down towards the front and thank you 1953 01:30:47.839 --> 01:30:50.854 for being willing to stay, but thank you before everyone 1954 01:30:50.854 --> 01:30:53.729 leaves for this wonderful, wonderful presentation. 1955 01:30:53.729 --> 01:30:55.001 - Oh you're welcome. 1956 01:30:55.001 --> 01:30:58.001 (audience clapping) 1957 01:30:59.214 --> 01:31:03.214 And really come down front if you want, even if, 1958 01:31:04.251 --> 01:31:07.163 you know don't feel any pressure about it it's also 1959 01:31:07.163 --> 01:31:09.663 a question and answer period.