- Good evening all of you.
It is my pleasure to welcome all of you to the
E. Diane Davis Memorial Lecture and the annual conference
here at the School for Social Work.
As I say to you every year annual conference
is an incredibly important time for our field faculty,
agency based supervisors, directors of training
and students to come together to address the
critically important issues facing social work
practice and field education.
And to plan for the training year ahead.
We truly could not do this work without you
and we're incredibly grateful for all that you offer
our students and the school.
I'd like to share just a bit with you about E. Diane Davis,
in whose memory this lecture is given.
Diane was a therapist, supervisor, administrator,
consultant, teacher, advocate, mentor and friend
of the Smith College School for Social Work,
where she taught over the course of a decade
a number of courses in our continuing ed program.
Including a particularly popular course which
she developed entitled the Developmental Origins
of Psychopathology.
Her connection with Smith College underlined her commitment
to using a psycho-dynamic frame in understanding
human behavior and she gave a great deal to the school.
Diane died at the incredible early age of 46
but in the years she had she gave an incredible amount
and touched not only the professional lives
but the personal lives of many.
She's deeply missed.
Let me now turn to the pleasure of introducing to you
our keynote speaker for this evening, Dr. Charles Swenson.
Dr. Swenson is an internationally known psychiatrist
and an associate professor of clinical psychiatry
at the University of Massachusetts Medical Center
in Worcester.
Dr. Swenson graduated from Harvard College
and Yale University Medical School
and then joined the faculty of Cornell University
Medical College in 1982,
where he directed a long term psychoanalytically
oriented inpatient program for clients diagnosed with
personality disorders.
While at Cornell he served as a DBT trainer
and consultant throughout the United States,
Canada and Europe, coordinating state wide implementation
of DBT in the public sectors at Illinois, Connecticut,
Massachusetts and the Canadian province of New Brunswick.
And was twice voted teacher of the year by the
psychiatric residents at Cornell.
Since 1987 Dr. Swenson has been involved in the
development, direction or oversight of over 500
inpatient, outpatient, residential and day treatment
programs for clients diagnosed with
Borderline Personality Disorders.
He served for a number of years as the Area
Medical Director for the Western Massachusetts area
of the Department of Mental Health,
overseeing clinical care in Western and Central Mass
for the Department of Mental Health.
Dr. Swenson has published widely on the treatment
of borderline clients and has a new book called
DBT Principles in Action,
which was published just last week.
We're very lucky to have gotten some copies of his
brand new book and Dr. Swenson has graciously offered
to stay after to answer your questions and sign
some books if people are interested in purchasing them.
Dr. Swenson is a highly regarded clinician,
an accomplished writer and an inspiring teacher.
I also know that he is known to write and perform
songs about DBT, even he says,
when they're not requested.
So I'm eager to see what the rest of the evening holds.
Please join me in welcoming Dr. Charles Swenson.
(audience applauds)
- Alright, hi.
Welcome.
Yeah I'll have to
see if the conditions are right for a song later.
(audience laughter)
My big challenge is to get going, I have one hour
to tell you everything, which is a lot.
I am grateful to be here.
I've done a number of things with the Social Work School,
some summer teaching and this year I'll be teaching
in their masters program a little bit about DBT.
So I'm grateful that I have this opportunity to come
and I was miked up for an interview this afternoon,
they're gonna put that on their website.
And I'm gonna put it on a website that I just started
two days ago, charlieswenson.com
if you want to find that.
And I'm grateful to them for inviting me to teach
in the summer, it's been a long haul,
I've been living in this town for 19 years,
I've been pretty reasonably well known in the DBT world
and I've always wondered why the Social Work School
didn't ask someone who lives down the street to teach DBT.
But it's because they weren't ready yet.
You know and there's a time for everything and this year
I'm being asked to do this so it's pretty cool.
I'm pretty happy about that.
And also for them to be willing to do a kind of
a book event.
So after we finish tonight I'll just hang around
and sign books and or talk and or sing songs,
whatever it will be.
And so it's nice to be here and I want to thank
all of you for coming out on a hot Friday night.
Okay.
Could we get to the first, whatever it is, the
second, first slide.
Let me tell you where this comes from,
I've been doing DBT since I learned about it in 1987,
1988 and started developing it in 1989
and since then have been practicing DBT,
supervising it, consulting about it and doing
a lot of implementations and trainings.
So I've adapted DBT to lots of situations
and what you learn when you adapt the same thing,
the same basic thing to so many situations
is that you learn it pretty well.
You learn the principles of it because you have to be
flexible, so you learn the difference between the
trappings of it and the principles of it.
The other thing that got me going in this direction
to look at the principles and take them so seriously
is that this is a treatment model,
whether you know this or not about it.
Some of you are probably very informed
and some of you not.
There's more than 85 treatment strategies,
there's more than a hundred skills,
there's many protocols,
such as the suicidal crisis protocol
if somebody's in a suicidal crisis.
And just how to do this and how to do that protocols.
In other words it's like a very large cookbook
of strategies and skills and all kinds of explanations
about when to use them.
And you're treating people that are really
difficult to treat, borderline personality disorder
and other people with severe chronic dis-regulation
of emotions.
So to put a really complex treatment with so many
alternatives in place, in minute number three and a half
of a session when some surprising thing comes up
and you find yourself thinking,
hmmm which of the 85 plus strategies should I use now?
You know it's done already, you're already done,
you're already cooked, I mean like its over.
And same with what skills should I teach?
Let's see and it's done so I realize that it's
one of the challenging things about this highly
evidence based treatment,
supported by more than 20 randomized control trials
which is pretty good for a psychotherapy.
This problem that even though there's evidence for the
treatment as a whole there's no evidence for what
you do in any one minute.
There's no evidence when you do one of the standard
things in DBT which is to review a diary card with the
patient about their week, a self monitoring instrument.
There's nothing that tells you which of the one million
ways to review it.
There's a lot of suggestions but actually it might make
a ton of difference whether you review it with compassion,
sympathy, whether you review it in a pushy way
that's kind of like factual and objective.
Everything in between or whether you don't even review
it at all on a given week, you know it's sort of like
how do you know?
So you realize there's this paradox when you have
evidence based treatments that are driven by manuals.
That there's evidence for the manualized treatment
but there's no evidence for what to do at
any given moment.
Or how to do it because there's so many ways to do
things if you're a psychotherapist, right.
I realized, wow so what do you do?
How do you do the strategies?
And what about in between the strategies
because even if you have 85 strategies
if you really add it up there's probably way more time
in between using strategies
then when you're actually saying something
or using an intervention.
What do you do during the in between times?
I realize it's really not so easy to think of that.
Then I realized, I remembered that my first learning
from Marsha Linehan in the late 80's
was that this is a principle based treatment
with protocols.
Protocols include skills, strategies
and the kind of protocols I mentioned.
Wow it's the principles you know,
like in between the strategies the nuances
of how to do the strategies, it's very helpful to know
the principles.
What are the principles?
And you know I went to ton of training,
I did a ton of training and we would usually teach
the principles on Friday morning out of a five day workshop.
I was really good at teaching the zen principles for DBT,
which is really weird to be good at teaching zen
since it's something you can't teach.
And so you realize wow, I'm teaching these things
in an hour and behavioral principles of behaviorism,
wow do we really teach those?
So I started to review and over the past four years
I decided to really get clear about the principles
that underlies a treatment.
The principles out of which the strategies flow,
the principles out of which the skills come
and the principles that guide the therapist
throughout the treatment and I thought,
maybe if there aren't so many things to think about,
you can make more decisive and efficient decisions
in the middle of a tough situation to navigate.
You know?
And it turns out, really, there's only a choice
of three directions to go.
At any given moment in DBT, if you know what
the principles are cause they're associated
with three paradigms.
You either go in the direction of pushing to change
the patients behavior
or in the direction of accepting the patient
in the moment as they are.
Or you go in the direction of dialectics
which is more of an improvisation approach
that has certain ingredients to it but it includes
trying to synthesize the opposition in the room,
somehow.
And I thought, oh okay I just have to choose
between acceptance, change, or dialectics,
and you know I did that for a long time
and I did in training, I did it in treatment,
I find that I can actually do that
and then if you already know these strategies
when you do acceptance you start doing acceptance
strategies.
You don't even have to think of the strategies
if you've already learned the strategy
you just have to think acceptance.
And then you're guided by your intuition
along with you sort of over learned
repertoire of strategies.
So, what I want to share with you, what I shared
in this book that I wrote which is called
DBT Principles in Action: Acceptance, Change,
and Dialectics, I want to share with you
these three paradigms and the principles
that I've articulated as being associated with each
and let me tell you that I've articulated
them means nothing about me, I mean I'm just sort
of like borrowing from everybody else.
And trying to extract what I think are really the most
helpful way to put what the principle's are
and I come up with five principles for each
of the three paradigms and they're listed up here.
One other thing about the way I've listed
these principles.
Not one of them is a DBT strategy.
The names I've chosen for these principles
are ordinary words, not all ordinary,
but they're not localized within a therapy
they're not localized within DBT, cognitive
behavioral therapy, or anything else,
they actually, I really reached for this
because I wanted to come up with a framework
of principles to identify that would not only
speak to DBT.
I've been so impressed with what Linehan did
with her own personal suicidal life experience.
It's such a moving story and I've been so impressed
with what she did to turn it into a complex
and evidence based treatment.
I've realized that you might instead of just thinking
of this as DBT if you really extract the principles,
you might think of this as a set of principles
for getting out of hell.
And hell comes in so many forms.
You might think in daily life that it's
a set of principles that will help you when you get
to dead ends in your life, raising kids,
being in a relationship, trying to push yourself
to the next level in an athletic performance,
or an artistic performance.
Trying to get out of the hell of just being
alone cause you can't find anyone to be with.
Trying to get out of the hell or deal with the
dead end of being in a medical condition
that's not getting better and is scaring
the life out of you.
All of these things, the hell of being
a caregiver for somebody who's demented,
who you've loved all your life,
and it's another dead end, and it's really painful.
And I've thought about these various situations
and realized, you know what?
These are pretty good principles, for a lot of these,
I don't know how good I'm gonna I'm gonna be
exploring this next, but I wanted to capture,
not just that this is how you do DBT
but also this is how maybe you face the dead ends
in your life and also it might transfer over
to other types of psychotherapy.
So that my other types that I've learned,
I started out in psychoanalytic training,
learn psychoanalytic approach and then worked
with Otto Kernberg for years in a psychoanalytic
approach to borderline patients.
I've been interested in family treatments
and I've been interested and wrote an article about
mentalization based therapy which I know less about
but enough to write an article.
If you're good at writing articles you can do this.
But actually, now I get to know more and more about it
but sort of like everyone of these things actually
requires reference to all of these principles
so I've been getting more interested in, you know,
is this useful or is it not,
if I write something for people to get out
of dead ends is this just gonna be book number
7,459 at an airport bookshop that tells you
how to cope with you life?
I mean or is there actually something unique because it
comes from an evidence based treatment from a really
smart woman who put together something that's
for people to get out of hell and it really works.
So, I wanna tell you about these, so lemme tell ya,
what I'm gonna do just to forecast this now,
I'm gonna tell you as concisely as I can,
which is tough for me, that's the hardest thing
about this whole talk for me tonight, is to try
to do it in an hour, so I'm really gonna try
to be concise, I'm gonna ask you not to ask any
questions til the end, I'm gonna be trying to leave
questions at the end, time for questions,
and I wanna tell you about each of the three
paradigms, each of the 15 principles briefly
and then demonstrate, just a brief sampling
of what it might look like by doing a brief, few minute
role play after each set of principles.
Okay.
So let's go to the next slide.
And this one I'll go through quickly because actually
this slide is now broken out in the next five slides,
this is just so you can see them for a minute.
This set of principles is derived from cognitive
behavioral therapy, which is really the original
backbone of DBT.
It's how do you solve problems behaviorally.
How do you push for change.
Alright?
And what I've done in those parentheses,
these are terms that belong to DBT,
where you find these things, like direction,
pushing for a certain specific direction
in DBT is specified as treatment targets,
there's primary targets, there's secondary targets
and I'll look back at this at the next slide,
and then there's force which is not a psychotherapy
term it's more of a physics term but it's really
captures that idea that if you're gonna go
in a certain direction and if it really matters
to you, you have to cultivate sufficient force
to get there.
You have to give it all, whatever it'll take
and in DBT that's gonna be called commitment,
commitment strategies and generating
an attachment because a lot of time the only reason
a patient does something in the first era of therapy
is because they get attached to you or someone else.
And then there's persistence which in DBT is represented
by the fact that every night the patient monitors
their progress on their target behaviors,
their emotions, their skills, the things you're trying
to do something about and every week brings that
card in and reviews it with a therapist
and one of the functions for that is to help
both parties stay on track.
It has lots of functions but a very important
one is persistence.
It's like you putting stars on your calendar
because you did exercise again today or something
like that.
Then there's intelligence, which is a larger,
important framework or principle within behavioral
change that I'll get back to and in DBT it consists
of three things, for those of you who know the treatment
it's behavioral analysis which is a way of assessing
the obstacles, case conceptualization which is a way
to formulate the obstacles driven by the theory,
the underlying theory, and treatment planning
which is where you go from your case conceptualization
in order to change the behavior.
So this is kind of the intelligent part of DBT
and you have to know all of these things
and how they actually sort of,
almost imperceptibly weave into each other.
And finally you have to know the techniques,
I mean you have to know how to do the strategies
and stuff, so there's protocol, strategies know
what the skills are.
Next slide.
So lets look at the direction part.
So the agenda, this is where each of these things is,
I mean I feel, I looked at this, I sat in the bathroom
before I came out here tonight and I thought,
I looked at these and I thought,
Jesus Christ this is nothing I should just go home,
I mean because they look so obvious
but actually they're probably not, I just think they
are because I've looked at 'em for four years.
But you know this is really important, I mean,
I find as a supervisor with people in DBT
and other models of treatment that one of the main
ways that therapists don't do very good job
is they actually aren't very clear about their direction.
They don't know what they're doing,
they know what they're doing maybe but they don't
know what they're trying to accomplish and so in DBT
it's something that's very directional,
it's very sequential, it's sort of linear,
it's sort of like this.
It's like we're getting from here to here.
We're getting from cutting yourself to not cutting
yourself which then will get you to where you
can experience your anger and your shame
without cutting yourself, now we'll get from
having anger and shame that you can't manage
to getting it down with more skillful techniques
and now we gotta get to where we're gonna go over
the trauma from your life that's really driving
all of this and we're gonna have to get from where
you experience traumatic cues in a way that's overwhelming
and anguishing and we're gonna get to where you can
experience traumatic cues
without so much anguish.
Alright, so there's step after step,
but every step is directional and it's getting
from here to here and that's important
because the other two sets of principles
have nothing to do with a sense of direction,
this is the direction.
This is the direction and getting to where you're
going is the measure for whether the treatment works.
It's the only one of the 15 principles that,
in the long run, matters.
But all the other 14 help you get there.
So but you gotta have a direction and if your direction is,
well I'm gonna work on my self cutting.
That's not what I mean, that's vague.
I'm gonna stop self cutting, alright when that's getting
better.
How bout stopping it starting this minute for one year.
Oh well I can't do that, oh now you know that you've
got a direction, I mean because now you've encountered
trouble because it's actually gonna be hard,
but if you don't have a specific direction,
you don't get as far and there's research
in psychotherapy research saying that what you target
is what changes.
Or what changes is what you target.
If you don't target substance abuse it usually
doesn't accidentally change while you're targeting
something else.
If you don't target an eating disorder it doesn't
usually accidentally change until you name it
and target it along with whatever else you're
targeting, so this idea of having a direction
and having it be specific and having it be public
between the patient and the therapist and aiming
for it and monitoring your progress towards it
is something that in this model you want to be
very deliberate about so that if I stopped
a therapist in the middle of a session
at any moment, and if I said to the therapist,
let's stop right there, what are you targeting?
What's your direction right now, what are you
trying to do?
And they say, "Well I was trying to target,
"the self cutting of the patient but actually
"she really didn't want to so now we're kinda
"targeting her underlying feelings."
But the person says, "I'm trying to target the overwhelming
"anger she feels because that seems to be
"the driving force for her self cutting."
Alright I'll take that.
You know that's a target towards the target.
Their best targets, I think in DBT and I think in life
in my sort of more grandiose self,
should be clear and specific I just have done so much
work with people that I say, okay what's the target?
And we're already in trouble when they tell me
what the target is, I wanna get a very, very specific
target and it just helps you get places.
It should be compelling to the person not just to you
not just to the therapist and not just in the model.
Stopping cutting for most people is not a very
compelling target.
Unless you link it to something else
that results from stopping cutting.
So you really have to figure out how to make
a target compelling.
You want it to be realistic so it's just not crazy
and won't work.
The person centered meaning it comes from
the patient not from what you think the patient
should do.
Patient in my day program back in White Plains,
New York, our DBT day program,
that sat down at her girls group,
with her fellow patients and her three female
staff members, all of whom are really good at
what they do, all of whom work really hard,
all of whom also have lives that they have to keep up,
working moms in a couple cases.
And the patients they said, "So Kathy what would be
"your goals?"
She said, "Well I'd like to meet a very rich man
"and marry him and take care of his house
"and give parties, I'd love that, that would be great."
And from what I heard from Kathy,
I was her individual therapist, Kathy said
then all the three women just sat there
and looked at her for an extra few seconds
then one of them said, "Well that's an interesting goal."
And you could just tell all of them were like,
but then somebody else said, "But in the meantime
"don't you think we should work towards you
"getting a job?"
You know probably working towards getting a job
was not gonna get her towards her goal as fast
as actually working towards finding a rich man,
I mean unless she changed her goal.
So we were really trying, I mean but this
was challenging, you know, people don't always
target what you want them to target.
And being collaborative so the target is shared
between the two.
Next slide.
Now you need enough force to get going
with your target and you can see here,
you know, there's a lot of things I think that
generate force in psychotherapy.
Having a strong enough attachment,
I think probably most people here are psychotherapists
and you know if you have a very strong connection with
a patient you can accomplish more behavioral progress
in five minutes than in an hour if you don't have that.
The effect of contingencies really laying out
why would you do this or why would you wanna
do this, is really critical.
And structuring life to support whatever the targets are,
you know if you're a teenager and you're targeting
becoming more assertive, with a teenager that has
been stepped on by everybody and doesn't speak
up for herself in a family that's been kind of invalidating,
you know and you have an environment that when she
speaks up she gets smacked around or told
that she's an idiot, is not gonna work.
So you have to work on the family environment with
that person, same with people who are in schools
and people who have a certain friend who is going
in the opposite direction of their treatment targets.
And then in DBT there's six to seven commitment
strategies that are very specific that you use to
try to generate a stronger commitment.
I had a patient that I spelled out the targets.
She wanted to stop cutting herself,
she was 16, she wanted to stop cutting herself
and that's why she came into therapy,
she also drank a lot.
Drank a lot to the point where it was obvious to anyone
but her that this was a big problem.
Cause while she drank on the weekends she would end
up at parties with people much older than her
at a college and she'd wake up in the morning
after blackouts and not know where she was sleeping
and she'd be with some guy that she hated
and her clothes would sometimes be ripped off
and she was sometimes hurt, and she would come in
and say but I don't want to stop drinking,
I just wanna stop cutting myself, I think I'm a freak.
So we spent a fair amount of time arguing,
I guess would be the normal term for it,
negotiating might sound better but we were kinda
arguing about whether her alcohol was a problem
and she just kept saying no and then she tried
to convince me by saying, "But I love alcohol.
"But I love it."
I said, okay you love it, I mean what if you loved
jumping off a cliff, and all these ordinary things
that all of us idiots would say, I mean it's like,
I'd just come up with the same things everybody
comes up with and it doesn't work, you know,
and she just says that, so I agreed since she
had been thrown out of three prior therapies
in the area, all three as it turns out when I called
people was because she wouldn't stop drinking
and they were afraid for her life.
I agreed to work with her on the cutting as our target,
like our 100% target, and that when we got that
under control I'd work on her next target with her
which she defined, and she defined it as
doing stupid things.
Doing stupid things meant she would do these things
like end up in peoples rooms in a black out
and then get hurt.
She didn't want that part to happen she just wanted
to have a good time at the party.
So, she wanted to stop doing stupid things
but not stop drinking.
I told her I didn't know that we could do that
cause I thought that drinking seemed to cause
or create the condition but she said, no she didn't
believe that.
So, I said alright, then I will do that,
if you can stop cutting, which she did instantly,
and didn't do it again cause this was so exciting for her
that we were gonna work on stopping doing stupid things,
but allow her "to keep drinking",
but I told her I would only do it if she would not drink
when she was driving cause that scared me that she
was gonna kill herself or somebody else.
She agreed to that.
And we created a little mini manual on how to stop
doing stupid things when you drink, at parties,
and it was like a two page manual that said
what to do before you go to the party,
what to do during the party, what to do if this happens,
what to do if that happens, very behaviorally oriented,
she really like working on this, and I had told her
that if we did this for three months and it didn't help.
I would quit with her.
Because I would feel I couldn't continue in good conscience.
So we worked on this and she liked this idea,
in fact I told her if this worked we could both
retire on this model by selling it to the world
because so many people would wanna be able
to do this, but she thought this was funny
and we got going, and nothing changed in three months,
three months came by and I said, we have to stop,
and it sort of caught her by surprise, she was upset
about it and then we stopped and she called me back
in about one to two months and said,
"Charlie I think I'm an alcoholic."
I said, okay, why don't you come in and let's
talk about that, and then we targeted her addictions.
Which was not, turned out not just alcohol.
So it's kinda like getting deliberate about your targets,
negotiation your targets and needing to generate the force
and realize if you don't have the force
it's almost pointless to really generate much
problem solving interventions, you actually don't have
a partner.
Next slide, persistence.
So this is sort of, getting persistence over time
of both the direction you have and the force
which really, you know, I don't know about you
in your treatments or your supervisions but I supervise
a lot of people and sometimes I find myself doing it
that I think I was working on one thing
and next thing I know I've drifted off on to
something else and it's sort of like how do we get here
or, and sometimes it's just cause we couldn't make
progress on the first one.
And so we move on and by doing that, it's not
a behavioral model, behaviorists line up the targets,
let's say you have four problems, OCD,
and you have panic disorder, and you have self cutting
and you have something else, you line them up in order
of priority and you tackle the highest priority one
for 100%.
Doesn't mean you never mention the other ones
but you go with the first on for 100% which sometimes
is really difficult cause the others are laying in wait,
they're still happening.
But you don't give up on the first one cause
it takes so much sometimes trial and error
to finally find something that makes the difference
on the first one so that's a behavioral way that
you treat targets which is very different than
psycho dynamically where you can sort of talk about
what ever story's going on and you kinda see
the underpittings of all four, and you're trying
to get at something that's under the surface.
Behavioral, no, we're trying to stop number one.
And then we'll go on to number two.
And the pressure builds sometimes.
So you use this diary card and you use the monitoring.
You know and sometimes I've had college students
in this area that have a great start and I feel like
I'm doing good direction, good force, and we got
persistence going, and it starts in September,
then the patient comes in and she's written down
all of her courses and what her schedule is
and she's very excited cause she feels organized
this time, and her ADHD as far as she's concerned
has gone away and now she's gonna make it,
and then November comes and she starts to write
her professors asking for extensions,
and then you know you're in big trouble.
Like it's drifted and you took your eye off the ball
and I take my eye off the ball cause it's really
hard to keep your eye on the ball with something
that's a student who's figuring out, because they always
have some reason to explain why they can't stay
on something and next thing you know they're in
a hospital in the end of November.
So you've gotta work on the persistence.
Alright, next slide.
The intelligence.
So as it says at the top, you do need direction,
I think, you do need sufficient force which is sometimes
a lot more than what you were thinking.
And you need persistence and to build that into
the relationship or the treatment.
And it's not sufficient because then you still run
in to obstacles, and when you run in to obstacles,
what do you do, then?
You could just double the force,
you could just strengthen the direction
but actually you might still find out,
no that just doesn't do it, just end up in a war
with your patient.
And so you actually have to step back
and both go, hmm.
What is the problem, what are we gonna do here?
And you have to have a model for coping with that,
when I learned object relations theory with Kernberg,
there was a whole way of thinking of how you formulate
this situation that has to do with identifying
underlying object relations, and affects,
and splitting, and so on.
You know with a behavioral model, you have to have
some way to conceptualize what's going on
and the way you start that is what, for those of you
who don't know DBT at all, you do a behavioral analysis,
a link by link analysis of what led up to the problem
behavior, and that becomes your template and everything
comes out on the chain, eventually, if you stick to
the chain.
And doing the chain is so central to DBT,
in more depth ways then I first encountered,
literally everything that I can think of in DBT
is on that chain so if you keep going through
the chain you find everything, you find the invalidating
environment on the chain, you find the person
who has biological vulnerabilities.
You find the trauma on the chain and you find these
lack of skills on the chain, so you just keep going
through the chain and looking for what is
the problem here?
Why cannot we get this to change?
With one patient it was that she just wouldn't
stop substance abuse, she just wouldn't stop,
she just wouldn't stop it and then she would say
she was and then she'd change her mind,
she wouldn't stop it.
So push, push, push, stay with the chain,
stay with the chain.
Hey, you have to show persistence as a therapist
yourself cause this is your target.
And then you find, in this case for instance,
that this person actually couldn't stop
substance abuse, because as she had explained,
she was better when she was high.
Well I said, of course, I mean what do you mean,
I mean of course you're better when you're high,
in many ways.
"No, no, no you're not getting it, my husband
"likes me better when I'm high."
Oh your husband, and so he knows about this?
She says, "No, no, no he doesn't know it's because I'm
"using substance, he thinks it's the normal me.
"So I need to keep doing this with, you know because,"
(audience laughing)
If I need water I know where it is.
Yeah, so I said so why don't you bring you husband in?
"Oh no, he can't know that this is why I'm better
"then he won't want to be with me cause of my normal
"self is pretty boring, you know he wouldn't like me."
I said okay, and then I learned that he's a doctor
and he's the one who writes for the medicines
that she's on that get her high, but he thinks it's
doing it because of pain and somehow he's getting
away with doing it cause as I know with my own family
I can't write those kind of medicines for my own family,
unless I say it's for my dog or somebody else,
you know.
So, then you find out by push, push, push,
chain, chain, chain, link, link, link
and then you run into oh that's it, now you know what
to do but you have to have a method and in DBT
that is the method and I use it all the time
and it's finding the missing link,
it's finding the hot link, it's finding the thing
that you never noticed.
With the patient of mine that had severe PTSD
after one year after she had been raped
at Hotel Northampton by her best friend,
who she had gone to hotels with for years.
They went out to a bar which they had always done,
they went into the hotel, they went in the room,
and she was half asleep he got in the bed
and raped her and she, a year later after one thing
after another shut down and she just became more
depressed, more suicidal, more avoidant, she had quit
her really good IT job and she had stayed in her apartment
and she got a lot of locks on the door.
Alright.
So, I'm thinking, oh I know why this happened,
so I go over the link by link analysis of that night
and find out, no, you know what after about five times
through the same story, link by link,
I found a link I didn't know before and it was the
most important link of all and it wasn't the big one
that you would think, that she was penetrated
by him when she's half asleep, and it totally freaked
her out and made her panic, no it actually was something
else, on the way in the door to the hotel,
as she told it the fifth time,
"Oh yeah,"
cause I started asking more microscopically,
what happened then?
She said, "Well then as we were going in the door
"there was something weird that happened but it was nothing,
"I went in the door first and he put his hand
"on my back of my neck, like an ordinary person
"would do it's just that he had never done
"that sort of thing.
"And then I went in the room and we close the door
"and that was it.
"And I got in the room and I thought, God that
"was weird."
But then she filed it away and later it was because
she didn't pay attention to that link,
not that she should have but she didn't pay attention
is the reason she felt she's always in danger
because she can no longer interpret the potential
that danger could happen, it wasn't that danger
did happen as much as the fact that she missed the cue
cause she prided herself in singles bars
for years as being a very assertive, very effective,
she could see danger coming a mile a way
and tell people off and so this blew it, you know?
But you don't find this out unless you sort of realize
okay I have a method lemme just use the method
and then keep doing it until you find what the link is.
Which can be really frustrating cause you wanna
move on and you realize you haven't found it.
And the only reason you stick with it is because
that's what the treatment says to do.
And even that I wouldn't stick with sometimes
unless I had a supervisor and I was doing one with
Marsha Linehan as my supervisor.
Came to Marsha and I said, Marsha, I cannot do
one more chain analysis on hair pulling
with this woman, nothing is changing,
she pulls her hair all the time, I mean it's
trichotillomania, it's really, you know,
and I said, I think we need to move onto another target.
And Linehan said then, which I thought was part of
her rigidity at the time and later I came to think
this is why she's so good.
She said, "Well, what can I tell you, Charlie,
"it might be better to move on but it wouldn't be DBT.
"And I'm trying to teach you DBT so if you're doing DBT,
"no you take the highest target, highest priority
target and you do chain analysis."
She said, "you know what the problem is,
"you're missing something.
"You're just missing something, open your eyes."
She said, "It can't be different every time,
it can't be the same every time.
"Nothing's the same for more than one instant
"in reality, at any level, so she's totally different
"every week, and you're totally different.
"Open your eyes, just wait, look, watch."
Pretty soon I did find something.
Probably come back to it.
And then you have a door opens and then you have
to have a way to formulate it and then build it
into your treatment plan to do something about it
with this woman, I really had to start to work with her,
not on her fear of danger happening, but her fear that
she couldn't recognize danger and that led to sort of
a different pathway of working with her.
Next slide, final slide on this.
This is sort of an obvious one, I mean I just thought,
what's the other thing you really need in addition
to these four things, you need to be able to do
the technique, if you're gonna be treating anxiety
disorders you need to be able in behaviorism
to do exposure and response prevention.
You need to be able to do skills training
and skills training and do cognitive restructuring
if you're working on people's cognition,
so it's kinda like you just have to hold yourself
to the fire about learning these things
and then there they are for you when you need them.
Now I wanna do the first role play and I know I'm probably
behind on time but I wanna invite Matthew Munich
who is a supervisor of students in the social work
school, he was a social work student here himself,
I've known Matt since he was 15.
So it's fun to have him do this.
We started playing golf together when he was 15
and his dad and I and he would play.
Come on up.
(crowd laughing)
And he doesn't want me to say any of this stuff.
So anyway, so he's agreed to be a 17 year old
teenage boy in treatment with me.
And here's the problem, cause we're only gonna
go for five or six minutes and I wanna demonstrate
how it might look if I was only doing these things
as opposed to the other principles.
I'm only doing these things which is what Linehan
did at the beginning of trying to develop DBT
and she found it didn't work.
So, here's a situation, in DBT you need to be in
individual therapy and a skills training group
and like many patients, Matt, or actually
he's gonna be Jacob, I learned today,
Jacob doesn't like being in skills training groups.
He just wants to be in individual therapy with me.
We've met a few times, I was supposed to force
him in the group the first week but I kinda let
it go cause I was sympathetic to him and he really
didn't want to go into group, I thought,
we'll ease into it.
Well it turns out it's not happening and now it's many
weeks later and I'm gonna tell him that he has
to be in the group, and that's where we're gonna be.
So obviously, already, the direction here is to get
him to go in the group, it's very specific,
it's sort of either he does or he doesn't,
so you kinda know what your direction is.
Alright, so I haven't really pre-scripted
or him pre-script what's gonna happen but I just,
and there's a little mic right here which might help
but maybe you'll hear him anyway.
Alright Jacob.
Hey.
What's happened?
- Hey.
- You alright?
- Yeah, yep.
- Yeah, good, good.
I missed ya last week, I don't know what happened
last week but you know I left a message for you,
were you gonna,
- I couldn't come in.
- You what?
- I couldn't come in.
- You couldn't come in?
- Yeah no I had other things to do.
- Other things?
Yeah.
More important than me?
Come on, come on man.
There's nothing more important than seeing me.
I swear to God.
What are you doing?
I mean I want you to be,
I want you to be on your game with me, every time.
Right?
Can you do that? - [Jacob] Usually I am.
- What?
- Usually I am.
- You are, you are and I like seeing you and you've
told me you like seeing me, it's only been a few
sessions but, you know we're not gonna stick
with this right now, I wanna come back to it at
some point, and you've only had this happen this one time
I just wanna make sure we're together.
Cause now I'm gonna bring up something that's gonna
be hard for you.
You know how at the beginning of treatment like a month
ago or so I told you that you needed to go,
you needed to be in a group every week for once
in a week you go to group and once you come and see me
cause you gotta learn these skills man,
they make all the difference, they're like,
they're the real thing here and then I help you use them.
So how bout going into group starting next week,
they do have an opening.
- No, no I thought you were kidding.
No come on man, no--
- Kidding, when did you think I was kidding?
- When you said,
before.
- You mean the first time I brought it up?
- Before, yeah.
- You thought I was kidding.
- Yeah.
- Haha.
I mean, you don't wanna go--
- No I told you I don't like that, that's just really
uncool of you, that's really harsh, that is really,
really harsh.
You're being harsh now.
- I am?
- You're being harsh.
- I am.
- Yeah, you're being harsh.
- Let me,
look, Jacob let me point out something,
cause you and I have worked together for awhile but this
is gonna be one of our challenges and we're gonna
get our relationship even stronger when we get
through this challenge but let me tell you
when you say that it hurts or that I'm being uncool
or unfair to you, you're like leaving aside the fact
that when you entered this program you knew this is part
of the program, it's not like I'm an asshole,
it's like if you wanna call the program an asshole
and maybe it could do that but it's like
the program is that way, and we have to do it,
and I expected you to do it.
- No, I told you I wasn't good in groups,
I told you, people don't like me, I don't like other people,
it just doesn't work.
It doesn't work, my ears clog up, I don't learn anything,
I learn things like this.
I told you that man--
- In other words you're like a one on one kind of guy.
- This is the way I like--
- This is the way you learn.
- This is the way I like it, this is hard enough for me,
you're pretty good, you're cool, kind of.
(audience laughing)
- No I think that's a pretty high praise,
but whatever it is the fact is that I understand
you don't want to go into group, you're not the first one,
the question is how can I help you go in the group
because you need to go in the group
because actually, and you might even get something
out of this going in the group.
- No.
- Look, let me be straight with you.
The reason we do this treatment is because there's
evidence that it helps teenagers who are doing the stuff
you're doing, it's like one of the best treatments
in the world.
And the only evidence is for when you go to the skills
group and you see your therapist, so if I just see you
that might be easier but it's taking the easy way out,
it's not like doing the thing that's gonna change your life.
So how bout it?
Try it, do it, like,
I do want to know what is it that's so bad?
But I'd like you first to just say, okay I understand
Charlie, I gotta do this.
And then let me work with you, let me help you
get in there without sacrificing too much,
you know?
- I don't know how.
- You don't know how.
But you know, to know how you'd need to,
I would need to help you with that, I need to know
what is the problem, like when I say go to group
what is it that sets you off when you think
I don't work well in groups.
Earlier you said, people say things to you
or they treat you a certain way, is that part
of the problem?
- It's the way they look, and my face feels so hot.
Just feels so hot.
- You're face feels hot.
Do you know what that's about?
Is it related to how people look at you?
- I feel a little bit of it now.
- You do?
Is it when you feel you're under a lot of pressure?
Yeah I feel like I'm putting you under pressure.
Yeah.
And I need you to work with me on this
cause we need you to get to the point where you
go into the group.
Okay we're gonna stop right there, thank you Matthew.
Alright.
(clapping)
Alright, whoa.
Nice job.
Yeah, so, alright.
Straight out pushing somebody.
There's the door let's get you through it, right?
That's how Linehan started.
That's the sort of core of DBT, it's very relentless,
it's very disciplined, and towards the end
there was a little bit of an opening to start
to use the intelligence part of my principles
and say, how do we understand what the problem
is cause then maybe we can work on it.
So now let's go to paradigm number two,
next slide.
So, you know these are five principles just listing
them but I wanna now go right on cause I'm already
gonna run short on time.
- [Voiceover] You're fine.
- Well we need time afterwards for,
but presence, so the first principle,
and by the way these five principles you might
say are all could be re-framed as insights
from a long time of meditation by people who have
taught meditation and learned meditation
beginning with the Buddha.
But these are really all profound principles,
hard to talk about, hard to get across,
and they're just this second paradigm.
They are the things you wanna be doing while you do
what I just did.
You want push for change at a context of acceptance.
That's Linehan's definition of the fundamental dialectic
of DBT, and what it means to me is that while doing
those five things relentlessly and in a firm
and intelligent way, you are also creating a context
of acceptance.
And how do you do that?
These five principles.
One is presence, while focusing on goals and targets
out there, the treatment takes place in here,
in this moment, no matter how much you have your eye
on the prize, the more important thing to have your
eye on, that sometimes has to eclipse you eye
on the prize is this other human being that's sitting
opposite you and how you're doing and how he's doing
or how she's doing.
The therapist establish him or herself
in the present moment,
which might done in a number of ways.
And invites the patient into the present moment,
a sort of metaphorically that's what I'm doing
at my best even if I'm gonna challenge the hell
out of somebody I wanna welcome them into my present
moment, I wanna stay there, if something very uncomfortable
happens I wanna stay with it and notice that it's
really uncomfortable.
And then I want to move on to the next thing
and I wanna notice if I've lost my mind,
if I've lost the present moment, if I've lost contact,
and sometimes it's just reminding yourself about
your butt on the chair.
Oh yeah, I'm still here.
You know, get back in your body.
Because when you start doing intense work
with disregulated people you get out of your body,
you're in your head, you get defensive,
you get too thoughtful, and you have to kind of like
be intuitive and automatic and be there in your body
so you sometimes have to use anchors to keep
getting yourself back in there.
Anchors such as attending to the breath.
So you're in the middle of a session and you start
to feel like oh my God I'm losing my mind
in this session, I'm going around in circles,
this person is confusing me, you know, sometimes
the best thing to do is get out of the change paradigm
and just say, (sighing)
notice one full breath, like totally, from beginning
to end and you don't have to announce it to your
patient, and say by the way, I need a breath here,
you know, you don't need to do that you can actually
notice your breath invisibly, I mean a really perceptive
patient knows you've done it, you know, but you can
do that or you can make your anchor point,
as I did once with one patient who was basically
screaming about, it was in a family session,
screaming about how her father was always coming down
on her and giving her no chance at controlling her life
and I don't really see it because in here he acts like
a normal human being but at home he acts like a complete
asshole and he makes her do the dishes every night,
and this stuff's going on and she's like,
and I'm thinking oh my God what am I gonna do,
you know, family therapy's really hard,
and here's the mom and the dad and she's there
and she's like going.
And I thought, Charlie take a breath.
Took a breath.
It wasn't enough.
You know sometimes one breath doesn't do it
and I started to just look at her face while she was
still yelling, it was almost like going into a mode
where you're still there but you're observing in a way
while you're still there and I looked at her face
and her face actually looked sad not angry.
When I actually let myself look at her face
I had to let go of my fear or my automatic defensiveness
to somebody who's yelling at me.
And I just looked at her and I said your face looks sad
and she burst into tears and said,
"If you had a father like mine your face would
"look sad too."
And suddenly we were at a different place.
And so sometimes these don't like cure anything
but they get you a different place, they cut
the tension in the air by just stopping and observing,
noticing and making a comment.
You never know what's gonna come.
But you might anchor yourself in your observation
of your patient, in your observation of your breath,
in your observation of sensations in your body.
In the sounds in the room or other things.
And so when you drift from the present, which is the
hardest thing is knowing you did,
I mean just like in mindfulness practices,
you drift and like then you say oops I'm thinking
about other stuff and you realize you've drifted
and it could've been an hour, you don't know,
it might've been 10 second or it might,
you really don't know but at that moment you've gotta
like say, alright let's go back, let's observe the breath.
It's like, let's get back here in my body, in the room
with my patient, establish my presence, so that we're here.
It's like loving your patient enough to be there
for your patient the way you wanna be for your partner.
Okay next slide.
Then there's the principal of impermanence.
And here the idea is that,
like I said earlier about a different one,
that things are changing all the time.
Like nothing ever stays the same.
When Linehan said to me, "Nothing's the same for
"more than a second."
So don't tell me it's the same as last week,
it's not the same, at all.
Just looks the same, you think it's the same.
The fact that you think it's the same
is a problem.
So it sort of like, how do you get yourself to be
aware that actually things are always changing,
even if stubborn patterns are still there
and then if you just remind yourself,
nothing's the same, things actually are changing.
The walls around us are changing, we can't see it
but you develop more patience.
And I remember when Kernberg first taught me
therapy one of the things he said that was really
mirrored by what Linehan said, but he had his way
of saying things and he said,
"With your borderline patient you're working with,
"you want to have intense urgency
"and infinite patience,
"at the same time."
And he wasn't teaching me dialectics but it was the
same idea, you wanted to be there and realize,
things will change, time will pass.
Gives you more hope and it helps you participate
in this moment and makes every moment fresh.
I had a patient who was suicidal most of the time
and it was one of these agonizing treatments,
where she was one of the patients I've had that I thought
is really gonna do it.
And it was really scary and she'd come in
and talk to me and in a very convincing way,
clearly she was convinced there was no point
in going on, and she was trying to convince me
there was no point in going on and that it was over,
that her body, in fact she would say sometimes
is actually dead already.
And it had a psychotic flavor, but there weren't
other ways in which she was psychotic, but she said,
"You don't realize, in my body I'm actually already dead.
"And there's no point in going on, it's just agony.
"And so I don't know how I'm gonna do it but I can't
"stand this anymore."
And I tried to change things and I tried to change
medications and I had her go to a hospital and come back
and do all kinds of things and she was still that way
and I just thought, this is really hard to bear.
And there was a certain point when I just started to think,
alright, alright, and I talked to other people,
try to get a little help with it.
Nobody was coming up with much and so I just decided,
okay alright I'm just gonna sit with her and believe
that this isn't the same every time.
And just listen, and just be there, and stop trying.
If I want to acknowledge that it scares me
I can acknowledge that it scares me to her.
Acknowledge that I don't know what to do with her
right now, that I have enormous empathy for her
but actually I can't think of exactly what we can do
but then try to give her reasons to keep going
but it sounded hollow to her.
And there was a certain point when I just started to
feel like, you know,
I just have to be here.
It's like realizing you're standing at a wall
and the walls a foot thick and your goal is to get
to the other side of the wall and there's not a hole in it
and you can't go around it and you can't go over it
and you can't go through it.
And there you are, what do you do?
Well you stand there.
You know in this model, impermanence says this wall's
gonna crumble some day.
Or a crack's gonna develop if I just keep paying attention,
I'm just gonna stay with her.
And I just did and not long after that,
and I would just hear bad things from her,
I went away for a week, which scared me, about her,
and I came back and she came into a session
with the first affect other than depression
I'd seen for long, she said,
"I'm moving to New York."
What do you mean you're moving to New York,
you can barely get out of your apartment.
"No, I've decided I need to go back to where the original
"problem is, where I was left by so and so and where
"everything fell apart, years ago.
"And I just need to go back there and I realized
"this is what I've figured out so that's what I'm gonna do."
I said I think think we should talk about,
"I've already got an apartment."
Oh, but how are you gonna,
"I've already got a job.
"I've got my old job back."
Oh, wow, you've gone a long ways since I went
on vacation.
Yeah, you know, and I don't know what the relationship
between these things were but I think sometimes you have
to write relax into the awareness that you don't have
another thing to try.
And so you realize impermanence and things will unfold
and sometimes they do and sometimes they don't work.
And then if you can think of anything to do,
by all means do it, but sometimes the valuable thing
is just to be there.
Marsha Linehan tells a story, when she was in
the Institute of Living,
when she was 19 years old and she was there
for a year and a half and she just went through
really a bad time and trying to hurt herself
and being impossible and being put into the security floor
over and over and over again
and then she says that when she came and gave her
coming out talk in Hartford at the Institute of Living
about three or four years ago telling her story
that's written in the New York Times and you can
watch it on YouTube or whatever, but she describes
that the thing that got her through the hospitalization
was two different doctors, one of them was a psychiatrist
and one was a psychologist, one was her therapist
one was her medicating doctor and both of them's
at different times talked to her,
especially the psychologist she had talked to her one day
and said, "Marsha I just wanna tell you,
"we are trying everything we know how to do.
"I think you must notice, we haven't helped you.
"And we feel terrible about it and we're just trying,
"we just want you to know that, you know,
"because we're looking for a way to do it but we know
"we haven't helped you."
She said that was unbelievably helpful.
That they were just persisting without knowing what to do,
being transparent about the fact they didn't know
what to do, made her feel connected for the first time
in a while, cause of that, so that kinda sense of
staying with things, things are impermanent,
they will evolve, doesn't always turn out that good
but I think, it's what I mean by this principle
and I think it often is a good way to go.
Next slide.
This is non attachment.
We get attached to what we want, this is just straight
Buddhist kinda teachings.
That we get attached to what we want and we try
to avoid what we don't want and so we get,
in therapy we get attached to a positive behavioral
outcome, and if it doesn't come we get really frustrated
because somehow for God knows why we actually think
that because we think we want to get there we should
be there.
Like it has nothing to do with reality, we just think
I'm gonna get this patient to not be suicidal,
they keep being suicidal and it's sort of like
oh my God, they're still suicidal, alright they're
still suicidal because that hasn't changed
but there is this way which once we attach our brain,
our thoughts, to I've got to do this,
you know you're at risk of burnout.
You're at risk of getting disregulated yourself
and therefore being less helpful to the patient
so it's a really tricky thing what to do
cause you don't wanna let go of the patient
but you have to let go of the belief that you
can help the patient, sometimes, and just work
without that belief anymore.
So sometimes you think the patient should cooperate more
and it drives you crazy, right, you wanna,
and you can't get the patient to cooperate
or comply with things and you just think,
oh my God if only she complied.
If only he complied.
But actually that might not be true.
But once you get hooked on that,
so it's sort of whatever we get hooked onto,
it's realizing that we're attached to something
that we actually can't control
and so, you know, practicing non attachment
we notice these things, we let go as much as we can
which help us to reduce our burnout and prevent
a limit with the situation and maybe then begin
to notice what's really going on.
It was a moment like that with that teenager
that had the alcoholism
but that didn't think it was a problem
and that I really, you know I went through with her,
I gotta do something about this.
And then the more I checked with the other
doctors she had I realized she's don't this with three
other people, she's only like 16 and she's done this.
She's really good at this and its sorta like,
so I had to let go,
to some degree of my belief that I should be able,
the great me, I should be able to figure this out
and become the omnipotent rescuer.
And as soon as you're into that category
you're attached to something you can't control
and it really can burn you out and can lead
to clinical, to bad outcomes.
I may mention this guy again
but there was a 16 year old boy who had cut
himself mercilessly for about a year and a half
and was depressed and had stopped going to school
and wouldn't leave his room above the garage
in his house.
And he,
when they brought him a tutor he called the police
and put out a restraining order on the tutor
and he just didn't want to go he just wanted
to be in his room and listen to his music
and the only thing he would come to is his parents
would bring him to me and it was a distance away.
And they'd come once a week and I'd do an
individual therapy session then I'd do a family
session and teach skills to the mom and dad and the kid.
And in the individual sessions with me for literally
three months he almost never spoke.
And he would stare at the wall sideways,
his head sideways to me, he had long hair,
I didn't even see his face, and it would go on
and on and on and I just, you know I have a lot
of patience with difficult people, working with people
but I was losing it and I went into my consultation,
DBT consultation team, and I said guys, I think this
kid hates me, he doesn't want to work with me,
I think I should really stop, this is not getting
anywhere I just think this could be making him worse,
blah, blah, blah.
And one of my team members who runs an adolescent
residential program, actually around here,
said, "Oh my God, you are such an idiot,
"I mean this kid goes nowhere, but he comes an hour
"to see you.
"You know, he puts restraining orders against people
"and he comes and he sits in your office and doesn't talk."
He says, "This kid loves you, you just gotta think that,
"you just gotta have the assumption.
"He loves you to pieces and he just
"doesn't know what to do about it."
And I didn't believe that, actually.
But it did help me let go of thinking I should
be able to get him to talk and I started thinking,
well we have a narrow idea of psychotherapy
it's all talk.
Alright so we'll just sit together.
I mean that's what they do a silent retreats,
right, we'll just sit next to each other, we'll
just sit, sit and then I'll tell him a story
now and then and then I eventually told him a story
that he got very curious about,
about my own two year old son.
When he thought that something happened that might
have hurt my son and he was suddenly very curious
and all of a sudden he was willing to talk to me
but it was sort of like I had to let go of trying
to get him and it made me more comfortable,
I just thought okay, I'm just gonna sit with this
guy and yet he would talk with the family meetings.
Next slide please.
Inter-being.
So in addition to being in the present moment entirely,
like really just being there,
which some people do more easily that others,
for me it's fair amount of work to be there,
I mean seems like I'm probably there but it's
actually not easy, get in my head and all kinds
of things but so now you wanna be able to be there,
you wanna notice the impermanence of everything,
it sort of helps open up the situation,
you wanna notice your attachments and be able to
see if you can just let them go and see things
as they are and be with things as they are,
longer than you wish you had to.
And then there's this idea of inter-being.
That captures several different Buddhist kind
of ideas, and the idea of inter-being has to do with
just that in spite of the fact that conventionally
we actually think we're unique, we actually think
we have a self, we actually think that we have thoughts
that other people don't have.
We actually think that there's a boundary between us
and other people in the world and that all that's true,
it isn't like that's not true, it's jut that's
what we all agree on, hey let's all agree that there's
a boundary between us and that we have a unique self,
and that we are pretty autonomous but we're
in relationships, conventional thinking.
Well this is not so conventional thinking.
It's really thinking, there is no boundary,
its like again at this situation like looking at waves
and whatever, what is it the two different models
of light, waves and something else.
What?
- [Voiceover] Particles.
I couldn't hear it.
- [Voiceover] Waves and particles.
Particles, waves and particles,
yeah you can look at light twice in two different ways,
so this is looking at the same situation
and saying, there's actually no boundary,
I've been talking to you guys for this long
and every word out of my mouth has been shaped
in conjunction with noticing you.
I've probably imitated some of you, in the most subtle way.
I probably think I'm making stuff up and it probably
was something that my grandfather would say
when he used to talk to dairy farmers
in Seattle Washington like 60 years ago
when he would give talk.
I mean, in other words, this idea that there's me
and there's a boundary and there's you over there
actually you're shaping every word that comes
out of me, every gesture and my pace and my tone.
And I'm shaping everything that's going into your thinking
to some degree, so the longer we're doing this together,
the more actually it's just we're just an entity here,
you know, we're the Starship Enterprise and there's
actually no difference between,
we're all just sharing the same air, the same food
if you went to the same place I did, some of you did,
the same conversation, the same ideas, and we all have
to preserve this idea that we're individual and different
and there's these boundaries but actually another point
of view is that you are influencing me profoundly
at every moment and even people that I don't even notice
are influencing me profoundly and people who aren't
even here right now are influencing my profoundly
and any idea that I'm this autonomous being,
sort of like when I was watching the New York Nix's
in Madison Square Garden with my best friend
a lot of years ago and I remember saying one time,
hey Cindy, we each thought we were pretty expert
about the strategy of the nix,
and I said something about the point guard and what
was going on and the strategy and God he really should
take him out, all these things, I'm saying this complicated
thing and I'm thinking God, I didn't pat myself on the back
but I thought, that was pretty smart, you know,
and Cindy's listening and nodding and then like
three minutes later a guy behind me who did not hear
me said the same thing.
Like a guy up there with the same level of enthusiasm
is telling his friend the same thing.
And I turn to Cindy and I said, did you hear that?
And she said "Yeah."
I said, he said just what I said like minutes ago,
she said, "Charlie we all listen to the same radio shows."
I go, oh right, you know that's right, I mean I think
I had an individual thought, I mean there's no such thing.
There's no such thing.
The nursing staff in a in-patient hospital thinks
the patient is manipulating the staff.
But if you look carefully, microsecond by microsecond,
it's just as likely that the staff is manipulating
the patient, in other words the only way to get attention
is to act that way and the staff is the one that's
in control of that, so it's sort of like there's no
such thing as this boundary.
But there is of course, so the idea of letting yourself
sort of sink, I have pictured it visually when I do it
with a patient and I feel like we're so at odds,
this kid keeps cutting himself, cutting himself,
cutting himself, if I shift my position I kind of drop
down into this level of thinking then I start to say,
we're cutting him.
He and I are cutting him.
What are we doing?
It's like, in other words I'm influencing him every
second, he's still cutting himself, so are other people
but it's sort of like, try that on, like just drop
conventional reality and say okay, why am I cutting him?
It's just a different kind of question and it might
be the case or maybe his mother's cutting him.
Because she's never wanted him to live anyway,
or something like that.
So, it just helps to be able to drop into that other level
and be there and it creates a profound sense of we
are connected to each other.
And the next slide.
The last of these which could otherwise be labeled
karma if it was just straight Buddhism,
is the idea that everything that happens,
every phenomenon that occurs has it's causes
and conditions and it arises out of those causes
and conditions, and the question is how could it
be otherwise.
Given everything, of course that occurred, I mean
it just had to and the more you can do that with people,
the more you can just say, well of course you did that.
The more you can kinda like accept where they're at.
There's a kind of deep acceptance that comes from that.
There was a 16 year old girl who was hospitalized
back in White Plains when I was working there,
and then I interviewed her in a case conference
and what had happened was she lived locally,
she got up on her house, it was the days when they
had TV antennas, and she grabbed the antenna
and she started swinging around the antenna
on top of her house singing all of those songs
to Westside Story, really loud, until the neighbors
next door called the police.
And the police came and got her off the roof
and took her to the hospital.
And I was gonna interview her and I just thought,
you know what a crazy story, I'll do this link by
link analysis of how it was and I did but at the same
time I tried to think, you know, I just tried
to start my interview by thinking,
of course this happened.
So I said something like that with her just as a little
different way of starting, saying, you know
I'm assuming that this was of course what you had to do.
She said, "Well yeah I did."
I thought, wow I was right.
I mean but it's sort of like, and then I said
well tell me about it, like why did you have to do that?
"Well my parents were having a big argument and they
"always have big arguments, they were inside
"and I thought, I hate their argument I did not want
"to be there so I went outside and I got up
"on the roof and I just swung around and I felt
"a lot freer."
I said, wow, so you're saying it made a lot of sense,
cause you know to your neighbors it didn't make much sense,
and I never want you to do it again cause you just risked
your life.
But it did make sense I mean is there any other way it
made sense, she said, "Yeah, got me in the hospital."
That's a good thing?
She said, "Yeah, are you kidding?
"This is the best place for me.
"My parents need help."
So there was a whole story and if you assume
that what you're seeing that's crazy is in some way
perfect as it is, it had to be that way
and whether you do it the way I just said or not,
you kinda come across the causes and conditions.
And get out of the judgement, so all of these
have to do with arriving at a place of being deeply
present and accepting, of the patient, even if you're
pushing the hell out of them, to get them to be
in a group.
Okay, so I wanna do a second role play.
So here's Jacob again and I'm gonna take these
principles as my main approach here.
Oh my gosh it's almost nine, we're not gonna get
to all three, I knew this would happen, what can I say,
but if you, oh forget it.
So, but I think it's good to see.
So, Jacob, hey, how you doing?
- Okay.
- Alright good, that's good.
I kind of missed you last week, kinda missed you,
I mean I don't know if you remember cause it's a long
time, a week, but,
you weren't here and we were just getting to know
each other so, yeah, I just want you to know
I miss you.
- Yeah, I bunked.
- What?
- I bunked.
I bunked.
- Okay, alright, alright.
So, hey there's something we need to talk about
I've been putting off and it has to do with going
into the group, the skills group,
that you knew about a few weeks ago but we haven't
really brought it up since and I haven't said a thing,
you haven't said a thing, you and I I guess have been
kinda joining each other in pretending it doesn't exist
but there's actually this requirement that
you're in the group.
I hate to bring this to your attention.
- No you don't.
- Yes actually I do, but you get, you know,
that's a good point.
What do mean I don't?
- You don't hate bringing it to my attention,
it seems like you're having fun.
- Here's the thing, you are so sharp, I mean I think
it's true I don't hate to bring it to your attention,
I wouldn't say I'm having fun, I didn't--
- I don't wanna go.
- I didn't look forward to the discussion.
You don't want to go?
- No I don't want to go, I'm not going.
I didn't think you were serious.
- Yeah?
- No I didn't think you were serious.
- Okay.
- I still don't.
- You still don't.
I'll be clear, that I am serious but I've let it go
cause I've kind of enjoyed, and this is true,
getting to know you and yet this is still hanging over
my head, that you have to get in there and there's
actually good reasons for it but I'm more
concerned right now with that just bringing it up
you just sort of say you can't go or you're not going
and I wanna know what that's about.
- Well is this cause I didn't come, cause I skipped
last week?
- No it's not, it has nothing to do with that,
I was gonna bring it up last week.
Now, probably you were smart to skip last week
and you didn't even know it.
No, the point was I just need to bring it up
and I want to know what is the problem with it
cause there's obviously a problem and I believe it's
probably a real problem you have with the idea,
what is the problem?
- I don't like people.
- You don't like people?
Okay.
That's a big one.
- I mean I really don't like people.
I don't think you get it.
- I might not get it yet but I get that you do
actually come to see me but I don't know how
you feel about that and that you don't like people,
we haven't talked much about that.
What do you mean you don't like people?
Anything, any people, anything about people?
Just like to know.
- I don't think they get me.
- No.
- I don't think they like me.
- Oh.
- I think it's mutual.
- And yet people are expecting you to be with people.
- Who?
- A lot, well the clinic expects you to be in a group
and your parents wanted you to be here with me.
I'm just trying to think what it would be like
to be in your shoes and not like people as much
as you don't like people.
I wanna know all about that, I just don't get it,
I don't get why, I don't get where it came from.
- You'd be afraid all the time.
All the time.
- You're afraid of other people all the time?
- All the time, like all the time.
- How do you get by?
How do you get by?
I mean you've had to go to school,
you have to be with other people sometimes
or maybe you don't maybe you find a lot of ways
to not be with people.
- I bunk out on a lot of things.
- You do a lot of that, a lot of that.
Is that a relief when you do it?
It's just, are you okay when you're with yourself?
Yeah?
Alright, we're gonna stop there.
Oh, very different direction.
Okay.
Now.
(clapping)
Alright we're gonna, you know, I'm gonna give
you the one minute version of the third principles
but we're not gonna do a role play.
The third set are the dialectical principles
and they're the ones that involve, they're the most
challenging, they involve creativity, improvisation,
going with the moment, all of that, let me just say,
in an interview with Michael Jordan where somebody
asked him, "What did you like best about basketball?"
and he actually looked like he took it seriously.
He said, "Well, you know the best thing was when
"I did things that I've never done before, just cause
"I had to, and then I would think, wow, look what
"I just did."
And there's something about that that captures
the quality of dialectical, that's not where it comes
from theoretically but that's what it's like
in therapy, you come up with a metaphor, you come up
with a move you've never done before, cause it feels like
the right thing and you know what your direction is
and you want to get there but you don't know how you're
gonna do it with this family,
with this kid, with this adult and so you try
something, it's within the ethical boundaries
but it is different and it is a way to cope
with polarization, basically, it's when you get stuck
and when you're stuck, there's one thing opposing
another thing one way or another, it's either
you opposing the other person, you opposing yourself,
you opposing something else but there's always a this
when you then use dialectics and you're trying to get
from this, to get these two things with the wisdom
of both sides to join in a different way
so that you don't have one beat out the other
but you come up with a new way
and I'll give you one example before we stop.
And these principles, are they up there yet?
No, put the principles up.
The principle that always involves opposition,
so there's always a this.
It always involves moving towards synthesis
which is finding that validity on both sides,
honoring the validity on both sides
and moving to something that encapsulates
both things and doesn't diss either one.
So it's very inclusive.
It involves systemic thinking so you broaden
your perspective out to the other elements
of the system in families it's obvious what that is.
But everybody's in a system so it opens up the door
for more ways to understand a person.
If you can intervene with a family member
and this person changes.
You can intervene with yourself and this person
changes, cause you and he are in transaction
and that's the next one is transaction that
everything including your own identity
is in transaction and finally that there's this
sense that things are always moving in flux,
everything's in flux, and that actually therapy
makes sense to try to keep generating movement,
keep going with movement as much as you can
unless you just can't and then there are these other
times in the acceptance paradigm where you just don't
do anything for awhile, anything very overt.
So the example I'll just leave you with is on an
inpatient unit, where we developed DBT in White Plains,
a 19 year old girl who had been a student at
Cornell University and had jumped off one of their
famous gorges to kill herself and she was in a hospital
and then she was referred to our program
and in our hospital unit, she was just this really smart,
capable person but kept hurting herself.
Trying to hurt herself, break a light bulb,
stab it into her arm, things like that.
And one day she came to her therapist, Ed Sheeran
who was a really smart
psychologist who had DBT training, a lot of it,
and she came up to him and said, "Ed I wanna leave today,
"I'm getting out of the hospital."
He said, "No, no, you can't leave today, this morning
"you tried to hurt yourself, so actually I want
"to get you out too but we can't get you out today."
"No, I'm leaving today, I'm leaving, I'm just telling
"you, Ed, I'm just giving you notice I'm leaving.
"How do I leave?"
"I'm telling you we can't really let you out today."
"How do I leave?"
"Well you could sign what's called a 72 hour notice,
"and then within 72 hours a judge has to see you
"and make the decision."
"Alright, I'm doing that.
"Where do I go?"
"The nursing station has those.
"Why don't you go get a paper and fill it out
"and then I think you and I should have a session
"right away."
"Well why should we have a session right away?"
And he said, "Because I wanna help you get ready
"for the hearing cause you're gonna have
"to present your case, I want you to do it skillfully."
"I thought you thought I should stay?"
"No I do think you should stay, but actually
"I have a higher goal for you which is that you
"whatever you do skillfully, so you come out of it
"proud of yourself even if you lose,
"which you probably will."
He said very casually, and she said, well she's a little
thrown by this and she says, "Yeah but I have a really good
"argument."
And he said, "But here's the problem,
"when the judge comes I'm the one who testifies against
"you and I'm really good at this, so I really want you
"to get your game up and so let's work on your skills
"and maybe you'll beat me, who knows,
you know there could always be a first one."
And so it was a brilliant maneuver that captured
the wisdom of both sides, it didn't diss her,
it didn't diss him, it found a way to put them together
in a synthesis.
It incorporated some movement and it didn't necessarily
encroach systemic thinking or anything but the transaction
was important, so in other words, when you get to DBT
there's a set of strategies called dialectical
and I think they're based on these principles,
it's eight different strategies for how to do
what Ed did, in a variety of different ways
when you're faced with opposition.
Alright.
Now, it's passed nine, so at 8:30 we're gonna stop
and have question and answer.
I'm sorry that I didn't leave time,
I just, I knew this would happen, it's what I was
worried about.
So, here's the thing, there's a set of,
so I wanna thank you guys for hanging in there,
listening to all of this I just have no idea
how it came across.
(audience clapping)
And, you know, now there's these books that Caroline
has, so the book that I wrote is about this topic
it's just, it actually gets to the end during the book,
so if you missed the end here, if you think you did,
thought actually we did just got fast to the end,
but anyway, so they're here and I've never done this,
literally, before, what this is,
it's called a book signing, but that means somebody
actually would then buy a book and I would sign
I'm not just gonna sign books, right?
- [Woman] No, you have to buy the books.
- But it's actually awkward situation, so if you wanna
buy a book then you ask to buy a book.
- So yeah, what I would suggest, because,
- And there could be Q and A.
- Exactly, people who have questions who want to continue
a conversation with Dr. Swenson, want to buy a book,
which was just published today, it just came out today,
but we were able to get some advanced copies,
so we have them and I would say why don't we close
the kind of formal part of the lecture,
everybody who's got questions, conversation, book needs,
come on down towards the front and thank you
for being willing to stay, but thank you before everyone
leaves for this wonderful, wonderful presentation.
- Oh you're welcome.
(audience clapping)
And really come down front if you want, even if,
you know don't feel any pressure about it it's also
a question and answer period.