Dialectical Behavior Therapy - Dr. Fruzzetti

Just to orient. In Dialectical Behavior Therapy, we have a treatment target hierarchy,  a set of targets that we've collaboratively agreed upon.

Already, we would have done that, in the first couple of sessions.

And out of that collaborative endeavor would have created a self monitoring diary card where the different things that we're working on are on a piece of paper, that are we calling you, Andrea, or we call on you, Alice, that Alice would be ideally, paying attention to every day she's practicing, noticing a variety of things in this particular case, given her targets that are in the in the vignette, she's paying attention every day to rating?

Does she have suicidal thoughts? Does she have suicidal urges? Does she actually self harm? Is she restricting her eating? How many hours of sleep is she getting?

What is the quality of her relationships every day, and she's doing this every day, ideally, the other thing we put on this is, it's a little thing that patients fill out just before they come into session.

And that varies from patient to patient what it might be, but for someone with her particular targets, it just be a little little box there would say urges right now, right at this moment coming into session, or urges to kill herself or to self harm, her urges to restrict eating because that's one of her her targets. If she were a substance user, it would be urges to use substances.

Always urges to quit therapy. Okay. And then for somebody who's as affiliative as she is, we'd also have something like, how connected does she feel to me? Okay, she'd rate that the very beginning of the session, usually like in the waiting room before she comes in, and we'd have a rating get rated again, just before leaving the session.

Okay, that would give us something that if there are big changes in the wrong direction, that would give us something to pick up on the following week. So let's assume that there's, yeah, let's, let's assume that left the last session. Now, the thing is that with with a third session, I think I'd like to make this to maybe like a fifth session or sixth session, if that's okay.

Because the first three or four sessions in DBT, are this orienting and cloud, establishing collaborative enterprise a commitment to treatment and establishing what the targets are.

So I'd rather assume that we've actually already done that we're actually in the treatment now. Okay. And so the diary card gives us, of course, a picture of what's been going on for the whole week, and allows us then to organize the session structure the session within the hierarchy.

So if there's something that's life threatening in DBT, we would prioritize that doesn't mean that's the only thing that we would do in the session.

But we would start with that if there's nothing life threatening going on this past week, or currently this moment, then we could look at treatment interfering behaviors. And then if there's nothing going on there, we then look within quality of life, things like eating disordered behavior and problems in her relationship with her boyfriend and a variety of other things drug use, or you know, whatever it might be housing problems, problems at school at work, whatever it might be. Okay, good enough.

Well, how things are going in your relationships with friends and yeah, tennis, you can do it from like minus 10 to positive 10, or however you want.

And diary cards, of course, are developed idiosyncratically, you know, so, Alice would have a different diary card than somebody else.

And even this month, Alice's diary card is going to look different in six months from now as things changed, her diary card will reflect some of those changes as our shift and focus continues over time. So Perfect, thank you.

Okay, so actually, once you hold on to this, you just come in and give it to me, because that's what you'd actually do. So come on. Okay. Oh, you look terrible. Okay, what can I say that differently? I think I stepped on your toe. You look like you feel terrible. Is that better? Yeah. Okay. Oh, sorry. Did that come out as mean? That's what I say to my wife.

She doesn't take it the same way. No, I meant actually just that you look like you feel terrible. I was a little too abrupt there, wasn't it?

Alright, let's take a look what's going on? Oh, my goodness. Like what's going on here? For what a week you've had. Wow. So you hurt yourself? Last week? on Friday.

Okay, right. I'm having trouble even focusing right now. Yeah, look, yeah, your urges to quit there. Yeah, there We are you want you? I want you.

Okay? Okay, look at me. Come on. Come on kiddo. Once you get that, okay, your suicidal urges are high, your urges to use drugs are high.

Your misery is a nine out of 10. And somehow you think I want to quit therapy. But somehow it's because I caught myself on Friday like, yeah, so yeah.

Okay, look at me. Look at my reaction. I'll do a little replay.

Okay. Watch my face. You said, Oh, boy, this looks like a terrible week for you. You look terrible. Okay, okay. Okay. Thank you. I appreciate that. Okay, watch my face when I noticed that you cut yourself on Friday. Okay, watch my face. You gotta watch my face because you've got a different idea in your head about me than history. Whose history Why? Okay, that's why we know right? But um, but you don't have we don't have so much history.

Alright, so I want to point out what you're doing right now is you are paying attention to what's in your head. You know, what's not what's right here. Know what's right here. Well, that your history if you brought it with you, right? Yeah, but it's not half. What if it's not happening right now? What if it's not? Could you be open to that? being open to the chance of it not happening? But I'm opening myself to the chance of it happening.

Oh, you've already decided this happened? Sounds like you've already got plenty of suffering as though that. Yeah. So can you just be open to the other possibility? Try it. Look at me. Sure. Come on my growing tumors or something? What's the story here? Okay. Okay, I'm looking. I say, Oh, my gosh, you had a terrible week.

You know, you're suicidal. But you got to keep looking. I know. It's hard. Gotta look at me, because you're worried about me firing. You know how terrible I am. How do you mean, you're judging yourself right now? Oh, you're judging. You're just gonna say all of the other. This is hard. You're making me hot. Okay, look, here's the thing. Here's what I don't want to do. What? Okay. I don't want you to get stuck on something that's not valid. In the present moment. Do you think having five therapists in a row fire you isn't valid? that's valid, but this one's not yet firing you. Okay. Yeah, knows and what happened? Okay, so tell me, maybe we didn't explore this enough. I thought we talked about this quite a bit a couple weeks ago with what are the most recent one. But what? Remember, we talked about this, right? We went over each one of these. Okay, each one. And we talked about our plan for how to handle those situations was hard to remember, you talk so much. That is true. But we made we made some arrangements. We made kind of some deals about how we were going to handle these situations. I didn't call you for coaching because I was I knew I was going to cut myself. Hang on, but you don't get fired for not calling for coaching. You'll get fired for that. Well, I didn't do what we agreed on. Yeah, but I never thought I was very clear with you that you don't get fired for having the problems that bring you into therapy. Yeah, well, that's what my last star said to you guys read the same book, baby. Okay, well, but here's what I'm trying to get at. But you're kind of stuck on that right now. And that's keeping us from working on what's actually going on in your life. That is true. So if you I guess I would say if you give me 30 seconds of your actual attention. We might move past that. Okay, I can do that. All right. Can you give me 30 seconds. That's all I'm asking for right now. Okay, so 30 seconds. I'm not firing. Well, you write it down? Yeah. Yeah, in fact, I'll even send you a mail and email me to text you know, I want you to write it down. Please. Sure. I just throw away my pen. my pen was hot, too. You dropped it on the floor, drop it on the floor. Okay. I'm not gonna run it on this one because I'm going to keep this but I'm going to read it on your next one. Okay. Please join me to sign it.

Okay. I won't fire you. Your Olive I'm serious. I did just write Alan. Alan. He was it seems a little formal. Dr. Holly. Okay. Dr. Allen, he presented the whole thing. Can you read that? Okay, you're the only one who can then. That's good. All right. Well, that help? I think that's fantastic. Actually, if that'll help. Now. Does that make a difference? Yeah. Yeah. But I mean, right this moment is I make a difference. That's pretty good. Okay, if you really, really got stuck on this, huh? You, I get it. I blame you. For what? For having this this horrible set of experiences that makes you worried about this now, it literally makes sense to me why you would be so scared of this. Completely makes sense. But what I want your job in this, okay, I've got a job in this view, better job than this. Okay. Okay. Look over here. I know. But look over here, even though it hurts. Yeah, you notice when you look over here, you're feeling really ashamed right now, right? But if you look at me, the shame will go down. You got to keep looking at me though. You've got to look at me and see that I'm actually not not being critical of you. I'm not sure I 100%. Understand, I think I got 95% of it. And if I don't, you'll tell me, okay, you can do that. Okay, I can but I want you to notice, if you just look at me and look at my reaction to my real my reaction, not the other five therapists you'll have a different experience. Okay, your shame will go down right here. Okay. We'll see. Okay, now what I want to do is, I want to, I want to record the rest of our session that we talked about this, I just forgot to turn it on. Because I want you to be able to listen to this later. Okay, because I think that you're so upset right now that some of this is just not gonna remember, right? It's gonna be hard to remember. Understandably, that's what happens, everybody. Okay. And I want you to be able to hear me say, Alice, I like you. I'm not firing you. You haven't done anything that I would fire you for? You know that? No, I want you to be mindful of what we talked about about that, you know? Do you get fired for cutting yourself? In this therapy from me? Do you get fired for cutting yourself? No. And if I tell myself that I'm hire you. That's right. And that's not fair. I promised I would not kill myself for the year. You got a promise you won't kill yourself for the year. Okay, good deal that we're even open. I can't control my thoughts. Okay. Well, let's work on that. So right now, look at you got pretty high urges right now. They're not all the way to 10 here at six. Right? Yeah. So the question is this. I mean, like, are you gonna Is there any chance that a sixth I, you know, we just don't know each other that well, that you will bolt out of the session and go kill yourself? Because if that's the situation, then I'm going to get really anxious or sit in front of the door? No, I'm going to go sit in front of the door. No, okay. Good. Because I don't like being anxious about like, leaving in the middle of a conversation. Yeah. And if you did that. Yeah. If I got up and left in the middle of the conversation, yeah. Well, I wouldn't expect you to. Okay. So it looks to me based on this that, you know, you did catch yourself on Friday, but you're kind of like on a suicide chain right now. Well, if your urges to kill yourself, are that high right now? Is this the most suicidal you've been in the last week right now? Okay, so Okay, that was worse. Okay. So let's go back and talk about that. I caught myself because I was feeling because you were feeling suicidal. Not going to kill me. So. Okay, great. Well, let's go back and talk about what happened on Friday. Okay, let's figure it out. And by the way, how is group you know, you started group, it's only been two weeks now. How's it going? Trying to give it a chance. Giving it a chance. Okay. What skill did you learn this week to remember? alternate rebellion? Excellent. Yeah, I like the smile. That means you've got alternate rebellion. Okay. Are you wearing boxers today? No, no. Okay. If I tell you the skill I use for alternate rebellion. It would really mean a lot to me that you don't use that as an example again. I don't use it. In other words, I don't push you to do it again. No to other people. Oh, you got to deal with other people because I think deal on Thursday after that's our group, we learn this You know, I got in a fight with john. And I wanted to start yelling at him. But instead I walked away and got in the shower and did something that would really small. Yeah. He hates. Yeah. And you didn't know Lysol afterwards. Yeah. And I, but he doesn't know. But he doesn't know it's not. He didn't hurt me. Right. He laughs That's good. Are you sure I can use this example? That's a really funny. Okay. All right. No, I think I think no public group, so please. No, I promise I wouldn't without your I won't know. I think it's such a great example, though. Actually. I think it shows that you really get the skill. That's fantastic. Okay. Any questions about group? Any questions? I don't think you have any questions of alternative. I think you've got that one. Yeah, I mean, sometimes the group leaders just go on and on. Yeah, they're like me that way. Yeah. But I think we'll see how it goes. Okay, great. Okay, fantastic. Well, let's talk about what happened Friday. What time did you would you did you cut yourself burgers? What do you do on Friday? I caught myself At what time? Well, Susie had a shift started at 11. So that means she left the house, it was probably like, okay, night tonight, okay. And it looks to me if I'm understanding your diary card, and you got to help me with this because we're just getting to know each other on the diary card. Okay. It looks to me like you had been restricting your eating. So you're probably hungry. Right? That you'd been drinking. I believe that when you restrict long enough, your body just says it miss you more. I mean, it gets very upset. Oh, it doesn't. I don't feel hungry. I just feel like sick and like, I can't eat anything. Right? Yeah, you know what happens? Right? I mean, you know, you feel your system is just all messed up. Okay. So, last time you ate by the way. I had coffee for breakfast. food. I had I had dinner last dinner last night. Okay, so you're getting some food. Okay. So it looks to me like, Oh, you didn't use you weren't drinking on Friday. Sorry, it was Thursday, you were drinking. So you were drinking Thursday, and not getting much sleep at all four to five hours to sleep on Thursday night, restricting your eating? So there's lots of reasons why Thursday by Friday would have been a lousy day. Okay. And then what happened? What happened? Like, I told you how john and i are trying this new thing where we take things slowly. And where he came over for an afternoon will be his idea. Okay. And we How are you feeling at that point? You're vulnerable? Right? What do you mean? Well, not eating, not much sleeping, drinking the night before? leaves you vulnerable to getting dysregulated? Right? Kind of makes us It makes everybody more sensitive and more reactive. Right. Okay. But you're kind of happy to use coming over the afternoon. Did that feel good? Or was that not so good. I was looking forward to it all day, and I was excited, but I was also really scared. Okay, um, and I was scared of exactly what did happen. Okay, hang on. So you're kind of prepped for something bad to happen? Where you Yeah, you know, when you say that it makes just my ears start to go. You know, because your idea of protecting yourself, I have to say it's a little funny. you're judging. No, I'm tired. It's like ineffective. It's kind of like driving on the wrong side of the street. Well, how does that protect you? That's my point. Well, that's okay. That's good. Well, I think sometimes, you know, protecting yourself is a good idea. Okay. But being stuck in kind of your I bet you how many how many calories of energy to put into worrying, and thinking and analyzing how you're going to protect yourself before he even came over to watch the movie. More than I consume that more than you consume that the Exactly. And do you think that made you more vulnerable to getting dysregulated and harder to just enjoy whatever there was, or you clearly Think so? Yeah, I do. What don't you think so? I could be but I'm also open to being wrong. I know. I know. You said that before. Yeah. Okay. And so like being in the moment, right, just like we started out the session where you were pretty sure I was gonna fire you. And that really made it hard to just notice that you're here sitting here with somebody who actually likes you. This thought of firing you hadn't crossed my mind. Right? You kind of missed that. Right? And so if you're kind of churning over and over how John's been on fuck it up, right? It's gonna fuck it up. It's that I okay, what did so alright, so tell me what to actually happen. So you came over from the movie What happened? Oh, before we watch movies you Lewis told me. He's trying to take things slowly with me to see if we can get on the track where you said you have kind of mixed feelings about that. That's hard. My reasonable mind gets it. Okay. And it's hard and your emotion. It's hard on your wise mind, right? Because you're an affiliate of person, right? relationships are important. You like to be close to people. Right? You like emotional? Right? Yeah. And you love him. Right? So, so slow means paying for the part that's not there. And it means satisfaction for the parts that are there. But right. You think you're the only affiliative person in the world? For right now you're more affiliative than he is? Right? I don't know. That will change. But right now you're more affiliative air like I do, but we leaving I get. I get scared of them just having a no. Right. So what happened? He's coming over. Were you thinking about about? Excuse me about harming yourself when he was coming over? had that crossed your mind yet? No. Okay, what happened? All right. I tried to get him to hold me and I asked him to hold me and he said, No, I want to watch the movie just next to you. So you're longing for some closeness, some kind of physical affection? Right? Is that reasonable? I just wanted to disappear. Okay, I just want to hold me in. You wanted to beat me up? Can you relax when that happens? Can you feel more peaceful when you're close to him? Okay, so kind of makes sense that you'd want that, doesn't it? The longing for that? Kind of makes sense? Yeah. What do you want to give it to me? I just thought so what did he do? What did he What did he do? Exactly? Precisely, what did he do? He looked at me and he said, he wants to hold you. You know, I want to hold you. I need us to take this slow, and I'm gonna focus on the movie, and I'm right next to you. Okay, that wasn't enough for me. No. Do you see how I don't mean this in a bad way about john. But do you see how that was kind of invalidating? No. He's he told me what he's told me before. Like he wants, like he cares about us and giving this a shot the right way. Right. But there's a certain implicate, I could be mistaken about this. But it sounds like there's a little implication in what he said that you shouldn't want it. How? Like, because he said he wanted to go slow that you shouldn't be disappointed in that. You should be satisfied with that, because he said it. Because we need Well, just because well. I don't know whether you need to or not. But if that's what he wants, and you would like something different. And that means that every time right every time you want a little more than he wants, you're going to be disappointed. And I don't I really want you to notice how reasonable that is. How completely sensible that would be every time we don't get what we want. We're disappointed. It hurts, right? Okay, but it didn't just hurt this time. Right. Where did you go with it? What happened next? I lost it. You lost it. It was an overwhelming hurt, like kind of like a black hole hurt. Yeah, black hole. But I hope committed I am so committed really trying so hard to do a little longer. Yeah, right. And I'm killing myself. Right. But that's where you have a black hole of emotion. And all you could do is stick it to it. Yeah. I just wanted to be over, right? No. So on the one hand, you want to sink into this luxurious lap of closeness and you got the cold instead that sink into that's a pretty big contrast. That's a pretty big contrast. It's awful. Right? That's why it's okay. I get that completely. What I don't know hang on but what I don't get here's what I don't get but it's not that I can't get it you just I don't get how you went from feeling so alone and despondent and empty. Well, you know, having all this longing that's not fulfilled, how you went from there, to wanting to harming yourself. I don't get how you went from there. I can't remember if you use this word or my last therapist. This is a time when I feel really desperate. Desperate, yeah. Okay. Desperate but you're desperate for for closeness. Yeah. For death. I did something good there, right? I grabbed one of my cat. Okay. At first when I grabbed it I want to be held so so frying pan into the fire right even the cat doesn't want no but I have two cats. So I grow the other one and she she wanted to be held and I just had her and I just what happened to so your arousal was about how high blackhole sounds to me like a 10 plus out of 10. Right? Okay, if somehow you had the wherewithal to get the cat that's really pretty good, right? She She got my attention actually cuz she was okay. meowing for food. Okay. And then what happened? I won't pay attention to what happened to your brows. Well, then when you got the cat. I held her and have you thought about harming yourself yet. And this is when I was thinking about killing myself killing yourself. Okay. All right. wasn't thinking about harming myself. Was it was that big?

Or did you actually start judging yourself? Like you shouldn't feel this way and it's your own fault. And I felt like, I want it. I'm never gonna have it and I don't want hopelessness. Okay. I don't. Oh, that sounds maybe just a tiny little tiny. Okay, okay. Okay. Yeah. Yeah. You know, what, if you had, what do you think you could have done differently right there. I grabbed my cat. That's great. That's great.

But but but what the judgment piece? Remember, we talked about mindfulness, you've had a lot of mindfulness in group now. What could you have done differently with that? I don't deserve it part.

You're pushing me and I think that's a good thing. That's good, because that's what I'm best at. It doesn't feel so annoying right now. But I'm having trouble answering it. Okay. So you know, that's okay.

Of course. I mean, I guess Can I Is it okay, if I give you an idea? I'm asking you to I think if you just notice that saying I don't deserve it as a judgment, just knowing that the judgment might allow you to let go of it a little bit. That's the judgment. It is a judgment, right?

Because we're kind of committed here to leaving the judgments behind whenever we can, in the bonus here, like the major bonus rocket ship out of the black hole might have been. How about this? It makes sense that I feel like shit right now. Because I'm not getting what I want.

I don't know about that one. But I can practice that judgment. Okay. Well, that's that's a good start.

But maybe you couldn't but what if you could have said that? Would that be worth practicing so that a month from now, you could do that? Would that make a difference?

My head's getting kind of cloudy, right? Yeah, this is a lot. This is a lot.

Alright, let's just start with the judgment one. You think you could do that? Thank you. Yeah. Okay. What do you think we could do this week? To help you practice?

The judgment part? I like to think of who I was my cat. Okay. Let's have the cats after you notice the judgment.

Okay. So let's try this. How about how many times a day you're willing to practice this you willing to practice once in the morning, once in the afternoon, once in the evening? To okay. morning, afternoon or evening? Which ones? Are doesn't matter?

Just do it at least twice. Morning and evening. Okay. How about if you just practice Have you can you set your if you have a like a smartphone or something like that? Can you set it to do all kinds of alarms? Can you set it to that anytime that you want to go off two times a day? And then when it goes off, you just kind of notice what judgements you might have been having lately?

Or look, especially for the I don't deserve something part. See me not when I'm having a black hole or with practice and an easier situation first, when the alarm goes off. It's like you've learned to ride a bicycle on flat ground. Know that going down the hill?

I mean, obviously, if you're not excellent, but obviously if, if you are in the black hole, and you can get yourself to remember this, that would be fantastic. I'll set it for 10am and 7pm. Each day, I could put a message on it. Great. I don't know what notice the judgment. Okay. And go play with a cat. Okay, how's that sound? All right now we're just about out of time. I wonder if you could just run through and we could fill out these things for right now.

Okay, so your urges to kill yourself right now. What are they three Okay, that's good. That's lower urges to use drugs. Like a three also went down. That's good.

Well, I didn't put my urges to quit therapy, but you want it? Yeah. What am I urges to fire you? Good For You got it. You got it perfect. What's the what are what number is 00 chance? Well, no, I can't say 0.00001 because I could get hit by a truck or something that's not firing you that's quitting. That's different. Well, your intention isn't to get hit by zero. Yeah. So yours is zero and mine. In terms of wanting to quit, I say it's like a one. But then in terms of not wanting you to fire me is a seven. Yeah, I'll make that. A 4.5. Excellent. Perfect. Great. Okay. And how miserable you're feeling right now. That's done. That's great. And what about just feeling connected to me like getting the highest? That's been so far? Great. Seven, okay.

Perfect. All right. If you get stuck with any of this stuff, call me. Send me an email. Okay. And I'll remind you, I'm going to add to my phone, notice judgment coaching call if helpful. Perfect. Sounds great.

Okay, same time next week. I'll see you then. Thank you.

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