The Difficulty of Understanding a Psychotic Patient

353: The Inner Scoop on “No" Practice! The “Inner” and “Outer” Dialogues— The “Inner” and “Outer” Solutions As you know, I have created many powerful communication techniques, including the Five Secrets of Effective Communication and more. One of the additional techniques is called “No” Practice, and it’s designed for people who have trouble saying “no,” or setting limits with other people. Essentially, you do a role-play with a colleague or therapist who keeps pestering you with pushy demands, and you have to practice saying “No” in a polite but firm and assertive way. Sounds simple, right? But it’s not! People have many reasons for not wanting to say “No.” For example, you may be afraid of hurting the other person’s feelings, or letting them down, or running the risk that they may get mad at you if you don’t say, “Yes.” In addition, you may feel like you’ll miss out on some special activity if you say no, so you end up way over-committed. In this session, you will meet an exceptionally compassionate and highly trained young psychiatrist named Lee, who asked for help with a problem relating to some of his patients. My co-therapist is Dr. Jill Levitt, who is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California. Lee explained how he struggles with saying “no” when patients make inappropriate requests, like pushing for a medication they’re addicted to, and wanting premature discharge from the inpatient unit when they have unrecognized safety issues. Instead, he seems to get drawn into long explanations of his thinking and why he’s declining the other person’s requests, sometimes for half an hour, and ends up frustrated when the other person still doesn’t “get it” and with himself for spending the time. People often think that therapy is easy, and that people just need encouragement, advice, or behavioral practice to change the way we interact with others. But as you will vividly see in this session, that is often not the case, and things that may seem simple or obvious can seem almost impossibly difficult to learn. Why does this happen? Why is it so difficult for people to learn new and seemingly simple verbal skills? Well, to find the answer, we have to go back to the teachings of the Buddha and Epictetus, who taught us that our negative feelings do NOT result from what’s happening, but from our thoughts. What does this mean? Well, Lee is an incredibly intelligent and compassionate young psychiatrist, and he’s clearly highly motivated, and yet he seems very slow in learning how to say “no.” Can his thoughts illuminate his apparent resistance to learning a new approach? During the session, Dr. Levitt reminded us of the fact that whenever you are involved in a conflict with someone, or any interaction for that matter, there are always two dialogues going on: the Inner and Outer Dialogues, and if you ignore either one of them, you may have difficulties triggering change. The Outer Dialogue involves what you say to the other person, and what they say next, and how you respond. For example, Patient says: “Doctor, I want to get discharged from the hospital.” Lee says: “No, I can’t do that because you’d be in danger and without a place to live. You’d be living on the streets, and it wouldn’t be safe for you.” Patient (who is in a state of psychosis) responds: “No doctor, I’ll be okay, because I’m living with Michael Jackson.” Then Lee tries to explain his thinking again, and then the patient asks to be discharged from the hospital again. And this cycle repeats itself many times, over and over, for as much as an hour. And they both end up frustrated and a bit miffed. Why is it so hard for Lee to say no in a kindly way and then move on to some other activity? That’s where the Inner Dialogue can be so important. It appears that Lee has two types of distortions that interfere with his ability / willingness to say “no.”

• Self-Directed Should Statements. Lee appears to believe that he “should” be able to explain his thinking to any patient. He wants to convey respect, responsiveness, and care when denying a request. This is, of course, an expression of his high standards, his compassion, and his desire to communicate clearly to his patients. But, as is so often the case, Lee takes this goal a little to far, think he should “always” be able to do this, regardless of how psychotic or confused or demanding a patient might be. Essentially, the healthy pursuit of excellence as a psychiatrist has gone a little too far and has arguably morphed into a self-defeating kind of medical perfectionism.

Self-Directed Shoulds typically trigger feelings of guilt, shame, anxiety, and inadequacy. They are often accompanied by several other distortions, including All-or-Nothing Thinking, Mind-Reading, and Self-Blame, to name just a few.

• Other-Directed Should Statements. Lee appears to think that his patients “should” understand and acknowledge his thinking if he’s being reasonable and realistic. He may also believe that if he’s doing his best, then his patients “should” argue fairly and acknowledge when they understand what he tells them and “shouldn’t” be manipulative, unreasonable or argumentative.

Other-Directed Shoulds often trigger feelings of frustration and anger, and are often associated with All-or-Nothing Thinking, Mind-Reading, Emotional Reasoning, and Other-Blame, to name just a few. Another teaching point is that we nearly always create our own interpersonal reality, but we don’t realize that because we feel like victims and see the problem as coming from outside of ourselves. Lee’s urge to continue to try to “win” the arguments with patients actually forces them to keep arguing their case and trying over and over again to get their way. That’s just human nature. We’ve all seen that people can be pretty obstinate and determined to get their way, no matter what. That’s why a focus on what you can do to change will often lead to a change in other people; in contrast, repeated efforts to persuade them to change is almost never effective. By way of analogy, my wife and I have recently had a bit of a problem with our cat, SweetiePie. She was a rescue cat, and we love her to death, and do everything we can to make her happy. She loves us intensely and shows her gratitude with loud purring almost all day long when she’s not asleep or out in the back yard exploring. BUT, she has been pestering us for cat candy, and has gained too much weight. Here’s what happens. She jumps up on my desk, and puts her paw on my keyboard, and stands if front of the computer terminal so I can’t see. So, I give her two or three pieces of cat candy on her perch next to me. She jumps up and greedily devours it. Next, she jumps back on the desk and puts her paw on the keyboard. I “explain” to her that she’s eating too much candy, and try to put her back on her perch, so she swats me with her claws and draws blood if I’m not quick to pull my hand away. So, I give her a few more pieces of candy, which she devours and then goes to sleep. Similar routine with my wife. She follows her, crying like she’s on the verge of death, and swatting at her ankles until she gets cat candy and / or a 30 minute lap snuggle. So, in short, we have been “forcing” her, inadvertently,  out of love, to manipulate us for cat candy. In other words, we “reward” her manipulations by giving her cat candy and love. As a result, our pour girl is gaining too much weight. Of course, the solution is simple. Melanie has agreed to give her only four pieces of cat candy per day, and I am limiting her to two pieces, just so she’ll know she’s still loved. And when she tries to swat me with her claws, I just explain in a kindly way that I don’t like that and put her on the floor. She caught on right away and seems to have accepted the new routine. Of course, we continue to give her abundant helpings of love every day, many times a day, as the love has zero calories! So, what’s the bottom line? If you’re trying to learn the Five Secrets of Effective Communication, and you want to change the way you communicate with others, remember to attend to your Inner Dialogue, as well as what you are actually saying to the other person during the conflict, especially if you’re getting anxious, defensive, angry, frustrated or upset. If you write down your negative thoughts, I think you’ll find many similar distortions to the ones described above, and this can give you another handle on change the way you think, feel, and connect with the people you care about, as well as the ones you don’t! Incidentally, the belief that we are separate from others and from our environment is the essence of evil, according to some Buddhists, and perhaps nearly all of the world’s religions have had similar beliefs, though couched in different language. But what this means to me is that when we struggle with friends of loved ones, and we are locked into frustrating conflicts, we typically feel like we are “separate” from the other person who is “doing something” to us. And this perception can not only trigger anger and frustration, but sometimes even violence. As humans, we seem to have great difficulty “seeing” our own role in the conflict. And sometimes, we don’t even WANT to, because the so-called “Great Death” of the self can be very painful. This is especially true when we see ourselves as morally superior to the other person who is “bad” or “to blame.” We are indebted to Lee for giving us this superb example of a problem that nearly all human beings struggle with, and also sharing his vulnerability and humanness with all of us in such an open and generous way! And we salute and thank Lee for courageously showing us the way with an intensely personal and real example. Contact info

• Dr. Rhonda Barovsky practices in Walnut Creek and Berkeley, California. She can be reached at rhonda@feelinggreattherapycenter.com. She is a Level 5 Certified TEAM-CBT therapist and trainer and specializes in the treatment of trauma, anxiety, depression, and relationship problems.
• You can reach Dr. Burns at david@feelinggood.com.
• You can reach Jill Levitt, Ph.D. at jilllevitt@feelinggoodinstitute.com. She is the Director of Clinical Training at the Feeling Good Institute in Mountain View, California (www.feelinggoodinstitute.com)
• You can reach Lee at bananaquitting@gmail.com

Group Feedback The following are a few of the comments in the feedback at the end of the Tuesday class. These are comments from the mental health professionals who observed the session with Lee. Please describe what you specifically disliked about the training? What could have been improved? Were there some things you disagreed with or did not understand?

• LOVED it!
• NOTHING
• Can't think of anything
• I only wish that we could have more time for this work with Lee.
• I kept feeling like I wanted to jump in and try some of these skills myself.

  Please describe what you specifically liked about the training? What was the most helpful? Were there some things you learned?

• I liked the externalization of resistance and would've like to see more with that or maybe even a “rules & roles” regarding patient/doctor relationships.
• I really liked Lee’s work. I also struggle with saying no, and I liked all of the role reversals and honest feedback from everyone involved.
• I found Jill's insight at the end of the session regarding the conceptualization of the problem, particularly the internal versus external solution (during the “no” practice), to be quite valuable. It was clear that Lee was facing conflicting desires - the need to act in the best interests of his clients while also seeking acceptance and approval. Taking the time to delve deeper into those internal factors may have further strengthened the effectiveness of the external solution (the “no” practice).
• Was helpful to see the miracle cure/goal clarified, as well as the 'acid test'.
• Good to see the model in action!
• I just enjoyed Lee's honesty , caring and professionalism. He brought up an issue that has been close to my heart as I worked with schizophrenic patients in clinic and day hospitalization settings and have experienced EXACTELY what Lee described. You feel between the devil and the deep blue sea when the medical staff conveniently toss responsibility to the less professional staff and when those in the trenches need to be there for the patients by saying NO. I LOVED David's comment about being disrespectful to patients with schizophrenia by going on and on with lofty brainy arguments while the loving thing to do is to be empathic stroking and firm. From my experience when I am real with my patients, they feel the best. Thank you, Lee, David and Jill. This was beautiful , heartwarming, and I am so touched to belong in this group.
• David and Jill's exquisite empathy, the Positive Reframe, and the NO practice.
• EVERYTHING!!! This was truly incredible! David and Jill are an unbeatable tag "TEAM!" Jill's warmth and empathy and teasing out the variables of Lee's story that were not always apparently obvious. Lee's vulnerability and seeing his depth and caring as a Psychiatrist was heartening and impressive.
• It helped me understand the flow of TEAM CBT and how things fit together better by seeing a live session from the beginning.
• I LOVED that Dr. Burns and Jill had to go down several different avenues to see what would work best. This closely reflects my own experience of therapy with my patients. Seeing them struggle a little made me feel even more sure that TEAM is the only approach that makes sense and cures people.
• This was a really wonderful session. I appreciate Lee volunteering, sharing with us his work challenges, and allowing us to see his kind and caring personality. I loved the masterful work of Jill and David. It seems to me that practicing responding to his patients with the use of the 5 secrets was imperative and I was amazed to see how that helped dropping down the feelings on the DML before we got to work on the Negative Thoughts. Once again, TEAM works like a charm!
• That this was a powerful real life issue that Lee shared. I enjoyed the empathy and how that led to sorting out conceptualization and miracle cure.
• David and Jill's combined efforts to go in many directions to help Lee see where he is stuck.
• I struggle in exactly the way Lee does in these sorts of situations, and it was so helpful and inspiring to me to see him do this work. Thank you, Lee! I was deeply moved by your deep caring for your patients and values around wanting your patients to have agency and understanding when there's so little in their world that they can control. I wish every psychiatrist had more Lee in him/her/them!
• I appreciate that Lee opened up himself in the group and I could observe the personal work of David and Jill, the amazing masters of TEAM-CBT. I admire Lee's compassion and warm heart toward his patients and I owed a lot to Lee who has very high standards to make things clear, just as he has done in his teaching in our Newbie group. And I think his sadness and anger might be an expression of his passion toward justice and dignity of his hospitalized patients.
• Appreciated Lee sharing with the group and doing personal work on a challenging problem. Liked when Jill brought up the internal versus external solution and then the session switched gears to work on the negative thoughts that made it so difficult for Lee to say no.
• Really enjoy the personal work, and getting to see the TEAM process unfold in skillful hands. I appreciate that you gave Lee time to explain his points, and that he was able to be truthful and disagree at times, and then you asked why and he explained further. This led to a more nuanced exploration and conceptualization of his issues and goals. I liked the focusing of a major part of the problem of "saying no" to a relationship / Five Secrets issue...resulting from internal and external shoulds. I appreciated the comparison with parent/child discipline, and not getting sucked into arguments. I also appreciate that you were able to pinpoint the problems around trying to get desperate, even schizophrenic patients, to understand one's point of view.
• It was great seeing the modeling of how to respond to some of these difficult patient situations. And how to clearly define the agenda when a patient is unclear about their goals. Also, so admiring of Lee.
• I liked how Jill and David navigated figuring out what Lee wanted to work on (when they came up with the three options). Issues that have "internal" and "external" components to them are difficult for me, and I often get confused. Seeing Jill and David work that out helps me wrap my head around how to go about it, thanks.

Please describe what you learned in today’s group.

• I appreciate Lee's vulnerability and I have so much respect for how he cares for his patients. I appreciated seeing the multiple role-playing attempts and was bummed when we ran out of time. I have so much admiration for Lee and feel for how much he's struggling.
• Personal work, externalization of voices, magic dial, Daily Mood Log (DML), 5 secrets, etc.
• How Five Secrets and No practice fit within the DML work
• That they could have started on the internal work of negative thoughts or the external work of "NO practice"
• TEAM at it's best!
• I observed NO practice and would like to learn more specifically about it ...
• Seeing the TEAM model unfold step by step in real time is always an incredibly valuable learning experience. Hearing Jill entertain potential directions to go in (i.e. crushing negative thoughts vs. No practice.) Learning challenging scenarios in context of "NO" practice was really awesome! Just magnificent overall! THANK YOU!!! Always feel so privileged to be part of this uniquely wonderful community of like-minded professionals! We are so lucky!
• I don't have to be smooth and have all the right answers immediately. This process is highly collaborative.
• How to employ the team model especially conceptualization and role play with NO practice and Five Secrets practice.
• How dealing with severely mentally ill pts can be so difficult.
• There's a sixth secret in effective communication: the willingness to use one's power in a kindly way to give the shot and get it over with. It's so helpful to me to add this secret to my armamentarium!
• Positive reframing and No practice, along with Externalization of Voices and Externalization of Resistance.
• I learned something about Lee, and about the difficulties of psychiatric hospital work for doctors! Also, seeing the process unfold skillfully, teasing out the problem to work on, Externalization of Resistance, Positive Reframing, Externalization of Voices, No/5 Secrets Practice, etc.
• How to be clear on agenda setting when patients are unclear on their goals.
• I was reminded about how to ask about a client's goal in order to guide agenda-setting.
• It was nice seeing the five secrets role-play / no practice. I've been inspired to start practicing daily like David said he did. Can never get enough of that!