One of the discombobulating aspects of working with patients in psychiatric treatment is the not uncommon occurrence of dramatic and swift changes in their state of being, that is, in their behavior, emotions, focus of thoughts and bodily state. It’s easy to be caught off guard, not having anticipated such ‘flips’ and not being prepared to address them. As treating professionals, we can develop a sense of lack of predictability and control, which can lead to stress and job dissatisfaction as well as to worse care for our patients.
Any one of us can experience such swift dramatic changes within ourselves but less commonly so. We tend to be a sober bunch, after all. It has helped me maintain my professional equilibrium when I realize that these types of cognitive-emotional-behavioral discontinuities are to be expected among many of the individuals who are in mental health treatment. These types of ‘flips’ are often a reflection of the person’s psychopathology and/or of their coping strategies. Thus, it would be better for us and for our patients if we accepted that such flips are a common occurrence in general and tried to anticipate them in individual patients. The questions are, why do such flips occur? And, how do we anticipate them? Before I say more, let me present an illustrative vignette.
A 24 year old woman starts treatment with you. She is self-referred and complains of being depressed and anxious, and generally ‘struggling.’ She has a 10 year history of waxing and waning depression and anxiety, some periods of binging and purging and drug experimentation. She was hospitalized twice as a teenager for ‘depression and suicidal ideation.’ She states that her childhood was ‘difficult’ but says she’s unwilling to go into that now. Her father is dead, and she is estranged from her mother and brother.
She is currently unemployed and living off dwindling savings. She broke up with her boyfriend two months ago, has few friends, and is feeling more desperate now but not ‘suicidal.’ You restart her on sertraline 50mg a day, which she reports has been the most effective med she’s ever been on, although it ‘was never all that great.’ You also start weekly individual therapy with her with a supportive focus. She identifies that she needs to get a job, since she’s low on savings, and to improve her social life because she’s very lonely.
Over the next four weeks she makes strong steady progress. You help her organize her job search efforts and encourage her to be more regular in sending out resumes, responding to ads, and scheduling interviews. At the fifth session, she comes into your office beaming, stating she was hired by a downtown law firm to be their receptionist. She looks very nicely dressed and her hair is newly styled. You compliment her on her job success and her new look. She says it is now part of her job to look great. During a session two weeks later she tells you that she started dating a young attorney in the firm and is on ‘cloud nine.’ Towards the close of the session you let her know that you will be going on vacation two weeks hence. You schedule her for the following week and tell her that at that time you will give her details on who to contact and what to do in case ‘any problems arise’ during your week away.
The next week, the one prior to your vacation, she doesn’t show up. You instruct your staff to call her to try to reschedule her into a time before you go, or failing that, upon your return. You also send her a letter that tells her how to get in touch with your backup clinician during your absence. In response you receive an email from her saying, “Have a great time on your vacation. Don’t worry about me. In fact, don’t think about me at all!”
Upon your return from your vacation, feeling rested and refreshed, you notice a note on your desk that your patient was psychiatrically hospitalized for a ‘suicidal crisis’ during your absence. Later that day, you go visit her on the unit. The nursing staff direct you to her room, saying she’s been refusing to participate in any unit activities and appears severely depressed. When you enter her room, you see that she’s curled up in bed with the covers over her head. When you gently call her name and say you’ve come to see her, she initially ignores you. As you persist, from under the covers, she tells you to go away. She makes no further verbal responses despite your entreaties to discuss the situation with you.
Hmmm – she was doing so well in so many ways for so long – several weeks. It’s always fascinated me that so many persons, such as our protagonist here, can be so astoundingly competent for so long – until they aren’t. Something always seems to happen and then it’s all shot to hell for the patient. But why?
In my personal life I’m a big believer in ‘Fake It ‘Til You Make It’ because once you’ve shown you can fake it, well then, you’ve made it! Or so it’s easy to think. I’ve asked myself dozens of times over the years, why couldn’t my patient ‘X’ just continue doing well as they’ve done over the last weeks, months or years? Just keep doing what you’re doing. Don’t change anything! So why does it so often fall apart?
Clearly, a difficult question to answer. But here are some ideas about why it’s hard for many of the people seeking help from us to maintain the steadiness, sense of safety, success, and equilibrium that they at times achieve for certain periods of time.
Marsha Linehan introduced the concept of behavioral patterns located on three axes or dimensions. Each dimension is characterized by a certain behavioral pattern on one end and a seemingly opposite pattern on the other end. People with borderline personality disorders – but not only they – will often swing from one behavioral pattern to its opposite. There exists an inability to synthesize the opposing patterns into an integrated whole, one that combines the opposing features and can flexibly access and deploy them anytime they are needed.
Note that although Dr. Linehan uses the term behavioral pattern – she was trained as a behaviorist – she means to include both public and private behaviors, those subsuming cognitions, emotions, and bodily sensations. It may be easier to understand if you think of them as different states of being, each characterized by a particular pattern of cognitions, emotions, bodily sensations, actions, and nervous system activations. In family systems these would be analogous to ‘roles’ and in schema therapy to ‘modes.’
So the patient described here, in the first weeks of therapy moved along the ‘competency’ dimension to the ‘apparent competency’ pole. She displayed myriad adaptive behaviors: she was effective in looking for and landing a job, improving her grooming to fit her new role, and in engaging socially and romantically. Then, upon her clinician’s one week leave, she ‘flipped’ to the opposing pole of ‘active passivity.’ Dr. Linehan has added the modifier ‘apparent’ to ‘competence’ to highlight that for some individuals their competence is brittle and dependent on current circumstances and emotional state. A change in circumstance and emotional state leads to a full collapse of the current state of being. Further, Dr. Linehan has added the modifier ‘active’ to ‘passivity’ to account for the tendency of some individuals when in this opposing mode to demand that others in the environment solve the problem for them. I would add a caution here to not assume that when a patient is in ‘passive’ mode, one of helplessness and hopelessness, that they are ‘actively’ choosing it or using it. (I’ll explain below). In any case, the question now arises, why did this patient flip from one state of being to another?
A relevant concept to introduce here is resilience and how it is damaged in individuals who have been traumatized. Following trauma, the autonomic nervous system becomes more reactive. A person’s range of adaptive arousal and flexible function shrinks. It takes much less of perceived threat to safety to send their autonomic nervous system into an extreme of hyperarousal or hypoarousal. A relatively moderate stimulus can lead to an extreme fight, flight or freeze response. We saw a little of the flight and fight responses in this patient’s case: she reacted to news of the clinician’s upcoming vacation by not keeping her appointment and sending an indirectly aggressive email. But primarily she reacted with the freeze response. The freeze response only occurs in the event of a severe trigger in some individuals (If you place any of us in a threating enough situation we will also enter a freeze response). For other individuals, especially those severely traumatized or traumatized early in life, the freeze response becomes the default. The freeze response is characterized by a sense of paralysis, numbing, fogginess, and dissociation from self, others, the present, and the world. Physiologically, blood pressure, breathing and heart rates fall. Depression often sets in and can last a long time. Thus, an acute trigger, some type of threat to safety, can lead both to immediate and long-lasting symptoms.
I’ll pick up on the discussion of trauma and its aftereffects in upcoming posts. Send me any vignettes or thoughts relevant to this topic. Thanks.
Until next time,
“Traumatized people chronically feel unsafe inside their bodies: The past is alive in the form of gnawing interior discomfort. Their bodies are constantly bombarded by visceral warning signs, and, in an attempt to control these processes, they often become expert at ignoring their gut feelings and in numbing awareness of what is played out inside. They learn to hide from their selves.”
– Bessel van der Kolk, author of The Body Keeps The Score
“rauma is not what happens to us, but what we hold inside in the absence of an empathetic witness.”
– Peter Levine, author of Waking the Tiger: Healing the Trauma