I remember the moment in my second year of psychiatric residency when a scary realization dawned on me. It was fall and I was sitting in my office, one I shared with another second-year resident. Since we second-years spent most of our time on the inpatient unit and not in our office, we did not often have conflicts when scheduling patients for psychotherapy. This was especially true since I, like all my second-year colleagues, were slow building our required “psychotherapy practice.” First, we didn’t know what we were doing and, second, our inpatient work was still new, hectic, and overwhelming. It was hard to begin learning still another new skill and hard to slow down into “psychotherapy” mode after the intensity of the unit. The unit felt like a bazaar or carnival; working alone with a patient in one’s small office felt like meditation.
Finally, in October, after frequent prodding by my psychotherapy supervisor, I started work with my first patient. During one of our early sessions he said something that led to my scary realization: he said that he had been thinking about what I said at our last session and imagining what I would say to him today.
That really frightened me. Such an innocuous confession and yet I was perturbed. I realized that there will now be all these people in the world – more and more of them as time went by – thinking about me, hearing my words in their heads at any time of day, even when I was asleep!
I felt unnerved as if learning I was being stalked, although, of course, nothing of the kind was happening to me. In fact, nothing bad was happening to me at all.
Over my PG2 year I gradually desensitized to knowing I was living in other peoples’ heads. From accepting this discomforting thought, I gradually embraced it, realizing that this “introjection” was part of the therapy, perhaps the main mechanism of beneficial action.
Once I realized that my living in patients’ head was inevitable, I started to work out its implications. First, if patients were recalling my words, I had to voice messages to them that made a positive impact and certainly to avoid making a negative impact – the potential downsides of therapy are often under-recognized.
So, these are the features of the kind of messages I wanted to convey to patient, that would then live on.
- Positive messages: Rather than focusing on telling patient what NOT to do, I wanted to tell them what to do and to encourage and reward them for undertaking positive changes. For example, I had a fixed way of starting a session with a returning patient. “It’s good to see you. I’m glad you’re here,” I’d say. Instead of only focusing on their missing appointments of being non-adherent in other ways, I wanted to reward them with a warm positive message for showing up. And I meant it: It was good to see them they were engaging in treatment, even if sometimes I knew that the time spent with the patient would be personally challenging.
- Aphoristic statements: Once I realized a patient would hear me in their heads, I wanted to leave them with clearer messages, as if they were written on billboards. Here are some examples:
- “One day at a time, and that ‘one day’ means today.” This is good for people who spend too much time regretting yesterday’s foolish actions and / or lack of positive actions, and then feel demoralized and repeat yesterday’s lack of positive action today.
- “Relax in to wind down.” I would say this to patients who couldn’t fall asleep because they were too active or watching / reading upsetting material before bed. We’d work together to develop an evening routine.
- “Narrow your window of concern.” I would say this to patients who would get overwhelmed by all the demands they had placed on them (by others and by themselves). It is a common error when stressed to ruminate about all the bad things that have happened over the last years and decades, and to worry about possible bad things occurring years or decades into the future. When stressed, I’d say, just focus down on today and the short term future, with just enough of a window to plan for upcoming events.
- “Worry is not planning. Do more planning and less worrying.” It’s so common that people fool themselves into believing that worry protects against future threats. It doesn’t: worry is focusing on what is uncontrollable, whereas planning is identifying and executing on what is controllable.
- “When upset, work your plan.” I’d use this with patients with affective instability and / or frequent suicidal or self-injurious acting out. I’d work with the patient to develop a safety plan. A safety plan is a written, detailed, and concrete series of steps on what to do when the patient feels at risk of acting out. I would have the patient carry a miniature version of the written plan, sometimes laminated, in their purse or wallet.
- Written and audio versions: At some point I realized that if my spoken words took on an independent existence in patients’ head, then maybe providing a more concrete version would be even more effective. I started writing down some aphorisms on index cards. Sometimes I would record instructions on their recording device or smart phone. The option of hearing my actual voice would help some people who otherwise couldn’t quite hear me in their heads. An example: “Hi, this is Dr. Krasuski. You are listening to me now because something has upset you. No worries. We both know that people or events occur that are upsetting. The important thing is not to let these people or events lead to negative consequences for you. After all, why would you let other people’s behavior leave YOU with all those negative consequences. That doesn’t sound fair. So, Step 1, if you’re at home, sit in your favorite chair and take off your shoes. Step 2, now begin your breathing exercises….” You get the picture.