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We left off last time with the 17 year old girl with poor impulse control and cutting behavior who was flirting with both drugs and one of her teachers. She “fired” her previous therapist for breaking confidentiality and telling her parents about her plans to snort heroin.
Thanks for the interesting comments that came from our readers: everyone noted the importance of trying to understand what was behind her cutting behavior, considering it as a possible sign of a potentially serious psychiatric condition; the idea being that using therapy as a forum for putting thoughts and feelings into words lessens the pressure to use action to deal with distressing emotions—aka acting out. One commenter picked up on what it must feel like for a young person to have lost control of her emotional life. Another mentioned the utility of Cognitive Behavioral Therapy (CBT), and by inference its close relative Dialectical Behavior Therapy (DBT). Although everyone agreed the teacher had to act responsibly, the question of responsibility of other adults in this young woman’s life, i.e. her therapist and her parents, remained to be addressed.
Today, impulsive behavior is incredibly risky and sometimes irreversible: as in unwanted pregnancy, sexually transmitted diseases, drug overdose and addiction—yes, sober to note, vulnerable individuals can get addicted to opiates in only a matter of days—and antisocial behavior like being arrested or expelled from school, the consequences of which can change the trajectory of one’s life. Cutting is almost always an expression of overwhelming distress (as in murderous rage or self-hatred) that is begging for an outlet. Teenagers who cut often say they need to “feel something” or “to let something out.” The pain of cutting can break through the dissociation between thought and feeling that results from feeling overwhelmed. Since the cutter regulates intensity of the pain he or she feels, there is a sense of control (probably mediated by endogenous opiate release), which is why authorities note cutting may become habit-forming, even addictive. Some therapists have even suggested having cutters immerse their hands in ice water, rather than damage their skin.
My therapist colleagues brought a different perspective, viewing this young woman as someone needing to be in a protected environment while the forces behind her impulsive behavior could be explored without the danger of destructive acting out. They thought that the parents (assuming they were responsible individuals) and therapist should assume a pivotal role and that allowing an irresponsible minor child to dictate the parameters of treatment (as in firing the therapist) missed the point of the therapist’s responsibility to prevent further acting out.
My colleagues (and I) believe that at the outset, therapy should be set up with an open line of communication between family and therapist, the idea being that the therapist is receptive to getting input from the family about the child’s behavior but does not share confidences unless he or she believes the patient’s well-being is in danger (as it was in this case).
So here’s what happened: the therapist was more concerned over the potential for destructive acting out than being fired by her impulsive patient. Emergency psychiatric evaluation was arranged (via collaboration between therapist and family) where the diagnosis of uncontrolled bipolar disorder was established. Indeed, there was a virulent strain of bipolar illness in the family and upon more-detailed inquiry it turned out that our young patient had had suicidal thoughts off and on for years, which she was too ashamed to admit less she be disparaged as “crazy” by her family. Once she hit puberty, the young woman’s moods became so unpredictable she hardly knew how she would feel on any given morning. Her moodiness affected her social life; her “highs” were characterized by recklessness—one night she practically did a strip tease at a party to show off her body; another time she was caught shop-lifting but was let off with a warning after she pleaded with the security guards not to tell her parents.
What precipitated the current situation was feeling relentlessly depressed and deeply betrayed after a recent blow-out with her best friend over a boy whose affections she (our patient) felt the friend had misappropriated. Our patient was consumed by both rage and depression, the feelings so overwhelming she resorted to emotional dissociation, which underlay her cutting behavior in that it allowed her to feel she had control over the emotional pain she could not otherwise escape. To her parents’ great relief, she agreed to a brief psychiatric hospitalization where proper doses of mood-stabilizer were titrated and she became a star pupil in the DBT class that taught mindfulness and management of powerful emotions.
The outcome: she left the hospital after three weeks, continued medication and outpatient DBT and returned to school where she did well. She still sees her doctors regularly, ingests a safe but effective medication regimen for bipolar disorder, and has settled into college life where she feels academically and socially fulfilled.
Of course, not every case of cutting and impulsivity means bipolar disorder, but see how essential it was to contain the acting out, diagnose and treat the bipolar disorder and teach the young woman DBT skills before she left for college, rather than dealing with some inevitable emotional disaster whose consequences might have been far worse.
Onto our next case:
A depressed businessman is separated from his wife; he’s taken several antidepressants which he claims only help for a short time. He has two children, including a boy with Down Syndrome and the thought of breaking up the family is heart-breaking. He and his wife are trying to make a go of it, but he got it in his head that she’s interested in another man; now he wants a different antidepressant. What next?
See you next time. Looking forward to hearing from you!
