Jeremy Clyman Psy.D.

Reel Therapy

Reality TV Star As Case Study for Dialectical Behavior Therapy

How a Real World contestant may benefit from DBT

Posted Dec 27, 2011

Frank, from the Real World San Diego (2011), is an interesting case, clinically speaking. It's striking how miserable he is, and it's clear that his misery is, to a large extent, psychological or self-imposed in nature. Meaning, he's not miserable because he lives in a war zone with constant external threat, he's miserable because of internal turmoil. Over the course of the televised season (final episode aired last week), we see Frank's misery emerge, we see him grow and become less miserable in some ways (remaining miserable in other ways), and we even see him enter into therapy for a brief time.

Let's present Frank as a clinical case and get a sense of what type of treatment might best serve him over the long-run (and not as part of a reality television process).

Frank is a White, male in his early twenties. He's gay or bisexual (his identification with a particular sexual orientation seemed to fluctuate as can sometimes be the case). He's currently single, and is employed by a reality television show. He's referred himself to treatment for anger management (that's the stated reason), and seems to suffer from some long-standing problems related to his identity and relationships.

The identity complaints (these are not so much stated by him as observable from his thoughts/behaviors - in short, I'm inferring...): He describes feeling empty inside, seems to live somewhat aimlessly and views himself in an unstable, often negative manner. He's unsure of who he is, which facilitates an occasional roller-coaster tendency to either beat himself up too harshly or disavow himself of all responsibility too neatly. He's got trouble holding a balance of self-acceptance and awareness as is needed for a healthy identity.   

The relationship complaints: He tends to misread others (especially when it comes to encounters related to rejection). He is very sensitive to rejection, and is prone to expressing his displeasure with others' treatment of him in, shall we say, loud and inappropriate ways (this is a non-judgmental way of saying he can be verbally abusive). And, clearly it's hard for him to attach to others in open, trusting ways as he gets preoccupied, anxious, and suspicious rather inexplicably, which leads to conflict and intense emotions (interpersonal stuff). He also shows the unhealthy tendency to NEED people. If he doesn't attain the social relationships that he pursues then watch out...

These problems with his sense of self and other people relates to how he handles emotion.  There's a lot of negative emotion bubbling up from within. He gets upset very quickly, it's a bit uncalled for (disproportionate to the situation) and takes him awhile to calm down. This emotional reactivity is punctuated by fears of being abandoned. This makes sense cause he has been abadoned (more on that in a moment). While some people walk through life on an even-keel there's a force within Frank that is restless, agitated and fragile.  Also, there's a clear pattern of impulsive, destructive activity - excessive alcohol abuse, promiscuous sex and, at times, some self-hitting (i.e. punching walls, etc.). I know these kind of behaviors are par for the course of reality television and, indeed, some of these tendencies may be 'pulled' out of Frank by implicit pressure to 'perform' to what is 'expected' on reality television, but if this is the case it's only a partial contributor.

These qualities in affect regulation, impulse-control and pattern of relating to self and others are consistent with the conceptualization of Borderline Personality Disorder (I'm not saying he has been appropriately assessed for this, I'm saying that, from a distance, he is displaying a pattern of interpersonal and intrapersonal activity that is both problematic and looks a lot like BPD). 

So where can Frank turn for treatment of these psychological difficulties? Navigating the mental health care system is confusing because there are a lot of different treatment approaches to engage in as a consumer/client, and there is very little in the way of marketing/advertising to provide guidance. As a novice clinician when I hear 'BPD' or anything close to that I associate to Dialectical Behavior Therapy - a treatment approach that is relatively new, very effective (empirically-supported), and designed specifically to meet the unique needs of this disorder.

DBT uses a bio-psycho-social model of development to understand people like Frank. In a nutshell, Frank's current functioning is the result of two processes - an emotionally dysregulated temperament (he was born with a biological predisposition to be 'too damn sensitive') and an invalidating environment (he was born into a household that did not meet his emotional needs with 'sufficient' consistency and care).

DBT is all about skills-building. Franks gets himself into a lot of difficult situations that he handles poorly and, in turn, shapes a life that is not worth living (as evidenced by his palpable misery). It's hypothesized that he can learn to live more skillfully. DBT would teach Frank skills for tolerating distress, being more mindful, regulating his affect and more effectively managing relationships. These are band-aid exercises that, if practiced consistently, can solidify into the healthy habits that underlie a fulfilling, successful life.

To flush out a few examples: When Frank starts to get really pissed, he could learn to distract his attention (i.e. grab an ice cube and follow the sensations) rather than punch the wall. When he starts to feel rejected by others' he could learn to react with social effectiveness (i.e. take a breath, get a reality check from a third-party and calmly inquire into the situation). If he's alone and starts to ruminate about a past upset he could respond mindfully and with sophisticated emotion regulation (i.e. self-soothe with a shower, chant some affirmations about being a good person, take a walk and breathe in the nature).

I should point out that toward the latter half of the show Frank showed signs of growth in these areas. Some therapy, some honest social feedback, and the forced gut check of being on television seemed to serve a health-inducing function.

But, as you can probably see, these skills need to be applied to core issues in order to really enact sustainable growth and positive change. What's a core issue in Frank's life? It tends to be the kind of thing that is very painful to talk about, and is avoided at all costs even though it plays an obviously central role. For Frank, identifying the core issue is fairly simple - the earth-shattering sense of rejection that he felt (as any child would) in response to his parents' rejection of his sexuality. Indeed, Frank rarely mentions this on the show (probably too painful), but we learn enough to know that his coming out of the closet experience was not exactly supported/validated/accepted/cushioned.

Let's note the meaning of this moment in Frank's life. Here he is, an insecure and emotional individual, just beginning to learn who he is and boldly laying out a fundamental feature of his identity (sexual identity) to his parents. And he gets outright alienation from his father and reluctant detachment from his mother. What a brutal experience. It's no wonder he's got a shaky sense of identity, and a template of fear and abandonment with regard to other people. And the residual effects of this experience is festering in his psyche, laying there completely unresolved and causing havoc in his current life in ways that are not always obvious. A therapy approach like DBT can teach more skillful living but it can also help Frank to more effectively process this life event and experience a healthier attachment experience.

For example: His parents' rejection sent him the implicit message that he is unlovable, unworthy of their acceptance and affection. As we could see from the show Frank is navigating through the world in need of emotional support, but too wounded and vulnerable to calmly and appropriately solicit it. A prime example is Frank's desperate, counter-productive pursuit of Ashley's friendship. Frank needs an intense injection of unconditional positive regard and acceptance to cleanup the mess his parents create, but friends, and especially people that are slow to warm up (like Ashley), are not appropriate targets for this. Therapists are. A DBT therapist can gain Frank's trust (no easy task as he often acts like a cornered animal in emotionally-charged contexts) and provide a safe emotional place of warm, genuine feedback that focuses on reversing the unlovable messages.  

A therapist can also help Frank integrate the parental rejection experience in a healthy way, which involves a blend of cognitive re-processing, emotional intelligence and past-present insights. For example, Frank would need to verbalize the anger and sadness that he likely feels toward his parents (not easy for a son to admit such affect about his parents). Further, it's possible if not predictable that Frank might feel some hostility toward his 'gayness.' After all, his gayness is what incited the rejection. Life would have definitely been easier for him without the gay urges and identification. Thus, he'll likely need to check-in with himself to see if he is fully and genuinely accepting and loving of his sexual self. Once these feelings enter into awareness, they can reduce in intensity and a therapist then has the opportunity to validate and clarify these feelings which will further de-intensify them. This will help Frank to stop seeing rejection in situations that are not rejecting, and to stop getting disproportionately angry at people (i.e. Zack's homophobic beliefs, Nate's social boundaries, etc.).

Some cognitive reframing might aid this process as well. For instance, Frank seems to harbor some guilt secondary to his anger. He seems to view himself as a bad person and likely (mis)perceives his parents' rejection not as the act of homophobic adults who should know better but as an inevitable response to a defective child. He needs to see the meaning of their response in a more balanced, realistic way. It may be sweet of him to feel bad about his parents' discomfort but it's not particularly accurate (their prejudice of gays - something within their control - is the culprit here).

I'm hypothesizing about Frank's inner state but these thoughts and feelings seem probable, and accurately identifying the affect and rationally examining the thoughts will help transform the rejection into something less devastating, perhaps even meaningful. Therapy could also help him with next steps. A more goal-oriented, problem-solving phase could help him address such questions as, what kind of relationship does he now want with his parents? What seems plausible? What can Frank do to effectively pursue the plausible scenario? And, if he can't get his core emotional needs met through his parents' how can he effectively meet his own needs and cope with the disappointment?

Frank has a lot of misery in his life. He also has a lot of innate strengths. This is a combination for success in therapy, especially DBT.


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