Dr. David B. Adams – Psychological Blog

Psychology of Illness, Pain, Anxiety and Depression

Explosive Patients

Dialectical Behavior Therapy (DBT) has been shown effective with patients with borderline personality disorder, patients with bulimia, and patients with widely swinging and often highly inappropriate moods.

In brief, whether genetic or learned, many injured workers lack the capacity for self-soothing (e.g. _calming down_) when confused, upset or disappointed.

Unable to calm, they either attempt to curb the feelings with drugs or alcohol, verbally or physically attack a convenient target, and/or in some cases harm themselves.

Since office visits are brief, and certainly not a place for psychotherapy, there are still approaches used in psychotherapy that you can implement:

a. _Let_s step back and look at this situation we are in with your back (neck, shoulder, knee, etc)_ allowing them a perceived distance from the immediacy of the threat.

b. Distract them by bringing up important, but not necessarily provocative topics such as _which of your medications (therapies, doctors, etc) are most effective for you?

c. Asking them _what would be of assistance to you this moment_what would help you relax_, reminding them, thereby that they need (can learn) to self-soothe (something they inherent lack without assistance)

d. Assisting them to not dichotomize things into good/evil__this is very unpleasant, but it is manageable if you will work with me._

Globally, the problem is that anything that they emotionally experience triggers their need for immediacy of relief. Aggression towards others or even themselves provides (learned) immediate relief and then drastic consequences.

Your goal is to both maintain control of your interactions with the patient but also to insure that they feel they can regulate their own distress without resorting to chemicals or verbal/physical violence.

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