How I Became "Suicidal Kids" Therapy Supervisor, with Mentalization Based Treatment (MBT)
How I Became a Therapy Supervisor, Part II
I went to Amherst College, and I majored in psychology —because the brain was interesting. Took every senior neuroscience seminar I possibly could to avoid going to medical school. I didn't take any pre-med requirements because I was scared. This is part two of three, describing how I became a Mentalization-Based Treatment supervisor —who specializes in working with suicidal individuals, including kids. Part one is here. Of note, the conversation this article is adapted from happened in 2017.
I have bipolar disorder.
It was not good for a very long time, for years and years and years. Like clockwork every fall— I would have a depressive episode. Winter would usually bring some kind of mania in my first 24 years. Summer could have it as well. Spring would have another depressive episode. The real “clockwork” time for depression was th 2nd and 3rd weeks of October.
Circadian Rhythms Matter in Mood Disorders
For depression, it turns out the reason is that the time when the change in sunlight over the course of the day is the greatest delta. Sunlight, the amount of sunlight you have on any given day, changes over the course of the year. The fastest change is in October. We have a photoreceptor in our eyes that does not project to the visual cortex.
It responds to 460 nanometer light, which is blue. And it projects to the suprachiasmatic nucleus, which regulates your circadian rhythm. And bipolar disorder is a circadian rhythm disorder even more than it's a mood disorder. So light that you aren't even knowing you're seeing, because those receptors don't go to the part of your brain that sees things.
That 460 light—it regulates mood in people with bipolar disorder. You can induce mania with bright blue wavelength light. Longer days, summer traditionally, have more mania symptoms present. There is more of that light hitting your eyeballs. It's part of full-spectrum light. “Virtual darkness” is an evidence-based treatment for bipolar disorder.1
So if you put on sunglasses that block out that one wavelength of light, for 14 hours a day, your mania will abate. I practice something with bipolar patients that there's one evidence-based type of psychotherapy called interpersonal social rhythms therapy, which is an adaptation of IPT, which includes the understanding that circadian rhythm dysfunction is core to bipolar disorder.
I do that kink of psychotherapy, and I love it. The only other psychotherapy I do is mentalization-based treatment.
I don't do bs therapies, also know as therapy I'm not going to be any good enough delivering! You can see someone who trained to do CBT, not me—who had one CBT case in residency. Not going to do it, because I am not trained well enough to provide good enough care.
People paid a lot to see me — nothing if they're going see my at Bellevue. It is a public health system. People should get their money's worth and see someone who's an expert in the thing you need! If I am doing therapy with you, it's either mentalization-based treatment. This also has variations: for family problems—MBT-for families. It has an adolescent model for adolescents, or the adult model if you're an adult.
I flew to London to do the MBT adolescent training on thanksgiving. I spent my thanksgiving break from fellowship doing training I was unable to get in the US!
I did the adult training with Anthony Bateman and Peter Fonagy. I did ongoing supervision with Brandon Unruh, M.D. at McLean. He is an excellent supervisor.
I Tried to Avoid Medical School
I intentionally did not take any classes that would allow me to go to medical school when at Amherst College. I had an illness— I thought if I got depressed, I wasn't going to be able to do medical school, and I was scared.
I did another career first. I thank God I got laid off from my job at Sony Music Studios. After a particularly bad night with Beyonce, they fired Tommy Mottola, the head of Sony Music, U. S. On that day, they fired a thousand other people. I was the most recent hire, so they laid me off.
I went, “oh fuck, I'm miserable, this is an overnight job for the past nine months,” — you can imagine how much of a good idea that is for someone with bipolar disorder. It's not. I had to figure out what to do with my life. My best friend from age zero skied into a tree at about the same time.
He was wearing a helmet, he had a C1 cervical fracture, and he couldn't swallow anything for a year. He was in a halo for the better part of a year. The next year, he relearned to swallow. He made a kind of miraculous physical recovery. He works in mental health, too, because he got cripplingly depressed after that accident.
His fiancé left him. And I'm like, Dude, we've been friends for a long time. I know what depression is like. Let's get you some help. And we went to a Depression Bipolar Support Alliance meeting every week for a year and a half. And at those meetings, I learned something that I did not know. I had a good psychiatrist.
I originally had Maria Oquendo, who's the a past president of the APA, as my psychiatrist. She did not continue to be my psychiatrist. And I see someone here in New York who I've seen for the past 25 years.
Dr. Oquendo was seeing me for the time of the research study, and I applied to Columbia for residency. She didn't even interview me. I don't know why; my step one score wasn't great. I have friends who work with her.
She's the voice of American psychiatry. And she took care of me for the time she took care of me and made a very good referral to someone who, it turns out, teaches personality disorders at NYU.
Not all things that are valid things are in the DSM. Some of the things that are in there are valid. I think personality disorders are a valid group of disorders. I think they existed well before we wrote the DSM.
The Depression-Bipolar Support Alliance Helped me Decide to go to Medical School.
So I had this illness, I changed my mind. I heard stories in that meeting of people who were suffering, who had shitty psychiatrists.
And some were great psychiatrists that made a huge difference. I went to Amherst College. I can probably do this. I went back, went to City College, did a post baccaulerate, applied to med school, went to the University of Rochester, and here I am.
So how did I start dealing with personality disorders?
When all you have is a hammer, everything looks like a nail. This is very true in psychiatry. So if you go see a bipolar expert, you're likely to walk out with a diagnosis of bipolar disorder. If you go and see a depression expert, you have depression, right? That's what happens. I decided if I wanted to be an expert on bipolar disorder, I should learn everything else it could be mistaken for.
I didn't like working borderline personality disorder patients at first. I wasn't very good at it. I didn't even see it that often. You're not excellently trained in adult residency in assessment of personality disorders. Probably less so in child psychiatry — some child psychiatrists don't believe these disorders exists in children.
I disagreed. I met my wife— who was already a child psychiatrist. She trained at McLean.
Brandon Unruh, M.D. was a senior resident of hers. He is the person who runs the outpatient mentalization program at McLean now. He was pouring the mentalization Kool-Aid into her coffee from a very early time in her training.
Carlene and I fell in love in Orlando at the 60th annual American Academy of Child and Adolescent Psychiatry meeting at Disney World.
She was really into the “personality disorder stuff.” Training at McLean, and they love that complexity there; they have Gunderson rounds. This is a place where they think about personality disorders and their existence. And she recognized that I was someone who could be on that sort of team. She said, hey, “there's this mentalization training, you have to do it.”
I said okay. I applied for a grant for it. I didn't know if I'd gotten when I signed up for the MBT Training. I did it anyway. Now I'm probably not getting busted for this.n I didn't have enough vacation days, so I literally “snuck off campus” to do the training for a day. I made sure I had no patients, carried my pager, discussed coverage needs with my colleagues, and attended an advanced training surreptitiously.
I went and did the MBT training. I later got the grant— great. And my whole world changed in three days. I believed personality disorders existed by that time, but seeing Anthony Bateman use mentalization-based treatment is like seeing Yoda fight with a lightsaber for the first time. It is life changing.
Assuming you're a young Jedi. If you don't know what's happening and you watch it, he looks like the best therapist ever. He just effortlessly, effortlessly reflects back what he hears. He's funnier than Larry David, lightning smart, lightning fast. And just able to control what goes into a therapeutic experience for the patient in a way I'd never seen before.
Fonagy's super smart, probably a little too smart. And watching him do it was great, too. But we also had Lois Choi-Khan their teaching, John Gunderson, and at my training were Alec Miller and Jill Rathus, the developers of DBT for Adolescents. It was a good group. I brought one of my supervisors with me, and he went and did the training with me as well, and we morphed my supervision in general residency into MBT peer supervision.
Suddenly, these patients, who I had not been doing a good job with psychotherapy?
“Oh, it's a personality disorder. It's not depression.”
More than one thing valid explanation can be true, but depression is not why they have no friends. They were in an abusive relationship for years, or they blew up at everybody, or a young child insulting a person could lead to hospitalization. The wool was pulled off —beneath was a crystal ball! I started understanding that personality disorders existed.
My patients commented:
“Hey since you came back from that training, you're way better.”
I was not a very good therapist before.
Thanks for being honest, patients. I did the MBT-A training in London. I started seeing kids in child psychiatry training who had a similar problem set to BPD in adults, and needed that help.
I did the Good Psychiatric Management (GPM) training for trainers, an approach for generalists that John Gunderson developed.
I have authored one chapter in a book on John’s GPM approach:
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Con’t... pieces into this puzzling childhood .
And yes , Sister was diagnosed borderline /bipolar...
Doc, I grew up with an untreated dad and sister before the days of lithium .
Our house was full of apprehension that one or the other would start raging . In the summer dad would be Mr. Up .. happy , talkative , mowing lawn & taking us 6 kids swimming .
Autumn brought on his months long depressions spent in bed .
You have helped me put a few more puzzle pieces