Hello, my name is Jon Murphy, psychiatric nurse practitioner and welcome back to line by line Survival Notes This podcast is brought to you by Focus Path. I'm available to meet with patients in Washington, Oregon, New Hampshire, and Massachusetts. Let's just dive into it today. I'm feeling pretty good. I just met with a patient I haven't seen in a minute, and I had an opportunity to work with him through what I call the survival code.
I developed this based upon understanding group psychology and various other factors working with my patients, working in trauma informed care, and for the purposes of using a therapeutic tool in psychotherapy with patients. I've realized there's about eight modes, survival modes. If you will, that help me understand what sort of default a certain patient's nervous system is currently in. What is the nature of the threat that the nervous system experiences for each patient?
The development of these eight roles, it has to do with understanding and sitting with and thinking about more complex cases. Because I started my career at age 23 in a psych unit for profit hospital, 27 beds, adult acute psychiatry making $10 an hour, it was an unsafe work environment, but I liked it. I said, this is pretty cool, you know what, I can do this, and it felt normal to me, but that's a story for a different day.
Sitting with agitated, uncomfortable, frustrated people, that's not hard for me. So when I moved into outpatient psychiatry initially, it felt wonderful because, wow, these are actually real people. These are people that are just completely out of their mind and agitated, it doesn't require as much strategy. I don't have to be as rigid with my boundaries. when I meet with a patient that is dysregulated or frustrated or agitated, I'm able to sit with it.
Putting in the time that I have, my read on my emotions is fairly strong. If they're activated during a patient appointment, I can reflect on it and maybe even talk about it. And then there are other times where patients are extremely agitated and I feel nothing. That's a really good indicator to me that a patient is responding to a threat that simply is not there.
So these more complex cases that I see patients that start the intake by saying, never had a psychiatrist, or I've had a, I've tried this before and it never works, and everywhere I go, no one loves me. No one will ever listen to me, and all that type of stuff. So are these people going to be receptive and responsive to me? Ultimately, I want to determine if any patient I see is actually able to be helped within a psychotherapy dynamic. That's not always the case.
Depending on the underlying pathology is the patient's underlying motives and drives, to engage within psychotherapy, are they conducive to the work that I'm doing? So in other words, do they wanna feel better and understand themselves or is there something else going on underneath the surface? If something is presenting to me as say, borderline personality disorder, it's pretty easy to determine and treatment doesn't continue.
So I'm able to rule out these things that these labels that people often place upon the patients that are agitated or frustrated or dysregulated, they're usually not accurate. So I'm sitting with patients that are acting outside of themselves and they'll often push me away, especially if they get a feeling for the fact that I might actually help them. The nervous system might have a lot of trouble with that.
So finding language, and not only intellectually understanding this, but finding a way to communicate this to the patient. Super helpful, and this current version of the reinforcement matrix that I use is 24 questions and these questions are broken up into six sort of domains, six domains that include nervous system responses as well as informed by group psychology, which I think is a very important factor here because we grow and develop in a group.
I was able to determine right now the incongruence that the patient is experiencing is very high because right now he's in the mode, what I call the diplomat. The diplomat is also known as the peacekeeper. The diplomat's nervous system has tied safety to group stabilization. This is achieved through peacekeeping and role extension. It is reinforced through the perception of relative group harmony and environmental safety.
But this isn't where the patient started He often talks about how he was the general, he was picked on in school, so therefore he became the general. The general is very agitated and fights. Other people are a threat, but by responding to that threat, the aggression is therefore reinforced through predictable, repeatable outcomes. That tells us a lot about our worthiness and our ability to survive and our identity, ultimately. This is who I am. I am a fighter, but we learn as we get older.
Maybe we didn't always want to fight, we didn't want to be the general, so we reluctantly become one. But the general who becomes the diplomat is presented with a particular challenge. They're gonna want to fight, they're gonna wanna lose it. They're wanna blow their top, and they often do, but nonetheless, they handle the stress. He found it immediately helpful and that was really, really good feedback for me.
This is a patient that has never met with anyone, many failed attempts at psychotherapy, and while I know I could sit with it, certainly didn't have a problem with someone yelling at me for an hour. Bottom line, you know, there wasn't malice or intent to harm. Nonetheless, I could just see this was an involuntary reaction that had nothing to do with me.
So it's not to say I should put up with abuse or mistreatment, but I don't characterize what I was going through in this dialogue is that it was a patient that was dysregulated but remained in the appointment. I didn't feel that they ever aggressed toward me, but they were extremely hostile and agitated and activated. That was something within that patient that was triggered. Now we talked a bit about the next step. The next step would be moving to the operator mode.
The operator is able to remain in the group, but plays just a functional role. They don't extend beyond their role. And that would be progress for him. So that's one quick clinical example of the survival code modality that I've developed, and I talked about three different survival modes from the general to the diplomat to the operator. And I'm very excited to talk about this more.
Not only has it helped me, but it's helped move the treatment forward for some of the most complex patients I've ever seen and it's not anything too fancy that I've done. I've just had my own healing journey. I've been curious and inquisitive about the patients that are struggling. Why is it so hard to change? It has to do with reinforcement. Whatever we did, if we're struggling with it now and or really, really stressed out and we feel stuck, it's because whatever we did worked really well.
It worked really well for that patient to become the general. So the general doesn't wanna stop fighting, but the diplomat just feels better. It's different. We don't have to fight, but we also don't need to keep everyone together all the time. So slowly we just need to teach our nervous system that we can relax, that we've done the work, we've grown. We became dependent even when we shouldn't have had to.
We did things and adapted and strategies in ways that we employed to get the job done to depend on the undependable. And now here we are, just another story in the pages of Survival Notes. Once again, this is Jon Murphy, psychiatric nurse practitioner. Thanks for listening. This podcast is brought to you by Focus Path. That's www.myfocuspath.com. So until next time. We will see you later