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