This is the story, the narrative, of a survivor, Marsha Linehan, an innovator in the treatment of borderline personality disorder (BPD) using a method she and her team
invented called Dialectical Behavioral Treatment (DBT). Linehan has written a memoir, not a treatment manual (separately available (see references at bottom)). Her memoir contextualizes the diverse interventions used by DBT such as acceptance, distress tolerance, emotional regulation skills, self soothing skills, communication skills, limit setting skills, assertiveness training, and so on. She attempts and largely succeeds in connecting the dots between DBT and its skills and the key events in her life, many of which had not been publicly available.
While courage is needed for someone who has suffered from invalidation all her life to risk further invalidation in some arbitrary book review, dishing on the details of one’s life is definitely trending. Being vulnerable is trending – see Brena Brown who has virtually branded vulnerability – and Linehan succeeds in spades in opening herself up. Linehan’s narrative is by turns spiritually enriching, educational, funny, discouraging, and inspiring.
For those who require an orientation – and at the risk of over-simplification – DBT combines acceptance and tolerance such as one develops in meditation and mindfulness with the specific cognitive behavioral therapy (CBT) skills designed to interrupt the dysfunctional thinking and negative self-talk of anxious and depressed neurotics. I see it as empathic validation plus homework in CBT skills.
More formally, DBT is an evidence-based, team-abed treatment, requiring individual and group work, that is included in clinical practice guidelines for the treatment of BPD, suicidality, and several other “acting out” types of addictive behavior such as substance dependency that have proved resistant to other forms of treatment.
Linehan’s memoir connects the dots between a specific DBT skill back to her experience in life. Often she calls out the instant in which the DBT skill was born, defined, invented, or got “borrowed” from another theory. For example, and once again at the risk of over-simplification, Linehan does a lot work on mindfulness, meditating in the context of Zen Buddhism; the DBT skill of acceptance is born. Another example, in the case of willingness – like, “I am willing to give it a try” – Linehan first encounters it at the Shalem Institute. Willingness is borrowed from the existential psychotherapists Gerald and Rollo May, but given its own special spin when combined with the Zen distinction of acceptance (p. 196).
In reading Linehan’s compelling and engaging narrative, she talks a lot about religion and love. The spiritual dimension is front and center.
William James’ The Varieties of Religious Experience (1902) has nothing on Dr Linehan – she sees the golden bright light at the Cenacle Retreat Center over on Fullerton – possibly at about the time I was living around the corner on Belden Avenue. She has the “blue hydrangea” moment, too. Hence, the title of this review, “Saint Linehan” is not an irreverent joke, in the DBT sense, though it is that, too.
Linehan documents at least two mystical experiences that belong in James’ work. As noted, at the Cenacale Retreat House on Fullerton Avenue, Chicago, she experiences the encompassing, enveloping “bright golden light shimmering all over” (p. 102, p. 200). Then later she has the “blue hydrangea” pantheism experience of God being everywhere at the Shalem Institute of Christina contemplative prayer with a strong admixture of existential therapy from Gerald and Rollo May (p. 196, 201).
Linehan was in psychoanalysis at the time of her “golden light” experience, and, of course, she told her analyst about it. Now one might expect the analysis had read Freud and he would associate to the “oceanic experience” from childhood that Freud so compelling quotes on the first pages of Civilization and Its Discontents. Instead Linehan reports that the analyst said: “Marsha, I’m an atheist, so I have no idea what happened to you. But I can tell you this: you don’t need therapy anymore.” That was that.
Wait a minute! Freud was an avowed atheist, too, which is where this analyst got the idea, though Freud highly valued Jewish culture and Hebrew teachings. It may be deeply cynical, but I wonder that this so-called analyst (Victor Zielinski, MD, who spent a lot of years at Hines – another bad fit (?)) had not been wishing for awhile that this difficult individual would just “go away.” Another breakdown of empathy?
Marsha did not see it that way, she was sooo happy as she left the office. Though I accept the happiness, the accuracy of her insight into the cause of this happiness is what I am a tad skeptical about. She had a narrow escape from yet another invalidating, unempathic environment like her mother’s home growing up. I hasten to add this was prior to Heinz Kohut, MD, and his innovations, which powerfully embrace empathic listening and responsiveness in the psychoanalytically inspired (and based) context of self psychology.
The causes of BPD are still being debated, but the person is vulnerable in three areas. The person must have a biological disposition; the group (society, community, family, and so on) to which she is a part leaves the person feeling they do not fit in; and, most importantly, the person is not given a chance to develop the interpersonal skills needed to relate to others, regulate their emotions, and self sooth. In short, the aetiology requires an invalidating environment. Key term: invalidation.
To me the invalidation environment often looks like one that lacks empathy or one in which the caretakers are significantly “out of tune” empathically with the child. Of course, the environment may also include more obvious adverse or traumatic experiences. I hasten to add that while it is fashionable to dump on the parents, that is inadequate. One can get similar results as extroverted children are born to introverted parents (and vice versa) and so on. See Andrew Solomon’s book, Far From the Tree (2012). The apple never falls far from the tree? Oh yes it does! Marsha fell far from the tree. But that is not all.
In Linehan’s life, the mother is the image of the invalidating environment – Marsha was never quite right – she came within a hair’s breath of inventing self psychology but once she ended up on the inpatient psychiatric unit and had been subjected to the rigors of electro shock “therapy” that game was over – to save herself she had to wok from the outside inwards behaviorally and invent DBT.
So what did Linehan actually have to survive? She was the round peg in the square hole of her family. She was smart, got good grades, was out-spoken, and even popular in her own eccentric way. All the women in the Linehan family are wife line – thin; Marsha is “large-boned” and if she is not caution those bones can acquire adipose tissue. The mother is prim and proper and the model of an executive’s wife. The executive was remote, taking solace in his work, and keeping his distance from the “house wife obsessions” of the mother of his children. He emotionally abandons Marsha. Meanwhile, according to Marsha’s mom, she [Marsha] just couldn’t do anything right.
Marsha needed fixing and no one knew better how to do it than mom. Yet no matter how much Marsha improved, no matter how good she got, Mom consistently found something to criticize. One can only get better for so long; then one has to be good enough.
The sister’s example was always there to be thrown at Marsha. And mom apparently even warned the sister to stay away from Marsha, further isolating her emotionally in the family, as Marsha was apparently a bad example. She was getting good grades and popular – a bad example of what? “Girls were supposed to be demure, sweetly charming, quietly spoken, and not given to expressing strong opinions, especially around men. They should defer to men at all times and in all things” (p, 111). Her mom valued a “girly girl,” who knew her place. This was not going to go well.
Marsha starts living into the devaluing judgments of her close relatives. Marsha gets to adolescence and her “apparent competence,” her skill in maintaining a false self [not Linehan’s term], the good girl, even if a tad eccentric, breaks down. She has some dates, but she never succeeds in getting a steady boy friend in high school. She comes unraveled, beset with acting out in the form of cutting – what would come to be called para suicidal behavior thanks to DBT.
There was an noticeable absence of trauma on Linehan’s life, except those traumas which she eventually inflicts on herself in cutting with a razor and related para suicidal acting out. But invalidation was pervasive. If empathy is like oxygen for the soul (psyche), Linehan was suffocating. She starts flailing about like someone who can’t breathe.
A constant drumbeat occurs of “you are not all right,” of “you are not important,” “you are less than.” Highly destructive to the nuclear self.
Even though Marsha eventually overcomes many of her demons, mom’s behavior never changes in spite of an honest effort. For example, years later, Marsha is getting her doctorate in social psychology, a significant accomplishment under any circumstances. Congratulations? “Mother had made a dress for me for Aline’s [her sister’s] wedding, and on the morning of graduation she was more focused on fitting my dress than she was on my getting a doctorate” (p. 118).
The word “empathy” occurs once in Linehan’s text (p. 94); and, of course, the word itself as a mere word is dispensable in principle. The text and Linehan’s life work is steeped in empathy. Empathy LIVEs in Linehan’s work. But not empathy as emotional contagion or “touchy feely” fragilization. Key word: fragilizing (p. 223). Not you are very fragile and have to be spoken to softly and treated with kid gloves.
There may indeed be moments for a quiet heart-to-heart talk, and such conversations are highly significant, but if a person is carving up their arm with a razor, this person may be a lot of things, but fragile is not exactly one of them. How shall I put it delicately? They are in a lot of pain and suffering and are employing emergency merges to try and survive the moment.
Paradoxically pain and suffering can become a highly uncomfortable “comfort zone” for the client. Personal suffering is ruining the person’s life, but the person is attached to the suffering. This is the case not only with BPD but with most kinds of mental and emotional disorders. This is different than moral masochism, but sometimes not different by that much. The patient has to be motivated to engage the tough work of moving beyond stuckness to have new experiences, which are by no means guaranteed to be immediately rewarding or satisfying. That is where validation comes in.
We have conceptualized invalidation as a cause of the suffering, so Linehan and DBT deliver validation as part of the treatment. But what is validation? A lot of work is done to meet the client where she is. The client says, “My life sucks.” And that is usually the most accurate available description. The person really is miserable and there are good reasons for it. What’s so about life needs to be validated before the individual can consider the possibility of moving forward out of stuckness. The therapist’s validation provides access to the client’s acceptance of their situation. Acceptance of the situation provides an opening for moving beyond the limits of the situation.
The challenge to the treatment is that acceptance and validation provide access to change, but it does not seem that way to the person who is in pain. The challenge is that pain and suffering can be sticky.
“Validation” means you experience your experience. Invalidation is being told – sometimes quire persuasively – you did not experience your experience. How is that even possible? Believe me, it happens a lot. Blaming the victim. Redescribing the experience as caused by the survivor’s own shortcomings. “Don’t you ever talk that way about Uncle John again! He did not pull down your pants” [not an example in Linehan]. Pretty soon the child does not know what he is experiencing.
The client usually likes to be validated. Validation is different than agreement or disagreement. It means the other person “gets who you are.” It means one is responded to as a whole person, not a diagnosis, label, body part, or partial entity. It means one is responded to as the possibility of flourishing and accomplishment, even if, at the moment, one is stuck in emotional misery. For my money, that is an alternative redescription of empathic understanding. For many, validation is itself a new experience and some can’t believe it or be open to it. It takes time, but most people promptly, though not instantaneously, perceive it as authentic, especially when it is authentic.
Then the client can be motivated, leveraged, incented, to practice new skills, take risks interpersonally, and just try stuff out instead of wallowing in a funk of anxiety and depression. The validation is the empathic moment. To get it right requires expanded empathy. Though the word is not much used, as noted, empathy LIVEs in the work Linehan and DBT treatment programs are doing. But then you also have to do the exercises.
Before I read Linehan’s memoir, I knew that she was a survivor. I knew she was a survivor of some of the things for which DBT is a successful treatment. I knew about the “physician, health thyself” aspect of her work and the work at Zen Buddhist retreats – as indeed is often the case with innovators who have to overcome personal demons in order to thrive – Kay Redfield Jameson and Elyn Saks, for example. Indeed Freud and Jung belong on this list – especially Jung.
I digress at this point to point out that Henri Ellenberger (Discovery of the Unconscious (1970)) has the distinction of a “creative illness” – which often has major psychosomatic aspects as the body is the best picture of the human soul/psyche – from which the individual emerges with renewed energies to produce his or her magnum opus or masterpiece. Arguably Linehan’s two years on the inpatient unit were her “creative illness,” though I cannot believe it seemed to her that way at the time.
What I did not know prior to reading the memoir was about the electro convulsive therapy (ECT). Linehan reports she once knew how to play the piano. The ability never returned after the ECT. She got into a pre med program at Loyola in college and found that she had forgotten all her biology and much of her science, once again probably as a result of it having it blasted out of her by ECT and significant does of anti-psychotics – you forget what is bothering you and a whole bunch of other stuff too). So Marsha Linehan is also a survivor of ECT, and not in the best sense of the words.
Need I add that Linehan, with some conditions and qualifications, does not endorse the inpatient treatment of psychiatric disorders? One of her many videos on Youtube makes the distinction between a “life worth living program” and a “suicide prevention program.” I paraphrase Linehan in redescribing suicide to a suicidal client: “It’s good that you see feeling suicidal is a problem; but really suicide is a solution to escape from a messy and painful life; and our job in DBT is to give you a better solution through skills such as self-soothing, distress tolerance, mindfulness, emotional equilibrium training,” By the way, “redescribing” is a DBT skill that has many origins, but most properly credited to the modern philosopher Elizabeth Anscombe.
Linehan’s makes a strength out of a weakness in the memoir as she enrolls important people in her life of giving her an account of publication of what was going on at the time, which she then quotes in the memoir. Still, the number of times is significant that she reports, “I just can’t remember” or “I don’t know why I did this” [or words to that effect].Such statements become an important part of the rhetorical stance of this work. They are also, in their own way, examples of a DBT skill. One does not always need to understand in order to get the result. Understanding has its uses, but also its limitations. If one sits around waiting to understand, it could be a long wait. Get in action. Try something. If it does not work, stop doing that, and try something different.
What I did not know was about the extent and depth of the self-harm. She gets put in isolation, and she launches herself head first off the chair in a frenzy of disequilibrated self-harm. Yes, people were supposed to be watching her, but somehow this kept happening. Traumatic brain injury?
What I did not know is that Linehan, finally on the road to recovery, considered becoming a monk or nun. She took vows of poverty, chastity, and obedience as a Lay Religious person instead. In the irreverent spirit of DBT, I note that her career total was zero for three, though here I am making an educated guess, I believe she honored the spirit of her vows.
Since this is not a softball review, I have critical observations. Linehan learned more from that unempathic psychoanalysis than she realized – she was working on an early version of self psychology. Thus, I have some “tough love” for one of the inventor’s of tough love in the context of treatment. However, the one thing I am not going to do is invalidate Linehan’s experience. Her report of her own experience is whole and complete and perfect in every way. She gets to say.
This business of “wise mind” – a DBT koan – needs work. My intuition is that human beings cannot intentionally “be wise.” Some people may end up being wise as a result of processing their experiences in profound ways. Wisdom comes forth “out of the mouth of babes” in that some individuals get in touch with a “beginner’s mind” and are able to express hard-to-capture distinctions hidden in plain view, about life, relationships, and everything. In that sense, yes, “wisdom happens.” Kant said, “Only God is wise.” Kohut said that a certain wisdom – along with humor and expanded empathy – can be brought forth as the result of a successful analysis of the self; but that wisdom was mostly acceptance of our limitations, suffering, and finitude. So I have NEVER been comfortable or “on board” with the over-simplifications in DBT about “wise mind.”
Linehan is often on a tear – standard behavioral therapy doesn’t work with the most seriously distressed (suicidal) patients and cognitive behavioral therapy has serious issues, too. You have to get a person whose life and all-available-evidence “prove” that “all the good one’s are taken” or “life sucks” to be reasonable and admit that “some of the good ones are not taken” or “life does not have to suck at all times.”
Emotional mind does not acknowledge cognitive penetrability or cognitive impenetrability. Cognitive mind does not acknowledge the emotions display a “logic” of their own, disclosing important aspects of a situation while also concealing other aspects. Cognitive mind can tell you “what’s so,” but cognition lacks the power to motivate you to do anything about it. Abstractions do not move people, emotions do. There is a dialectical encounter between the two – and that is commitment, which tries to find a emotional motivation for what cognition shows to be an authentically valid path forward.
The thing about the iceberg is that it’s the iceberg “all the way down.” The visible part of the iceberg is not a different iceberg than the less visible part submerged beneath the water. The behavior is visible, but the biology is not visible, what the individual had to survive is not visible, how the community reacts to the individual of is not visible. But unlike – or perhaps just like – the iceberg, research treats these all as different siloes. It is true that we all – including Linehan – now speak of the bio-psycho-social individual and express authentic commitment to integration. But the effort required to integrate just shows how dis-integrated the entire phenomenon is.
The tip of the iceberg does not regard itself as distinct from the iceberg. The “tip” is our abstraction. Likewise, with behavior. Linehan demonstrates this compelling as she takes the psychoanalytic distinction of “introject,” operationalizes it, and shows collects evidence that DBT improves measures of introject over against a stricter behavioral intervention. Amazing.
How shall I put it delicately? Like every other individual, Linehan has a privileged access to her own first person experience – the golden light moment, the blue hydrangea moment. She also has many advantages in interpreting what that experience means, since, like every other individual, she knows a lot about her own history that others might or might not know. But as to what the experience “really means,” one individual has as good a chance of getting it right as another once the experience has been captured and reported. At first she says “The golden light means God loves me”; but then, since that experience was like [felt like] her love for Ed [a person who she actually loved deeply], she reinterprets the golden light to mean “I love God.” So she has to continue searching for God’s love for her, which brings us to the blue hydrangea by which time the meaning of God and of love have shifted.
But wait. Her Zen experience will eventually have taught her this is just another Zen koan – it is like the ambiguous Gestalt image the duck-rabbit where the rabbit’s ears and the duck’s bill and the figure spontaneously reverses – perhaps she got it right the first time – “God is God” and “love is love.” In short, Linehan is really slinging it here, and there is nothing wrong with that. It works. Her rhetoric is that of the beginner’s mind after long struggle. She is irreverent, assertive, disruptive within limits (and without), and contrary within limits (and without), innovative, all DBT skills, and we thank you, Marsha, for being Marsha.
Marsha M. Linehan. (2020). Building a Life Worth Living: A Memoir. New York: Random House, 384 pp.
Marsha M. Linehan. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Marsha Linehan Interviews Kelly: https://www.youtube.com/watch?v=tgzw50SbokM
© Lou Agosta, PhD and the Chicago Empathy Project
Categories: Borderline Personality Disorder (BPD), Dialectical Behavioral Therapy (DBT), Empathy, extreme empathy, Marsah Linehan, talk therapy, TBI Traumatic Brain Injury