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Saint Linehan: Marsha Linehan dishes on what she had to survive to innovate her way to DBT

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

Cover Art: Building a Life Worth Living by Marsha M. Linehan

Cover Art: Building a Life Worth Living by Marsha M. Linehan

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.

References

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

Noted in Passing: Elizabeth Wurtzel, Author, Prozac Nation

Elizabeth Wurtzel (1967–2020) died at the age of 52 on January 7th in New York City of metastatic breast cancer. Wurtzel became a notorious “bad girl,” with a wicked sense of black humor, sparing few, least of all herself, and a disarming “tell all” candor in her break through memoir Prozac Nation.

Full disclosure: I am catching up on my reading. Triggered by Wurtzel’s passing

Elizabeth Wurtzel (her young self): Cover Art: Prozac Nation

Elizabeth Wurtzel (her young self): Cover Art: Prozac Nation

away, I had not read her best selling Prozac Nation until earlier this week (01/14/2020). I acknowledge I need to get out more.

Now I am familiar with pathographies – autobiographies and biographies of mental pathology – having read Kay Redfield Jamison’s An Unquiet Mind, Jamison’s “Robert Lowell: Setting the River on Fire: A Study of Genius, Mani, and Character,” and Elyn Saks’ The Center Will Not Hold, all worth reading – as is Prozac Nation. Thus, I bring an innocent reading – and eye – to a work that is anything but innocent.

Wurtzel is credited with putting the funny but self-lacerating memoir on the literary map, with its account of her emotional struggles against the Black Wave of depression, volatile internal conflicts, and acting out in the form of cutting, starting at age eleven. Subsequent attempts to attain emotional equilibrium through substance abuse and volatile relationships with members of the opposite sex, the narrative actually turns into a coming of age story. Some coming; some aging.

Not quite stream of consciousness, but definitely a rapid fire, back-and-forth conversation of Wurtzel with herself, it puts me in mind of the cliché: your mind can be a bad neighborhood; if you go there, you are going to get mugged, albeit in a comical way; mugged by negative self-talk, devaluing self assessments, and rage at the narcissistic slights inflicted by intimates, strangers, and intimate-strangers alike.

Wurtzel’s writing is shot from a cannon. The character sketches are wickedly funny and just as cutting as her own practices of self-injury. One example: “If Archer weren’t so good-looking, I’m not sure he’d exist at all, since he lacks most vital signs [….][H]e is the best opportunity to hang out with a gorgeous man and be certain that there will be no sexual tension whatsoever” (p. 224).

Wurtzel literally calls out the elephant in her family’s living room early in the narrative (p. 58): her parents are fighting, from the time Elizabeth is two years old, when her mom divorces her dad. The parents continue to fight (including in court) throughout her childhood, adolescence, and emerging adulthood, all the while “telling me that their [hostile] feelings for one another shouldn’t affect me,” blaming the victim if she feels affected, making the child an unwitting pawn.

Usually an emotion will shift after a few hours and a depression will shift after a few months, even if no intervention is undertaken other than good rest and good nourishment. To keep the disorder in place, active measure must be undertaken by the person, environment or both. The ongoing family situation is a significant contributor to the extraordinary duration of the distress.

It gets worse. The dad has access to health benefits through a good, albeit low level, corporate job; but it seems that every time the growing Wurtzel gets into an emotional crisis (chronic emergency would be more like it), the dad stops paying for psychotherapy, telling her its nothing personal. The real reason is usually a dust up with the mom.

Queue up the late rock-and-roller Stevie Ray Vaughn: Caught in the cross fire. Elizabeth is. She cannot help but internalize the conflict. Any kid would. This is the way it is. It starts so early and continues so unremittingly, that one must be positively as blind as the parents not to see it: this is an invalidating environment.

Another example of invalidation that might be straight out of Heinz Kohut, MD: “For instance, I’ll walk into her [mom’s] apartment and she’ll just blurt out, Those shoes are so ugly! And I never asked her. And I like my shoes […] The concept of Who asked you? does not exist in my family […] We’re all meshed together” (p. 231). Unremitting, serial breakdowns in empathy, resulting in emotional contagion, conflict, and enmeshment with the toxic self-object and hostile introject. Ouch!

Abandonment comes up early and often. In year-after-year of being sent off to a different camp, depending on which one offers a discount to her and her mom, who are living in a kind of genteel poverty. It induces a real panic about abandonment in the young Wurtzel, resulting in dozens of calls requesting rescue. Having been dutifully rehearsed during latency, this fear takes on a life of its own. “[…] [B]eing alone turns into a terrible fear that I will have no friends” (p. 89).

In several relationships with college BFs (at Harvard College) Wurtzel cries and cries sad tears, angry tears, at the prospect of separation such that the behavior creates the dreaded self-fulfilling prophecy. She goes well beyond “high maintenance” into the land of continuous confrontation, just plain crazy shit, and the bottomless pit of infinite upset all the time. Meanwhile, the guy wants a friend with whom he can go to the movies and party, maybe perform some consensual sex acts between reading about Derrida and Marxism. Enough.

Years later it comes out. The man Elizabeth thought was her dad, who was divorced after two years by the mom, and who also thought he was the dad, is not the biological father. Even though he did not have the DNA data, somehow he was never able to relate to Elizabeth in quite the proper parental way. (See the article by Wurtzel entitled Bastard, cited at the bottom of this post.)

Wurtzel has a gift for zingy one-liners, coming out of the blue, and yet creating their own context instantaneously. As regards the above-cited elephant, “We went to Alaska and we froze to death” (58) – emotionally. More like the abandoning, ice box father and the bonfire mother. Things heat up, especially with her mom: “I come from a family of screamers” (p. 185). Balance is hard to find.

The subtitle is “Young and depressed in America,” and one can sees Wurtzel’s editor’s skillful hand in connecting the dots between individual suffering, of which there is an abundance, and the breakdown of communities, ongoing, whether due to globalization, an opioid epidemic, or the malling / mauling of America.

The reader learns the difference between sadness and negative self-talk and what we might call existential depression: “I’d been expelled from the place where possibility still existed” (p. 60). Depression is the loss of the possibility of possibility. It is not just that I lose love and long for love; I lose the possibility of the possibility of love. This is gonna be tough going.

This is definitely a page-turner. Hard to put down. However, there are also some loose ends. I mean in the narrative, looser than Wurtzel herself. 

The title is premised on the interpretation that Wurtzel suffered between the ages of eleven and twenty one from a hard to treat Black Wave. Tons of talk therapy – finally she can’t stop crying for days – and not for the first time – and her shrink prescribes an anti-psychotic – Mellaril [thioridazine] – and its anticholinergic effects promptly dry up her mucus membranes, allowing her “to get a grip on it.” She is able to stop crying.

I am reading this passage and scratching my head. This is an emergency measure, right? Wurtzel is a lot of things, but her reality testing of the everyday is good enough. I know nothing, really, and am not a prescriber. However, I have been know to echo Lou Marinoff’s saying, “Plato, not Prozac!” And yet: An actual antidepressant such as imipramine or disiprimine would have had the same anticholinergic effects, have dried up the tears physiologically, and it might actually also operate as an antidepressant, would it not?!

Perhaps it was because of the unremitting of suicidal ideation that Wurtzel endorsed and expressed that no medical doctor recommended a tricyclic antidepressant. A person can actually hurt themselves with the tricyclic antidepressants, as with any powerful drug, which can cause a fatal heart arrhythmia if consumed contrary to proper guidance and in volume. But if this is supposed to be an emergency measure, a small number of pills in small dosages, closely supervised, would also have been possible would it not? Was Wurtzel getting adequate medical treatment even by advanced 1994 care standards? We may never know.

I am not one noted to value psychiatric labels, seeing them as getting in the way of being fully present with the other person as a possibility. Yet Wurtzel has a breakthrough towards the end of her narrative when she gets one – a label – along with the newly available fluoxetine (Prozac). Her psychiatrist gives her a diagnosis of atypical depression. I would add, demonstrably treatment resistant. “Atypical” because years of talk therapy and first line antipsychotics have barely made a dent in her unremitting self-abuse, inclination to self-medicate with weed, alcohol, and acting out with a series of boy friends, a couple of whom are the target of an intense romantic idealization combined with a neediness calculated eventually to drive them all away. However, at this point, the Prozac seems to work – except that about two weeks after starting to take it, she is feeling a tad better, and her only serious suicide attempt reported in the book occurs. Hold that thought.

One thing lifted Wurtzel’s work head and shoulders above your average narrative of suffering and redemption for me. Wurtzel is working through her invalidating environment and she gets it: “…[M]y addiction to depression …involved the same mental mechanism as someone else’s alcoholism” (p. 23).

Suffering is sticky. The risk of suffering is that it becomes an uncomfortable comfort zone. The body and the mind adapt to chronic pain and chronic stress. Even when the result is still pain, not numbness, the entire messy complex takes on a life of its own and becomes: suffering. If you water the tree of your sorrows, the tree grows. It grows until the suffering becomes the man-eating plant in the back of the Broadway play Little Shop of Horrors. That seems to have been going on here.

Empathy lessons occur in abundance in Prozac Nation, but they are mostly in a privative mode – that is, empathy is conspicuously missing.

Wurtzel is hungry for someone to respond to her as a whole person, writing: “I love you and I support you just the way you are because you’re wonderful just the way you are. They don’t understand that I don’t remember anyone ever saying that to me” (p. 231).

Wurtzel’s mother “loves” her as long as (if) she is brilliant, gets into Harvard, and they can continue intermittently to tear at one another’s guts on special occasions. He dad “loves” her as long as she does not make herself too needy, will pose for his photos, and otherwise leave him alone. Her friends “love” her as long she as is funny and amazing and the life of the party. Her boy friends “love” her as long as she continues to put out, which she does all too casually, leaving her feeling cheap. The impingements come fast and thick; here “love” means acknowledging someone as a whole human being, i.e., empathy; but no one gets her as a possibility.  

My take on it? If, at any point, someone would have given her a good sustained listening, something important would have shifted. Nor is it quite so simple. Her suffering would not have been magically disappeared; but it would have been decisively reduced. Once again, we will never know for sure.

Page after page of this page-turner, Wurtzel is explicitly crying out for “love,” and people are trying to love this individual, who seemingly inevitably gets caustically cutting towards others or becomes a needy emotional sponge, an unlovable rag of self-pity, albeit with a sense of humor, driving them away. Thus, Wurtzel’s ultimate test of love: love me even when I am deep down unlovable. It doesn’t work that well.

One can have empathy with the loveable but loving the unlovable is a high bar, by definition impossible. This person needs the firm boundaries of a rigorous and critical empathy. But instead Wurtzel’s friends and counselors efforts are lost in translation and become emotional contagion, projection, and inconsistent efforts to force compliance and conformity.

Finally, Wurtzel does get some empathy from the shrink disguised in the narrative as “Dr Sterling.” She was. Wurtzel writes: “Dr Sterling knew that somewhere in my personality there was a giggly girl who just wanted to have fun, and she thought it was important that I be allowed to express that aspect of myself (pp. 211–212). Predictably the breakdowns and out-of-attunements are frequent. The cutting remits but the acting out – street drugs, sexual misadventures (including the “accidental blow job”), and repetitive, endless phone calls – ramp up.

So what happens? Along comes Prozac [fluoxetine] and Dr Sterling gives it to her. Wurtzel is feeling better as a result of the medicine. But “better” is relative. Wurtzel gets into it with her psychiatrist, and she locks herself in the bathroom and takes the whole bottle of Mellaril [thioridazine], knowing that her shrink is waiting outside the door for her. As Wurtzel feels herself going under from the effects of the drug and she hears her shrink shouting outside the door, she unlocks it.

Now never say that someone who threatens suicide or actually swallows the pills is not suicidal. Never. People have been known to be all-too-unlucky in such situations and succeed where they are using a bad method to try and solve the problem of their suffering. I suggest this was one of those, and arguably as a result of the un-inhibiting effects of the Prozac.

Those are such facts as reported in the narrative. Throughout the book, Wurtzel is plagued by suicidal thoughts, she cuts herself and engages in taking street drugs and crazy sex, but not until she gets the Prozac does she actually take action and make a serious attempt at suicide. Hmmm.

I am not making this up. It is in the book. Has anyone read it since 1994? This is the book entitled “Prozac Nation” and is regarded as some kind of strange endorsement for Prozac. Wurtzel subsequently and consistently denied it was an endorsement of fluoxetine [Prozac], emphasizing her commitment to being self-expressed. That she succeeds in doing in spades. Definitely. What some authors won’t do to move some copy!

I read Wurtzel’s memoir for the first time ever upon learning of her passing on January 7, 2020. We can measure the distance between the publication in 1994 and today in that of all the reviews between then and now no one – not one – mentioned that the fear of abandonment, the invalidating early environment and ongoing invalidating entanglement with the warring parents, the volatile emotions (especially atypical depression), volatile relationships, volatile self-identity, and para suicidal behavior are the check list for borderline personality disorder.  I hasten to add checklists are overrated, and I acknowledge I might have missed something.

However, it does put me in mind of a quotation from Marsha Linehan, innovator in Dialectical Behavioral Therapy (DBT), and who, in the  video cited below, is talking on camera with permission with an avowedly suicidal patient. Linehan says: “I think it is good that you see it as a problem that you feel suicidal and want to fix that; but suicide is not so much a problem as a solution.” Pause for jaw dropping effect. “People’s lives are so messed up that they want to check out as away of solving the problem. What our program does is help you find a better solution – so it is not really a suicide prevention program so much as a life worth living program.”

Elizabeth Wurtzel succeeded in having one of those lives worth living, even without a formal program and in spite of all the challenges put in her path by accidents of biology, early experience, and her own demons. She had gifts aplenty and she managed to use them to attain a good measure of power, freedom, and full self-expression. Above all, self-expression. We are enriched by Wurtzel’s comet-like trajectory through our post-modern modernity and diminished by her passing. It is truly an ask-not-for-whom-the-bell-tolls moment.

REFERENCES

Elizabeth Wurtzel, (1994) Prozac Nation: Young and Depressed in America, New York: Mariner Books (Houghton Mifflin Harcourt (paperback edition), pp. 339, $16.99.

‘I believe in love’: Elizabeth’s Wurtzel’s final year, in her own words by Elizabeth Wurtzel, https://gen.medium.com/i-believe-in-love-elizabeth-wurtzel-s-final-year-in-her-own-words-e34320e41ee0 

Bastard Neither of my parents was exactly who I thought they were by Elizabeth Wurtzel, https://www.thecut.com/2018/12/elizabeth-wurtzel-on-discovering-the-truth-about-her-parents.html

Elizabeth Wurtzel by Liz Phair, June 16, 2017, https://www.interviewmagazine.com/culture/elizabeth-wurtzel

Lou Agosta, (2018), Empathy Lessons, Chicago: Two Pears Press: https://www.amazon.com/Lou-Agosta/e/B07Q4XX6PF/ref=dp_byline_cont_book_1

Marsha Linehan talks with a patient about borderline personality disorder and dialectical behavioral therapy: https://www.youtube.com/watch?v=tgzw50SbokM

© Lou Agosta, PhD and the Chicago Empathy Project

Interpersonal Therapy (IPT) Gets Traction: Dynamic Therapy “Lite”?

Review of: The Guide to Interpersonal Psychotherapy: Updated and Expanded Edition (2007/2018), Myrna M. Weissman, John C. Markowitz, Gerald L. Klerman; Oxford, UK: Oxford University Press, 283 pp. ($34.10 (US$)).

Interpersonal therapy (IPT) is a promising, evidence-based, talk therapy. IPT is the innovative brainchild of Gerald L. Klerman, Myrna M. Weissman, John C. Markowitz, and a team of dedicated professionals. IPT has received expanding CoverArtGuideToInterpersonalPsychotherapyattention since the mid- and late 2000s.

This book is an IPT manual and it emphasizes:  It is important to keep IPT grounded in affect. Therapy feels meaningful to the patient when it comes alive with emotions related to important issues in the patient’s life. The IPT sessions focus each meeting on a recent, affectively charged event in the patient’s life. In short, the therapist encourages the patient to talk about what happened in their life during the past week. Sounds familiar?

The novice practitioner – perhaps a resident in psychiatry who has been concentrating on psychopharmacology, because that is the prevailing paradigm – is given helpful scripts (what to say to the patient):  “In interpersonal psychotherapy, we work on the connection between your feelings and your life situation. In the next X weeks, we will work on unfulfilled wishes and problematic relationships that are contributing to your depression. You should begin to become more comfortable with your feelings in problematic close relationships and decide how to use them to change the relationship/situation you’re in”  (p. 106).

Originally developed as an intervention for depression, IPT has been progressively extended to other disorders including anxiety, trauma, and personality disorders including borderline personality disorder. Also of note, IPT demonstrably does not work for substance abuse, including alcohol.

IPT draws on the insight of dynamic psychotherapy that events in the patient’s life evoke strong feelings (or not) and that the processing of those feelings (or not) contributes to the patient’s behavior in the community. The “deep history” of the work invokes the tradition of Harry Stack Sullivan (1842 – 1949) and the William Alanson White Institute, acknowledging the interaction of the cultural dynamics between the self and the community.

IPT acknowledges that sadness and depressed mood are part of the human condition. Low mood is a nearly universal response to disruption of close interpersonal relations. John Bowlby argued that attachment bonds [key term: attachment] are necessary to survival: the attachment of the helpless infant to the mother helps to preserve the infant’s life and well-being (p. 10).

However, the resemblance between IPT and the anti-psychiatry sometimes characteristic of the Neo-Freudians such as Sullivan or Bowlby is soon dispelled. IPT embraces the medical model, asserting that (e.g.) depression is an illness such as the flu or even an appendicitis. IPT proudly embraces the common factor – something shared by all [or most] forms of psychotherapy – that the role of doctor and patient are essential to the process.

 The IPT doctor is active in educating the patient about what to expect and what to do, along with more subtle forms of inspirational guidance and suggestion. While the patient may usefully learn directly from experience as redescribed in the process of therapy, he or she had better do so promptly – as the process is time-limited to some sixteen sessions.

The time-limit is an essential part of IPT, acting as a “forcing function” to cause both patient and doctor – but mostly the patient – to “cut to the chase,” say what is bothering her, and take action to do something about it. Hence, IPT’s strengths – the cost is relatively predictable and insurance payers love that – it is relatively easy to define a comparative process test (say, against CBT or psychopharm) – and grant writers and approvers like that – and its weaknesses – it is time-limited.

One clarification upfront. When the trainers of interpersonal therapy say that it is “interpersonal,” they do not mean that the therapy targets the relationship between the patient and the therapist. “Interpersonal” means that it is about the interpersonal relationships in the patient’s life.

The powerful insight of IPT is that the way the person feels about what is going on in her or his life results in behavior, including symptomatic behavior such as depression and anxiety, that remits if one connects the dots between the two, i.e., between the feelings as called forth in the therapy and the dysfunctional symptoms.  IPT is unconcerned about transference or the deep past of childhood and it tries to identify the focal interpersonal problem area in the patient’s current life. “IPT does not interpret the transference, but rather helps the patient to relate emotions to interpersonal interactions in the here and now” (p. 74) – otherwise known as interpreting the transference.

Basically, with some conditions and qualifications, the patient is allowed one problem area, though each of the area is potentially vast and overlapping: grief (e.g., death, loss), role disputes (interpersonal conflict), role transitions (e.g., divorce), and interpersonal deficits of attachment (aloneness, isolation) (p. 11). 

According to Weissman and Markowitz, more than 100 clinical trials of IPT (Barth et al., 2013; Cuijpers et al., 2008, 2011, 2016) are available (p. 12). That is what makes IPT so attractive as “dynamic therapy lite”, especially to psychiatrics who find prescribing insufficient to produce wellbeing in their patients.

The meta analysis by Cuijpers et al. (2016 / see the excellent and extensive bibliography in the book), based on eight randomized trials, suggests efficacy for anxiety disorders: “In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT.” No less effective, but perhaps also no more. [P. 187] However, for those entry level therapists who are not comfortable with the over-intellectualizations of CPT, IPT can have an advantage of validating an approach that empathically gets one in touch with emotions and feelings.

A recurring theme in this approach is that IPT talks to patients about how they feel about what is happening or has happened in their lives and invites patients to make the crucial recognition that their interpersonal encounters evoke strong feelings. Then the IPT mantra (at least in this text):  that, rather than being “bad” or “dangerous,” feelings provide interpersonal information (e.g., anger means someone is bothering you) they can reflect upon and use to handle their environment.

The instructions to the IPT psychiatrist in training? “Your aim will be to link the patient’s interpersonal situation (a spouse’s affair, a mother’s death, a move to a different city) to the onset of symptoms in a brief contextualizing narrative that makes sense to both the patient and you. [….] Use the initial sessions to ensure that you have focused on a pivotal, emotionally meaningful area for the patient and that you have ruled out surprises that might otherwise arise later in treatment” (p. 36).

So, for example, IPT points out that patients with panic disorder experience their paralyzing physical attacks as coming “out of the blue,” yet most talk therapies, including IPT, suggest that panic is a response to interpersonal events: one study found that three-quarters of panic patients had had an interpersonal loss within six weeks of panic onset (p. 191).

 So what happens when, for example, a woman who presents saying, “My children are my big problem” later, as she gets to know you, calls out the more pressing area of distress: her spouse’s extramarital affair? Given the time-limited name of the treatment, what to say? Well, IPT tries to address this typical situation, allowing for “maintenance,” typically once a month extensions. Twice a month? However, somehow extended the duration of the sessions by means of maintenance seems not  to be the right answer. A new contract and a new engagement is needed.

IPT is quite explicit about giving patients the Sick Role. This does indeed relieve patients of blame. It is not your fault – you are sick. “The sick role excuses patients from what their illness precludes them from doing, but it carries the responsibility to work as a patient to get better” (p. 115). Definitely. A sensible trade-off.

However, the therapist is then left with the difficulty that the illness in question – depression, anxiety, trauma, personality disorder, and so on – is significantly unlike most other diseases in the world of medicine. Yes, there is an underlying molecular process; but it is just that, in most cases, science has not identified the biomarkers.

The IPT role-playing script (p. 39) suggests telling the patient that depression is no different the appendicitis or the flu. Wow. Don’t call Carl Rogers – page the surgeon! We can cure an appendicitis even if the patient is unconscious. Indeed at a certain point in the treatment it is required. However, that is not the case with a significant mental disorder. You cannot cure an unconscious psychiatric patient. More to the point, today the patient’s intentional participation in the process is required.

I can’t resist. The history of the heroic age of psychiatry does present “the sleep cure.” Stay in bed for about three months, highly sedated, with the doctor on call fulltime, waking the person once every twenty four hours for nourishment and bowel movement, and at the end of three months – voila! – something significant has shifted – the individual no longer feels depressed. This is the reduction to absurdity of the medical model – yet, in its day, it worked!

For example, in the case of complicated grief, treatment is not a sign of disrespect for the deceased – but that respect is the way treatment shows up – LIVES– for the patient. Complicated grief is a form of depression (p. 45). The doctor must truly have a magisterial authority in order to overcome the patient’s commitment to her or his suffering. You see the problem? It says right there in the manual: your grief is really depression. But the patient’s experience is that they cannot live without the other person. Yes, it violates the IPT contract that the person seems unwilling or unable to try. That is the therapy – you are in violation of your therapeutic contract?

Whereas in CBT, a therapist might ask a patient to look at the evidence about an anxious thought, an IPT therapist lets the patient sit with the feelings, pointing out at an opportune moment that guilt is a actually a symptom of the depression. What is the evidence that when your friend does not answer your text message, it is because she or he is cheating on you? Are there any facts here? In IPT rather, let’s talk about your feelings about the relationship: have you ever had any feelings of temptation towards cheating? In short, in IPT the therapy is to talk about the temptation (loss, fear, anger, and so on) and bring forth a catharsis – yes, it says it right there in the manual – catharsis makes you better.

IPT acknowledges the need to manage magical thinking, but IPT does not call it that]: The bereaved person fears that if they recover from the grief (i.e., the depressive episode), it means they did not love the deceased as much as they had believed. To their way of thinking, if they really loved the person, the loss would be so great that they could never recover. The treatment? Acknowledge, validate, and work through the loss by talking about it. In that sense, IPT is a talking cure.

The guidance for those practicing IPT (p. 57)?  Ask for the details of the interaction. Often, the patient will come in with in interpretation: “He is a jerk.” Okay, got it; but what did he actually say? : “What did you say? What did he say? How did you feel then? Then what did you say?” and so on. Get in touch with facts and feelings. The reconstruction of interpersonal encounters provides a sense of how the patient functions interpersonally, what may be going wrong in the relationship, and where the patient ignores or suppresses emotional responses to the other party

It is a strong point of IPT’s approach to treatment – get the facts. Freud pointed out long ago – the patient comes in and cannot give a coherent account of his or her life. Freud noted the gaps – repression – but equally important are the distorted communications, interpretations, and positions. “The boss is a jerk.” “Okay – I got that – what did he actually say?”

For those curious as to what is a “role transition”:  Moving one’s household, taking a new career or job, leaving home after school or divorce, being diagnosed with a serious medical condition, taking on new responsibilities due to the illness of a family member, or a change (decline) in economic status, are other examples of life role transitions. Refugee status has become a transition problems for significant populations in many countries.

Unlike many descriptions of cognitive behavioral therapy (CBT), IPT focuses on discussing feelings, normalizing them as responses to interpersonal interactions and as useful interpersonal information, and using them to take action to change the patient’s interactions in order to resolve the identified problem area (p. 88). That a person feels angry about a perceived or actual interaction contains valuable information for the person, which is usually overlooked due to over-intellectualization or being overwhelmed by emotions (under-intellectualization).

IPT emphasizes, “depression is a medical vulnerability, sort of like having an ulcer. If you should get depressed in the future, the important thing to remember is that it’s a treatable illness, it’s not your fault, and you just need to return for treatment, the way you would for any other medical problem” (p. 113).

IPT is a sensible, practical approach. The take away is that whatever the intervention one should actively try to solve the problem – working on solving the problem = x drives the therapy. The hidden / confounding variable is that the problem seems to be = x but is actually = y or = (x & y). In that case, the openness of psychodynamic therapy will surface an issue of which IPT remains unaware. Of course, the process will require more time.

There are many applications of IPT – to postpartum depression, depression in adolescents, depression in children of tender age (recommendation: treat the parent(s), depression in senior citizen, – here we go into the weed, there are many studies, and the results are generally favorable – the guidance? If one tries, one gets better.

Since this is not a softball review, the most critical thing I can think to say is that it is not really treating what the DSM describes as depression – it is treating stress – and there is nothing wrong with that – the cytokine theory of depression makes the case that “depression” is “sickness behavior” – this aligns well with the repetition (nearly ad nauseam) to the patient that “depression” is a sickness like the flu or [incredibly] enough an appendicitis. Okay, let’s take this seriously. This is supposed to be a common factor – but you would not hear Carl Rogers say it. You would not hear CBT practitioners say it – rather they would say, “you have a skills deficit – and while that is not your fault, no one ever taught you the skill, we are not “blaming” biology, we are blaming the parent or the early environment

At times and at risk of over-simplification, CBT is committed to how thinking causes, brings forth, determines one’s feelings. IPT emphasizes how one’s emotional experiences cause, bring forth, and determine one’s thinking. “Therapists work hard with […] patients to identify emotions— and particularly negative affect and feelings of competitiveness, anger, and sadness— that arise in everyday situations. The therapist and patient discuss whether such feelings are understandable and warranted. The idea of a transgression— that there are some behaviors that break expected social conduct, warrant anger, and deserve at the least an apology— may be helpful in normalizing such feelings for patients” (see p. 164).

I call out some statements that, strictly speaking, make no sense: “Klerman advocated for research standards in psychotherapy that were comparable to those in pharmacotherapy research” (p. 12). Okay, but: The authors cannot be referring to double blind testing where neither the patient nor the doctor knows what treatment he is delivering. I am giving you CBT versus IPT versus psychopharm, but neither of us knows what it is. Notwithstanding the many useful results provided by IPT practitioners, this points to a significant blind spot.

A silly statement by the authors, in which the authors get carried away with their own greatness: “No other psychotherapies explicitly focus on the IPT problem areas” (p. 106). Really? Counter-examples? Freud’s “Mourning and melancholia”? Life transitions in DBT? Lack of skills in CBT? Role disputes and discrepancies (all of the above)?

Another thing that seems just plain crazy to this author is the approach to trauma, though, once again, trauma survivors have benefited from IPT in evidence-based studies. IPT acknowledges accurately: The trauma explains why the patient is struggling interpersonally, but receives no further direct discussion (p. 195). However, a time occurs in most conversations with trauma survivors (with or without a bit of nudging) when the trauma seems to erupt – spontaneously comes up – and IPT ties the therapist’s hands because she or he cannot engage with it. Why not? It is not part of the definition of IPT? The researchers are doing an evidence-based study and to do so would “confuse” the modality with exposure focused treatments? So much the worse for the evidence ( am inclined to say). If the patient brings up the trauma and is willing – indeed wants and give every evidence of wanting to talk about it – then it would be unethical not to do so. Did anyone think of that?

The ultimate true but trivial statement, apparently now required to be fully buzzword compliant: “Neuroimaging studies have shown that psychotherapy changes your brain chemistry [Brody et al., 2001; Martin et al., 2001 9see the excellent bibliography in the book itself for details)]: it’s a biological treatment” (p. 110). Hey, studying French will change your brain and brain chemistry. Studying French is now a biological treatment?

Time-limits are essential to IPT and are a kind of “good news,” “bad news” sort of practice. Freud himself made use of setting a time limit in the case of Sergei Pankejeff (“the Wolf Man”) when Freud felt, after months and months of work, the treatment was stalled, the patient was living in genteel poverty, burring through his modest fortune, couldn’t pay, and it was time to fish or cut bait (my expression, not Freud’s). It seemed to have worked, or at least worked well enough, as a “forcing function.” However, this parameter on Freud’s part was used on an exception basis. IPT takes the “forcing function” and makes it the rule. In fact, traditional Freudians may see IPT as a case collection of parameters (exceptional practices that are employed in the face of contingencies in treatment) that try to add up to “psychoanalysis lite.”

The risk is that while a medical molecular process may not aware of the clock, the blind spots, self-deceptions, and self-serving behaviors by which people afflict themselves unwittingly are acutely aware of the passage time. Therefore, the “disorder” goes under ground until the time is up. In a telling analogy, the process is like announcing to the local armed insurgency, freedom fighters, or your opponent of choice that the UN expeditionary force is going to pull out in sixteen weeks. The opponent’s strategy strategy going forward is clear. Lay low until the powers-that-be pull out. Then it is back to business as usual.

Meanwhile, once feelings are identified and normalized, role playing is needed to help patients become comfortable with self-assertion or confrontation. “They may never have expressed a wish and almost never have said “no” to anyone. Yet if a patient has a successful experience in one of these situations (e.g., asking for and receiving a raise, confronting a spouse), the patient will have learned a new skill, discover some sense of control over the local environment, and likely feel better” (p. 164).

The IPT text and training repeatedly emphasize that “feelings are powerful, but not dangerous—and in fact, you need them [feelings] to decide whom you can trust. Expressing your feelings to another person may seem risky, but it provides a test of whether the other person is trustworthy or not. If you feel angry and voice it to another person, the other person has the chance either to apologize and change behavior, or to confirm that he or she is uncaring or untrustworthy” (pp. 194 – 195).

Agree – but there is a big “but.” The thing is that for some people feelings ARE dangerous if the feelings threaten to fragment the coherence and integrity of the sense of self. This is especially the case with survivors of trauma. There is it not just an over-feeling, but a feeling “I am gonna die!” One can dismiss this as a “personality disorder,” but I do not believe such dismissal would be fair or accurate. If subjected to strong enough feelings, just about anyone is capable of being shaken to their core. Therefore, methods are for strengthening the person’s self’s sense of stability and equilibrium in the face of strong feelings. Expanded distress tolerance? Expanded emotional regulation? Self-soothing? Working through? Exposure? Transmuting internalization? Suggestion? Encouragement? All of the above?

Having gotten in touch with emotions, patients can proceed to more usual IPT maneuvers, such as solving a role transition. As patients gain comfort with their feelings, they engage interpersonal situations with expanded competence, life feels safer, and they begin spontaneously—without IPT therapist encouragement—to face the situations and traumatic reminders they have been avoiding. In the vast majority of instances, the authors assume the patient is out of touch with his or her feelings. The therapy consists in invoking the feeling so that the patient can get in touch with it. But what about being over-whelmed by one’s feelings? Yes, one can also lose touch with one’s feelings if one is overwhelmed, but it is significantly different mode of losing touch. What about that?

We end on a positive note. IPT is demonstrably effective with borderline personality disorder, though the time-limited aspect is “finessed” by [apparently] doubling the number of sessions to distinguish between establishing trust with the therapist and actually doing the work.

We give the last word to the authors of this engaging, practical text: “The therapist presents BPD to the patient as a poorly named syndrome that has a significant depressive component. A major difference between MDD [major depressive disorder] and BPD [borderline personality disorder] is that while depressed patients often have difficulty expressing any anger, patients with BPD often do the same much of the time but then periodically explode with excessive anger, which reinforces their tendency to avoid expressing anger whenever possible. The goals of treatment are, as is usually the case in IPT, to link mood (including anger) to interpersonal situations, to find better ways of handling such situations, and to build better social supports and skills.” (p. 201).  

(c) Lou Agosta, PhD and the Chicago Empathy Project

 

 

REVIEW: Surviving the Borderline Mother

I am catching up on my reading. Christine Ann Lawson’s Understanding the Borderline Mother is a classic in its field, with a whopping 396 Amazon reviews (Q1 2019), enjoying a rating of 4.7 out of 5.0. Impressive. (See the bottom of this review for bibliographic information on the book [1].)

Numerous readers have remarked that this book opened their eyes to what they had to survive growing up. These survivors were not bad,

Review: Understanding the Borderline Mother by Christine Lawson

Review: Understanding the Borderline Mother by Christine Lawson

crazy, or broken in the way they were led to believe by what was fundamentally an invalidating child-rearing environment. The vignettes and analyses in Lawson’s book provided them with a transformational “Ah ha!” moment. For many survivors this was a tad like Saul becoming Saint Paul on the road to Damascus – a bolt of lightening out of the blue. They then could begin the hard work of incremental change needed to restore the self-soothing, emotional regulation, and distress tolerance capabilities needed to feel like whole persons again – or for the first time ever.

So up front and considering this is not a “soft ball” review, I acknowledge the importance of Lawson’s contribution and recognize that her work made a profound difference for many survivors. It is especially important to keep that in mind, given that I express significant reservations and criticisms.

The technical details? The borderline personality disorder (BPD) gets precisely defined as a psychiatric entity in 1980, entering the third version of the Diagnostic and Statistical Manual (DSM-III). However, long before that signal event “borderline” was understood to be a person whose personality structure (or lack thereof) is characterized by a compensatory but problematic defensive structure that guards against a psychotic breakdown.

Here “psychotic” means “out of touch with everyday reality.” The implication was that such borderline individuals were at risk of completing losing contact with the world of everyday life, decompensating into a full-blown psychotic breakdown. In particular, if the borderline person were treated with psychoanalytic methods, itself encouraging a mild form of regression back to the childhood fixations, whether real or imagined, the risk was of causing the borderline treatment to “go off the rails” into explicit mental illness. In a different, allegedly humorous context, the description “borderline” has come to mean that the patient is hard to work with, difficult, or simply “the therapist doesn’t like the patient.” 

A bit more background will be useful. Innovations in treating personality disorders by Heinz Kohut, MD, including new forms of transference such as self-object transference, made narcissistic personality disorders (NPD), arguably on a continuum with borderline personality in a pre-1980 sense, accessible to psychoanalytic methods. (See footnote [2] below.) However, NPD remains distinct from BPD. The treatment of NPD is relevant here since the children of BPD parents do not necessarily acquire BPD themselves, but sometimes suffer from a pervasive narcissistic vulnerability.

In contrast with Kohut’s deficit model of the narcissistic self, Otto Kernberg, MD, developed a formulation that posited actual defects in the structure of the borderline personality – aspects that were not merely missing but broken. The resulting borderline behaviors need to be confronted and rooted out by a kind of “tough love” on the part of the therapist.

Meanwhile, Marsha Linehan, PhD, a self-styled radical behaviorist, is the innovator who created a treatment approach called “Dialectical Behavioral Therapy” (DBT) that often is effective in treating BPD while other approaches have been [are] less successful. No short description of Linehan’s program is available, but a suitable over-simplification may be useful: DBT combines cognitive behavioral therapy (CBT) within a framework that emphasizes mindfulness, empathic listening, and validation of the grain of truth in even the BPD person’s most perplexing distortions to restore the BPD individual’s capabilities for emotional regulation, distress tolerance, self-soothing, interpersonal skills, and self-esteem. DBT is not for the faint of heart and requires an entire team, including both one-on-one counseling and extensive work in groups. It is different than boot camp, but sometimes not by much. Substantial evidence-based, peer-reviewed publications support the effectiveness and validity of the approach.[3]

Lawson, gets matters right with her use of Marsha Linehan, Heinz Kohut, Otto Kernberg, and Ernest Wolf, even when these innovators are not specifically addressing borderline personality disorder (DPB). As noted, Kohut and Wolf have done a deep dive on narcissistic personality disorders. In comparison to BPD, though related, neither the symptoms nor the treatments options are the same. This points to the hazards of broad-brush stroke labeling segments of suffering humanity, albeit with the worthy end of expanding our empathy and understanding for the survivors.

Lawson gets the Diagnostic and Statistical Manual(DSM) criteria right in terms of the BPD person’s fear of abandonment [“I hate you – don’t leave me!”], volatility of relationships, volatility of emotions, volatility of self-image, self-injurious (para suicidal) behavior, impulsivity and acting out, and physiological symptoms. People have different ways of expressing their suffering and the suffering of the BPD person can be intense, so engaging with them is not for the faint of heart.

One strong point. Lawson’s is perceptive in the use of Christina Crawford’s searing memoire, Mommy Dearest, about Christina’s Academy Award winning movie star mother, Joan Crawford (1905 – 1977). This paints a convincing picture of growing up with and surviving the BPD mother (in this case, Joan Crawford). Once again, such material is not for the faint of heart. It turns out that many Hollywood movie starts are good actors both in front of the camera on stage and off of it. “Acting” is different than “faking,” but to a child of tender age the distinction is not always clear. “All the world is a stage,” but when one is a child of tender age, one cannot simply walk out of the show if one does not like it or is being traumatized by it. The lives of the rich and famous are as susceptible to mental and emotional disorders as anyone.

The criticism? To generalize from the example of the tortured genius of Joan Crawford to the run-of-the-mill perpetrations, self-deceptions and manipulations of the standard, working class BPD mother is to go from the sublime to the ridiculous or at least to tear a passion to tatters. It makes for bad theatre, but then again so does real life. I would have liked to hear more about how Christina and her brother dealt with the worst of the perpetrations and escaped the disorder themselves, even if it did leave them with a pervasive narcissistic vulnerability.

Christina describes an invalidating environment, one of the principle causes of BPD. Yet she retained powers of self-expression and freedom that allowed her to overcome [some of] the worst consequences of her environment. This is not to say she did not suffer. She did. What made a difference? What enabled her to compensate – acquiring the distress tolerance, emotional regulation, and self-soothing skills in which mother was so dramatically lacking? Strange to say, maybe Christina got these life saving skills from the nuns at the religious boarding school where she was sent. No doubt the matter is more complex.

Thus, the help promised in the subtitle “Helping her children transcend the intense, unpredictable, and volatile relationship” is mostly targeted at the grown ups who have survived childhood with a BPD mother. It is not clear what such help would look like for a child of tender age other than to turn to the other parent, relative, or mentor-like friend of the family for the mirroring and recognition needed to acquire skills in emotional regulation, distress tolerance, and self-soothing. In some cases cited by Lawson, the abuses rises to a level at which intervention by the state (Children and Family Services) would be appropriate, though such is sometimes like going from the frying pan into the fire.

For example, Lawson’s examples of the mother who drowned her two children, strapped into their car seats in her SUV (Susan Smith (1994)), and the mother who shot her three children at close range (Diane Downs (1983)). These examples result in the reader feeling vicariously traumatized. I am not saying these are not horrific examples of criminality, insanity, or both. They are. I am saying these examples in the book are symptomatic of Lawson’s rhetorically “over the top” approach. 

DBP is properly distinguished from manic depression (Bipolar I), post partum depression that reaches psychotic proportions, psychopathy, or paranoid schizophrenia. My concern is that Lawson gathers wide-ranging and provocative examples of trauma, deceptions, perpetrations, manipulations, lies, dangerous half-truths, and total nonsense – and attributes them to BPD. BPD is characterized by boundary issues – and violations – and so are the distinctions in this book. 

In short, BPD mother is straight out of Grimm’s fairy tales – now the waif, now the hermit, now the queen, now the wicked witch. Well and good. This is not a treatise on fairy tales; yet Lawson misses the point about the uses of enchantment. To the child who is being weaned, the loving (not BPD!) mother who is temporarily withholding the breast in favor of a Sippy-cup, this standard mother suddenly seems  like the devouring witch. She is now and will be the loving caretaker again once the crisis of weaning has passed, but with an enriched personality that includes both positive and negative aspects instead of the splitting and extremes of early childhood. In short, there is nothing wrong – but something is missing – empathy.

For example, Lawson does a nice job marshaling a nightmare and candidate BPD mother from the ancient Greeks, Euripides’ Medea. When Medea’s faithless husband, Jason, proposes to leave Medea for another woman, the gates of chaos are opened. In revenge, Media kills her children and the other woman. This is perhaps the literary origin of the expression “hell hath no fury like a woman scorned.” From another perspective, a common place exists that when people do not get the empathy or dignity that they feel they deserved, they become enraged. But this takes rage to new, heretofore unprecedented levels. Medea “acts out” her revenge with chilling effectiveness. Medea’s pending loss gets transformed into psychopathic, psychotic, criminally insane rage. Does anyone besides me think that to attribute such perpetrations to BPD would be overstating the case?

One of Lawson’s commitments is to expand the reader’s empathy for the child of a BPD mother. Of course, to the child it is not BPD. It is just behavior that leaves the child bewildered, confused, in semi-shock, or even traumatized. By definition, the diagnosis of BPD cannot be applied to anyone younger than adolescence. Personality disorders usually show up in puberty or adolescence.

The BPD person’s behavior is a study in invalidation, misuse, abuse, emotional disregulation, boundary issues, boundary violations, lack of empathy, lack of recognition, lack of mirroring, lack of response to the child as a whole person, and inconsistent, intermittent, low quality parenting. When the environment is sufficiently invalidating and the child lacks resilience or another sane adult model to help compensate, then the result can indeed be a perpetration of generational BPD.

Ultimately Lawson shocks, shifts, and shakes our complacency about BPD. She may even leave some vicariously traumatized by her narratives of child abuse and boundary issues. However, she fails to enhance our empathy with the BPD person by sensationalizing and “demonizing” the worst excesses of BPD.

I hasten to add that BPD can be described as lying a spectrum with demonic behavior. This is especially so if one is describing BPD from the perspective of the child of tender age. But, once again, that is the issue. The devouring witch of Hansel and Gretel is a representation of the standard mother who is withholding the breast from the child as the latter is being weaned. But the standard mother is usually not suffering from BPD.

The fairy tale narrative informs our empathy with the child. Within the story, the story teller inspires empathy with the children (Hansel and Gretel) such that it seems to them alternatively like a death sentence by starvation, leaving a hunger big enough to eat a house (which is how the children first encounter the gingerbread house). It is of course neither of these, but the narrative enables the grown up empathically to get inside the child’s experience.

The issue with Lawson’s book is that it does not distinguish between BPD, child abuse, and criminality. Yes, BPD mothers’ relationships with their children sometimes cross the boundary between “mere” BPD and even more severe forms of loss of reality testing, psychosis, and sheer insanity. However, BPD is distinct from narcissistic exploitation, manipulation, and criminality. It takes more than BPD to produce the kinds of horrific results that occur when a parent murders her child, but we only hear about BPD as if it were the only “cause.”

No one is endorsing using a child as a narcissistic extension of the parent’s defective grandiosity. The mental health consequences of the latter are severe, especially when occurring habitually. No one is endorsing everyday, run-of-the-mill bad parenting. There is not a lot of good news here. However, all these failings are different than child abuse and criminality.

Lawson rides the slippery slope from perpetrations and emotionally traumatizing behavior all the way down to dehumanization and homicide. Granted it may seem to the survivor of a BPD mother as if she or he were a Holocaust survivor – nor should anyone devalue the suffering of what anyone else had to survive, including the Holocaust – but a significant difference between the two still exists.

Lawson’s best guidance for surviving the BPD mother, whether as a child of tender age or a grown up survivor, may be summarized: set limits, deploy different ways of setting limits to inbound aggression, insist on respect for boundaries, drain the emotion out of emotionally fraught situations, deconstruct upsets, do not personalize accusations, call out “crazy making” behavior. These are all ways of managing manipulation, bullying, emotional perpetration, and so on.  All are easier said than done. 

The most critical remark I can think of? Lawson deploys the main psychological mechanism underlying BPD, splitting, resulting in a black and white representation of the BPD mother – only there is no white. In short, the BPD mother is literally described as a “witch” (as well as a queen, waif, and hermit). This satisfies the definition of “demonization,” both literally and metaphorically.

I am just getting warmed up here. Granted Lawson does not aspire to evidence-based peer-reviewed research. Her argument is narratively and rhetorically strong. However, how is Lawson’s argument that the BPD mother is the cause of the child’s suffering any different than that the “ice box” mother (usually attributed to Bruno Bettelheim (but the matter is debatable)) is the cause of childhood autism?

In both cases, as the mother enters the narrative – or the room – the audience expresses its negative opinion of the mother by breaking out in hisses and boos. Well and good. You have got to blame someone. Blame the mother?! Still, as usual, correlation is not causation; and the correlation is indeed compelling in the case of BPD in the ways that escape the “ice box” mother description.

Lawson documents that the BPD mother enacts a long list of behaviors that are manipulative, perpetrating, and out-and-out boundary violations. This is not disputed. Unacceptable. From the perspective of the child of tender age, the behaviors are particularly appalling.

What Lawson may usefully have acknowledged is people have different way of expressing their suffering. The BPD person’s dramatic, para suicidal behavior – cutting, substance abuse, acting out – inevitably gets our attention. That is the effect of the behavior – it gets our attention. But that is not the reason why the person misbehaves in this way.

The BPD person is trying to regulate her emotions, deal with the distress she is experiencing, or sooth herself. The person is trying to survive her life – survive the distress of the moment. That one can attain emotional equilibrium in an emotional emergency by carving up one’s upper arm with an Exacto knife is hard for the non mental health professional to get one’s head around. Indeed it is hard for anyone to get their head around it; but that is what needs to happen to understand the BPD person.

Lawson properly directs such empathy as is available in the conversation at what the children have to survive. I am not proposing at this late point that Lawson needs to have expanded her empathy for the BPD mother. Rhetorically and narratively that is not in the cards. However, this may be a moment to hate the sin and “love” – or at least provide treatment for – the sinner. That someone ends up in jail for child abuse does not mean that the perpetrator does not need treatment. She does – as does the child.

By the time the survivor of the BPD mother shows up at the door of Lawson’s clinic, it is too late for early intervention. It is too late for empathy lessons in child development. It is too late to teach parenting skills. It is too late. Period.

Still, I came away persuaded, identifying and devaluing the BPD mother as the cause of the survivor’s suffering, too – fully enrolled in Lawson’s project and interpretation. However, what did not happen was creating a space of validation, toleration and acceptance in order to engage the tough issues of recovery, transformation, change, and mourning one’s losses.

Borderline personality disorder remains stigmatized even today. Lawson’s account does nothing to remove the stigma, and, in several ways, reinforces it with devaluing labels such as “witch.” Once again, I hasten to add there is no excuse for bad behavior on the part of anyone, including BPD persons or those committed to treating them.

Truth and reconciliation commissions are in short supply in the political world; and, likewise, such is the case in the milieu of psychotherapeutic treatment. Rare is the instance in which a BPD mother says, “I did it – I was the perpetrator – no excuses – I was a shit. This is what happened [….]” And the survivor then gets to say whether or not she accepts that as the truth and can go forward on that basis. However, I would have appreciated Lawson’s at least calling out the value of such interventions in the context of community mental health – prior to referring the subjects and survivors to Dialectical Behavioral Therapy.

REFERENCES

[1] Christine Ann Lawson, (2004), Understanding the Borderline Mother: Helping Her Children Transcend the Intense, Unpredictable, and Volatile Relationship. New York: Rowan and Littlefield. 330 pp. $46.92 [“free” Audiobook with (Amazon) Audible Subscription].

[2] Heinz Kohut, (1971), The Analysis of the Self. New York: International Universities Press.

[3] Marsha M. Linehan, (1993), Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

© Lou Agosta, PhD and the Chicago Empathy Project