Wounded healers


Expert on Mental Illness Reveals Her Own Fight

The Power of Rescuing Others: Marsha Linehan, a therapist and researcher at the University of Washington who suffered from borderline personality disorder, recalls the religious experience that transformed her as a young woman.

Lives Restored

Damon Winter/The New York Times

“So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward,” said Marsha M. Linehan, a psychologist at the University of Washington.

The patient wanted to know, and her therapist — Marsha M. Linehan of theUniversity of Washington, creator of a treatment used worldwide for severely suicidal people — had a ready answer. It was the one she always used to cut the question short, whether a patient asked it hopefully, accusingly or knowingly, having glimpsed the macramé of faded burns, cuts andwelts on Dr. Linehan’s arms:

“You mean, have I suffered?”

“No, Marsha,” the patient replied, in an encounter last spring. “I mean one of us. Like us. Because if you were, it would give all of us so much hope.”

“That did it,” said Dr. Linehan, 68, who told her story in public for the first time last week before an audience of friends, family and doctors at the Institute of Living, the Hartford clinic where she was first treated for extreme social withdrawal at age 17. “So many people have begged me to come forward, and I just thought — well, I have to do this. I owe it to them. I cannot die a coward.”

No one knows how many people with severe mental illness live what appear to be normal, successful lives, because such people are not in the habit of announcing themselves. They are too busy juggling responsibilities, paying the bills, studying, raising families — all while weathering gusts of dark emotions or delusions that would quickly overwhelm almost anyone else.

Now, an increasing number of them are risking exposure of their secret, saying that the time is right. The nation’s mental health system is a shambles, they say, criminalizing many patients and warehousing some of the most severe in nursing and group homes where they receive care from workers with minimal qualifications.

Moreover, the enduring stigma of mental illness teaches people with such a diagnosis to think of themselves as victims, snuffing out the one thing that can motivate them to find treatment: hope.

“There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life,” said Elyn R. Saks, a professor at the University of Southern California School of Law who chronicles her own struggles with schizophrenia in “The Center Cannot Hold: My Journey Through Madness.” “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

These include medication (usually), therapy (often), a measure of good luck (always) — and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places, these former patients say: love, forgiveness, faith in God, a lifelong friendship.

But Dr. Linehan’s case shows there is no recipe. She was driven by a mission to rescue people who are chronically suicidal, often as a result of borderline personality disorder, an enigmatic condition characterized in part by self-destructive urges.

“I honestly didn’t realize at the time that I was dealing with myself,” she said. “But I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got.”

‘I Was in Hell’

She learned the central tragedy of severe mental illness the hard way, banging her head against the wall of a locked room.

Marsha Linehan arrived at the Institute of Living on March 9, 1961, at age 17, and quickly became the sole occupant of the seclusion room on the unit known as Thompson Two, for the most severely ill patients. The staff saw no alternative: The girl attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on.

The seclusion room, a small cell with a bed, a chair and a tiny, barred window, had no such weapon. Yet her urge to die only deepened. So she did the only thing that made any sense to her at the time: banged her head against the wall and, later, the floor. Hard.

“My whole experience of these episodes was that someone else was doing it; it was like ‘I know this is coming, I’m out of control, somebody help me; where are you, God?’ ” she said. “I felt totally empty, like the Tin Man; I had no way to communicate what was going on, no way to understand it.”

Her childhood, in Tulsa, Okla., provided few clues. An excellent student from early on, a natural on the piano, she was the third of six children of an oilman and his wife, an outgoing woman who juggled child care with the Junior League and Tulsa social events.

People who knew the Linehans at that time remember that their precocious third child was often in trouble at home, and Dr. Linehan recalls feeling deeply inadequate compared with her attractive and accomplished siblings. But whatever currents of distress ran under the surface, no one took much notice until she was bedridden with headaches in her senior year of high school.

Her younger sister, Aline Haynes, said: “This was Tulsa in the 1960s, and I don’t think my parents had any idea what to do with Marsha. No one really knew what mental illness was.”

Soon, a local psychiatrist recommended a stay at the Institute of Living, to get to the bottom of the problem. There, doctors gave her a diagnosis of schizophrenia; dosed her with ThorazineLibrium and other powerful drugs, as well as hours of Freudian analysis; and strapped her down for electroshock treatments, 14 shocks the first time through and 16 the second, according to her medical records. Nothing changed, and soon enough the patient was back in seclusion on the locked ward.

“Everyone was terrified of ending up in there,” said Sebern Fisher, a fellow patient who became a close friend. But whatever her surroundings, Ms. Fisher added, “Marsha was capable of caring a great deal about another person; her passion was as deep as her loneliness.”

Damon Winter/The New York Times

The door to the room where as a teenager Dr. Linehan was put in seclusion. The room has since been turned into a small office.

Damon Winter/The New York Times

“My whole experience of these episodes was that someone else was doing it; it was like ‘I know this is coming, I’m out of control, somebody help me; where are you, God?’”   -Marsha M. Linehan

A discharge summary, dated May 31, 1963, noted that “during 26 months of hospitalization, Miss Linehan was, for a considerable part of this time, one of the most disturbed patients in the hospital.”

A verse the troubled girl wrote at the time reads:

They put me in a four-walled room

But left me really out

My soul was tossed somewhere askew

My limbs were tossed here about

Bang her head where she would, the tragedy remained: no one knew what was happening to her, and as a result medical care only made it worse. Any real treatment would have to be based not on some theory, she later concluded, but on facts: which precise emotion led to which thought led to the latest gruesome act. It would have to break that chain — and teach a new behavior.

“I was in hell,” she said. “And I made a vow: when I get out, I’m going to come back and get others out of here.”

Radical Acceptance

She sensed the power of another principle while praying in a small chapel in Chicago.

It was 1967, several years after she left the institute as a desperate 20-year-old whom doctors gave little chance of surviving outside the hospital. Survive she did, barely: there was at least one suicide attempt in Tulsa, when she first arrived home; and another episode after she moved to a Y.M.C.A. in Chicago to start over.

She was hospitalized again and emerged confused, lonely and more committed than ever to her Catholic faith. She moved into another Y, found a job as a clerk in an insurance company, started taking night classes at Loyola University — and prayed, often, at a chapel in the Cenacle Retreat Center.

“One night I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me,” she said. “It was this shimmering experience, and I just ran back to my room and said, ‘I love myself.’ It was the first time I remember talking to myself in the first person. I felt transformed.”

The high lasted about a year, before the feelings of devastation returned in the wake of a romance that ended. But something was different. She could now weather her emotional storms without cutting or harming herself.

What had changed?

It took years of study in psychology — she earned a Ph.D. at Loyola in 1971 — before she found an answer. On the surface, it seemed obvious: She had accepted herself as she was. She had tried to kill herself so many times because the gulf between the person she wanted to be and the person she was left her desperate, hopeless, deeply homesick for a life she would never know. That gulf was real, and unbridgeable.

That basic idea — radical acceptance, she now calls it — became increasingly important as she began working with patients, first at a suicide clinic in Buffalo and later as a researcher. Yes, real change was possible. The emerging discipline of behaviorism taught that people could learn new behaviors — and that acting differently can in time alter underlying emotions from the top down.

But deeply suicidal people have tried to change a million times and failed. The only way to get through to them was to acknowledge that their behavior made sense: Thoughts of death were sweet release given what they were suffering.

“She was very creative with people. I saw that right away,” said Gerald C. Davison, who in 1972 admitted Dr. Linehan into a postdoctoral program in behavioral therapy at Stony Brook University. (He is now a psychologist at the University of Southern California.) “She could get people off center, challenge them with things they didn’t want to hear without making them feel put down.”

No therapist could promise a quick transformation or even sudden “insight,” much less a shimmering religious vision. But now Dr. Linehan was closing in on two seemingly opposed principles that could form the basis of a treatment: acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it. The only way to know for sure whether she had something more than a theory was to test it scientifically in the real world — and there was never any doubt where to start.

Getting Through the Day

“I decided to get supersuicidal people, the very worst cases, because I figured these are the most miserable people in the world — they think they’re evil, that they’re bad, bad, bad — and I understood that they weren’t,” she said. “I understood their suffering because I’d been there, in hell, with no idea how to get out.”

In particular she chose to treat people with a diagnosis that she would have given her young self: borderline personality disorder, a poorly understood condition characterized by neediness, outbursts and self-destructive urges, often leading to cutting or burning. In therapy, borderline patients can be terrors — manipulative, hostile, sometimes ominously mute, and notorious for storming out threatening suicide.

Dr. Linehan found that the tension of acceptance could at least keep people in the room: patients accept who they are, that they feel the mental squalls of rage, emptiness and anxiety far more intensely than most people do. In turn, the therapist accepts that given all this, cutting, burning and suicide attempts make some sense.

Finally, the therapist elicits a commitment from the patient to change his or her behavior, a verbal pledge in exchange for a chance to live: “Therapy does not work for people who are dead” is one way she puts it.

Yet even as she climbed the academic ladder, moving from the Catholic University of America to the University of Washington in 1977, she understood from her own experience that acceptance and change were hardly enough. During those first years in Seattle she sometimes felt suicidal while driving to work; even today, she can feel rushes of panic, most recently while driving through tunnels. She relied on therapists herself, off and on over the years, for support and guidance (she does not remember taking medication after leaving the institute).

Dr. Linehan’s own emerging approach to treatment — now called dialectical behavior therapy, or D.B.T. — would also have to include day-to-day skills. A commitment means very little, after all, if people do not have the tools to carry it out. She borrowed some of these from other behavioral therapies and added elements, like opposite action, in which patients act opposite to the way they feel when an emotion is inappropriate; and mindfulness meditation, a Zen technique in which people focus on their breath and observe their emotions come and go without acting on them. (Mindfulness is now a staple of many kinds of psychotherapy.)

In studies in the 1980s and ’90s, researchers at the University of Washington and elsewhere tracked the progress of hundreds of borderline patients at high risk of suicide who attended weekly dialectical therapy sessions. Compared with similar patients who got other experts’ treatments, those who learned Dr. Linehan’s approach made far fewer suicide attempts, landed in the hospital less often and were much more likely to stay in treatment. D.B.T. is now widely used for a variety of stubborn clients, including juvenile offenders, people with eating disorders and those with drug addictions.

“I think the reason D.B.T. has made such a splash is that it addresses something that couldn’t be treated before; people were just at a loss when it came to borderline,” said Lisa Onken, chief of the behavioral and integrative treatment branch of the National Institutes of Health. “But I think the reason it has resonated so much with community therapists has a lot to do with Marsha Linehan’s charisma, her ability to connect with clinical people as well as a scientific audience.”

Most remarkably, perhaps, Dr. Linehan has reached a place where she can stand up and tell her story, come what will. “I’m a very happy person now,” she said in an interview at her house near campus, where she lives with her adopted daughter, Geraldine, and Geraldine’s husband, Nate. “I still have ups and downs, of course, but I think no more than anyone else.”

After her coming-out speech last week, she visited the seclusion room, which has since been converted to a small office. “Well, look at that, they changed the windows,” she said, holding her palms up. “There’s so much more light.”




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National intelligence?

The Intelligence of Nations

globe22Modern Japan has very few of the world’s natural resources—oil, forests, precious metals. Yet this archipelago has given rise to the world’s third largest economy. Nigeria, by contrast, is blessed with ample natural resources, including lots of land, yet it is one of the planet’s poorer nations. Why is that? Why is there not a simple link between natural bounty and prosperity?

The short answer is national intelligence. A nation’s cognitive resources amplify its natural resources. That’s the view of University of Washington psychological scientist Earl Hunt, who argues that, given equal national intelligence, Nigeria would be richer than Japan. But where does national intelligence come from, and why does Nigeria lack it?

Hunt sketched out an answer to that question in his James McKeen Cattell Award address, delivered this week at the 23rd annual convention of the Association for Psychological Science. According to his model, intelligence is not what IQ tests measure, but rather the ability to solve social problems using “cultural artifacts”—computers, books, the scientific method and rule of law, for example. All countries start off with the same genetic potential for intelligence—there is no evidence otherwise—but this raw potential is developed much more effectively in some nations than in others, because of dramatic differences in physical and social environments.

A detrimental physical environment consists of malnutrition, disease and environment pollutants—all of which can directly affect the developing nervous system—and thus working memory and attention—and also create a social burden that interferes with education and learning. The social environment also shapes individual and national intelligence. This includes the sheer amount of schooling, because practicing thinking makes people better thinkers. It also includes the existence of a “cognitive elite”—people with enough advanced education to familiarize them with the cognitive artifacts needed for problem solving. And it includes family, which plays the role of motivator, encouraging children to learn things like trigonometry even when they can’t see the value. Small families are better; large families are associated with drops in both cognitive and economic well-being.

National intelligence also requires a national “willingness to listen,” Hunt argues. No nation can come up with all of its own cognitive tools, but nations can borrow if they are open to new cognitive advances elsewhere. When Japan’s leaders decided to isolate the country from the world in the 17th century, the intelligence of its people declined. It’s not that they were unaware of modernization; they rejected it. When the nation reopened its cultural borders in the 19th century, national intelligence bloomed.

The simple fact is, it’s good to be intelligent—for nations no less than individuals. Various studies have linked a country’s cognitive resources positively not only with economic prosperity, but also with rule of law, the quality of bureaucracy, and successful homicide prosecutions. The same studies have linked low national intelligence with HIV infection, fertility rate, homicide rate, and income inequality. What’s more, national intelligence and prosperity appear to interact and reinforce one another: In one study, national intelligence in the 1970s influenced wealth in the year 2000, and wealth in the 70s influenced intelligence in the year 2000. As Hunt concludes: “The smart got richer and the rich got smarter.”


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Learning to dance in relationships

Learning to dance in relationships

I often imagine the ‘Self’ to be akin to an amoebic organism that is in a constant state of flux, it is continually influenced by the environment it finds itself in and by the processes that occur within its own membranes. As this self matures it is forced to change in order to adapt, improvise and in many cases overcome the difficulties it often encounters within its environment. If it does not adapt it is prone to atrophy and decay. Relational contexts are a good example of two or more selves coming into contact with each other thereby influencing what happens within each person. If someone’s relational self is prone to the repetition of destructive patterns in intimate relationship, without awareness, these patterns will continue to haunt an individual’s capacity to form intimate nourishing relationships with others.

Clients enter into therapy for a variety of different reasons, but in many cases the underlying cause of distress is a difficulty in relating to others. Whether the relationship in question is work, family (usually mother related for women and father related for men), social or intimate, how we relate and are related to, continues to be grist for the therapeutic mill.

I’ve often wondered how many people do an effective relational postmortem at the end of a meaningful intimate relationship? What percentage of those who have, are able to separate out the facts from the often overwhelming emotions that present themselves when we separate from an other to which we have been emotionally linked? Are you able to own the possibly destructive projections that you have contributed into the relational matrix?  Or are you prone to blaming the other for all the ills that you feel you suffered at the hands of this benighted, beloved other? How we make sense of past relationships dictates, to a large degree, the pattern of our capacity for future intimacy.

I have found the following ‘lens’ useful in finding clients (and my own) habitual positions within different relationships.



VICTIM                                                                                             PERPETRATOR

Perhaps a brief clinical vignette will help to illustrate the model.

Claire* is a 36 year old attorney who during our initial session cited  long standing relational difficulties with her mother as being the primary presenting problem.  Her mother and her had been ‘at each others throats’ for “as long as I can remember”. I would need an entire book to outline the particular dynamics that often occur between mother and daughter but the aim of this post is to highlight a very specific set of roles that many of us fall into, often unconsciously. In the relationship with her mother, Claire  often adopted the rescuer position, she always fielded her mother’s anguished phone calls, listening to her mother’s endless series of struggles with the world. Although Claire felt that it was a daughter’s duty to be there for her mother, it often left her feeling depleted and resentful of her mother’s intrusion into her life. What became evident through our work in therapy, was that Claire vacillated between being the rescuer or feeling like a victim in many of her relationships. Claire claimed that she often felt like a “bad person” if she attempted to put down boundaries with other people in her life i.e. she had such anxiety about being perceived as a perpetrator (her father was an abusive alcoholic), that she could not distinguish between being seen as a perpetrator and appropriate boundary setting in order to protect her self. This struggle had led her to self soothe through various inappropriate  mechanisms such as binge drinking on the weekends and casual sexual encounters in a search for brief ‘hits’ of intimacy. So, the way out of the dance? Claire had to learn to build a capacity for being an ‘adult’, i.e. not a rescuer, victim or perpetrator, but someone who would not be coerced into positions that her inner truth balked at. With time she learnt to ‘stand in her truth’, ultimately this means learning to take responsibility for one’s actions and staying in alignment with your internal integrity. Using truth, integrity and accountability as navigational tools enabled Claire to draw clear, concise boundaries, not only with her mother and co-workers, but with her Self.

Claire* is not the client’s real name and various stories have been combined so as to disguise the identities of various narratives.




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Does talk therapy work?

(From psychology today- an introduction to psychodynamic therapy)

A young woman came to see me on the recommendation of her physician. “I don’t know what she thinks you can do for me,” she said. “I just can’t get myself to do what I need to do. Maybe some cognitive therapy – something that would change my thinking. Maybe that would help.”

I asked her to tell me in her own words why her doctor had referred her to me. “I don’t have any energy. There’s nothing wrong with me physically. I was depressed for awhile, but I’m not anymore. But she thought it might help me to talk to someone. I don’t need longterm psychotherapy to understand myself. I just need someone to help me change my thoughts.”

I thought of this young woman as I read a wonderful article in the November 2010 issue of Scientific American Mind: “Getting to Know Me: Psychodynamic therapy has been caricatured as navel-gazing, but studies show powerful benefits,” by Jonathan Shedler.*

Shedler, who is an associate professor of psychiatry at the University of Colorado School of Medicine and director of psychology at the University of Colorado Hospital Outpatient Psychiatry Service, combines anecdotes from clients and therapists with fascinating research to explain something that those of us who have practiced “insight” therapy (sometimes also called “talk” therapy) have known for a long time: psychodynamic psychotherapy works. It helps clients find solutions not only to specific symptoms but also to difficulties at work, in their social lives, and with self-esteem.

Shedler describes fascinating research evidence that “psychodynamic therapy alleviates symptoms as effectively as newer, more targeted therapies” (like cognitive behavioral therapy).

He also offers evidence “that people who receive psychodynamic therapy actually continue to improve after therapy ends – presumably because the understanding they gain is global.” In other words, this kind of therapy helps us learn about ourselves in such a deep and broad way that we can utilize our understanding in a variety of situations; and further, that with the help of therapy, we also learn how to continue to learn more about ourselves even when we are no longer seeing our therapist.

Shedler says that people often shy away from psychodynamic psychotherapy because they assume that it won’t help them with their immediate problems and they fear that they will have to make a commitment to years of expensive, time-consuming and unproductive “navel-gazing.” He suggests that this is partly the fault of those of us who practice this kind of therapy. We shun research and fail to explain what we are doing. I would add that we also fail to tell our clients that they should start to feel some relief fairly quickly, and that if they are not feeling better, it may be that we’re not helping them get to something important in the work. Nor do we always explain, as Shedler does in a beautiful example, why talking about what is happening between therapist and client is an important – sometimes crucial -part of the work.

I encourage you to read Shedler’s article yourself; but as an appetizer, I offer this brief highlighting of some of his points:

§ Psychodynamic therapy as practiced today is not your father’s psychoanalysis. For one thing, Shedler says, clients “do not lie on a couch free-associating as an inscrutable therapist silently looks on, nor must they commit to four or five sessions a week for years on end.”

§ In this kind of therapy clients get an opportunity to explore and broaden the range of feelings that they are comfortable with. This exploratory process not only helps a person understand subtle and often unnoticed emotions, but also helps them begin to manage strong and often uncomfortable feelings more effectively.

§ Research confirms that psychodynamic psychotherapy is highly effective. For example, Shedler writes, “One major study found an ‘effect size’-a measure of treatment benefit – of 0.97” for psychodynamic psychotherapy. “For CBT (cognitive behavioral therapy), 0.68 is a typical effect size. For antidepressant medication, the average effect size is 0.31.”

§ Shedler describes seven features that researchers have found contribute to the power and effectiveness of psychodynamic psychotherapy: “exploring emotions, examining avoidances, identifying recurring patterns, discussing past experience, focusing on relationships, and examining the patient/therapist relationship.”

Obviously, of course, not all psychodynamic psychotherapists are created equal. It is important, when looking for someone to help with your problems, to get recommendations from people you trust, to interview several different therapists, to ask about their training, and finally, to trust your instinct. (For more specifics, check out my post on choosing a psychotherapist). But if you decide to go with a psychodynamically-oriented psychotherapist and friends or family tell you there’s no evidence that it works, give them a copy of Shedler’s article.

As for the client I described at the beginning of this post, after we had been working together psychodynamically for several months, she came into my office and said, “You know, I am starting to feel better.” I told her I was glad and asked if she had any thoughts about what had contributed to the change. “I think it helps to talk about things to someone who listens and doesn’t tell me what to think. You’re always asking me to try to put into words what I think about something. And that helps me think about what I’m feeling, too. And somehow, that’s helping me to feel better.”



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Physician…heal thyself

Over the years I have developed a meditative practice, i have a busy mind and meditation enables me to find a calm, grounded space within, which has helped me navigate some pretty steep personal terrain. I, like many others, am prone to entropy, to the breakdown over time of ongoing positive nourishing structures (like exercise, a good diet, meditation etc). The problem is that when i feel really good and in harmony with myself, i tend to stop doing the very things that have brought me to that point. With winter upon our doorstep i have chosen to stay warmly tucked in bed for the extra half an hour which i would’ve previously spent meditating, the effect of this has been subtle but increasingly noticeable. At first i find that my mind becomes increasingly restless, more prone to attaching itself to meaningless chatter, within a week, my mind is more vulnerable to stress. An image of a homeless person looking in a dustbin for nourishment comes to mind, my thinking becomes agitated and distractible and instead of reading and writing i watch crap on television, don’t go to yoga (for a variety of self defeating reasons) and start eating processed but tasty meals with little energetic content.

So, what happens on subtle levels of the mind when i begin to lose traction in my life? I am a great fan of Lord of the Rings, in the book, there is an evil character called ‘Wormtongue’ who whispers toxic lies into the King of Rohan’s ear, keeping him trapped and paralyzed with passivity. Sometimes, when my mind is restless, distractible and stressed, Wormtongue comes out to play and begins to cast doubt and anxiety into my thought-stream, polluting my thinking and puncturing my self esteem. Slowly all my scaffolding for living a connected, clear, creative life begins to break down leading into a stagnant quagmire of passivity, a low, flat mood and a general dissatisfaction with life.

Thomas Jefferson once said “the price of freedom is eternal vigilance”, in order for me to build evidence of a life well lived, to remain free, i too need to remain vigilant, to maintain those structures that allow for my growth and connection.



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