Tuesday, September 25th, marked the first celebration of National Psychotherapy Day. National Psychotherapy Day is the brainchild of PT blogger and clinical psychologist Dr. Ryan Howes, who deserves credit and congratulations for conceiving of, organizing, and getting it off the ground.
In honor of National Psychotherapy Day, I posted a series of my previously published pieces on the practice of psychotherapy. A different posting each day this week, Monday through Friday. In effect, extending National Psychotherapy Day into National Psychotherapy Week here at Psychology Today. Here is the final post of the series. Hope you enjoy! And remember that National Psychotherapy Day happens again next year, on September 25, 2013. So start planning for it now!
Recently, 68-year-old clinical psychologist Dr. Marsha Linehan, famous for her fusion of spiritual, cognitive, and behavioral treatment known as Dialectical Behavior Therapy, made a shocking and courageous public confession: Linehan has suffered from what she believes to be Borderline Personality Disorder all her adult life. (See The New York Times article here.)
While BPD is Dr. Linehan's retrospective self-diagnosis, the fact is that, when she was seventeen, her doctors diagnosed her as schizophrenic. While it is not clear precisely what symptoms she experienced at that time—whether, for example, they included delusions and/or hallucinations, two of the classic criteria for Schizophrenia—it seems likely that at least some subjective and objective signs of psychosis were present. (See my prior post.) Even if such psychotic symptoms were perhaps transitory. A diagnosis of Schizophrenia probably looked likely given the fact that the typical onset of this devastating psychiatric disorder commonly occurs during late adolescence, though, as statistics show, often a little later in women than men. She was psychiatrically institutionalized for more than two years, and described in the hospital's medical records as being, for much of that time, perhaps the most severely disturbed, deeply withdrawn, and difficult to manage patient on the unit. The adolescent Linehan would evidently violently thrash about—not unlike Keira Knightley's depiction of a "hysterical" Sabina Spielrein being admitted to the Burgholzli Psychiatric Hospital at the start of the newly released A Dangerous Method (see my prior post for a review of this fine film)—and engaged consistently in self-mutilating behaviors: burning herself with cigarettes, cutting her wrists, arms, legs, stomach, and, when unable to burn or cut herself, banging her head violently against walls and floors. Because of the severity of her symptoms, she was kept in a (probably padded) isolation cell and physically restrained during much of her twenty-six month stay.
Not all that long ago—and, in some religious circles even today—patients like this might have been perceived as being victims of demonic possession, and treated by exorcism. (See my prior post.) Despite daily psychoanalytic sessions (such as those with which Jung successfully treated Spielrein), psychotropic medication and even repeated electro-convulsive therapy (ECT), this self-destructive behavior persisted even beyond being discharged from the institution at the age of twenty, including depression, anxiety, a number of suicide attempts, and subsequent psychiatric hospitalizations. But, eventually, apparently with the help of outpatient psychotherapy, Linehan, like Spielrein--who became a prominent child psychiatrist after her therapy with Jung--turned her life around, deciding to study psychology, earned a Ph.D., trained as a Behavior Therapist, and became one of the most prominent clinicians and researchers in the psychotherapy world today. One fascinating question regarding her remarkable recovery would be: What type of psychotherapy, if any, helped Linehan? Certainly not DBT, which she had yet to create. And CBT was then but in its infancy. Behavior Therapy was widely available at that time. Or was it possibly some form of depth psychology or psychodynamic psychotherapy? Psychoanalysis? Or Jung's Analytical Psychology?
Dr. Linehan, now a Professor of Psychology, Psychiatry, and Behavioral Sciences at the University of Washington, specializes in working with patients suffering from Borderline Personality Disorder. And this is the diagnosis she assigns to herself in hindsight. Yet, as mentioned above, the doctors who treated her as a teen-ager and young adult diagnosed her as being schizophrenic, which, by definition, is a psychotic disorder. Why this diagnostic discrepancy? From the sounds of it, the young Ms. Linehan may have very well been psychotic early on. Historically, the term "borderline" referred to patients whose symptoms straddled (and occasionally crossed) the border between neurosis and psychosis. And, as we know today, some sufferers from BPD can, under stress, become psychotic—though, despite the resemblance, this is typically a transitory and brief rather than permanent state of mind, unlike chronic schizophrenia, which carries a poorer prognosis. However, BPD did not become an official diagnosis in DSM-lll until 1980, long after Linehan's first hospitalization. Given the benefit of seeing the subsequent course and trajectory of her life, I would tend to agree with Linehan about severe BPD being her principal (though perhaps not only) underlying diagnosis.
The fact of the matter is that BPD covers an extremely broad spectrum of disturbance and symptomatology, ranging from mild symptoms (with relatively high functioning) that are almost undetectable by most untrained (and many trained) observers to severe and chronic dysfunction, debilitation and life-threatening behaviors. BPD is a very real and devastating phenomenon. According to DSM-IV-TR, the prevalence of BPD is estimated to be about 2 percent of the general population, 10 percent among individuals seen in outpatient psychiatric clinics, and 20 percent among psychiatric inpatients. Indeed, I believe BPD to be much more prevalent than presently believed, especially in men (currently about 75 percent of BPD patients are women) primarily because it can be covered up by the co-occurrence of other disorders, like depression and addiction, while at the same time can mimic and be mistaken for those same "major" mental disorders. For example, the intense outbursts of rage, impulsivity, and affective instability and reactivity of mood that commonly accompany BPD can look a lot like that other BPD—Bipolar Disorder—and are regularly mistakenly diagnosed as such. This is a serious and dangerous misdiagnosis, since if the patient is incorrectly perceived to be suffering from Bipolar Disorder, they will be medicated with mood-stabilizing drugs and not be treated at all for Borderline Personality Disorder. And, in my view, this is precisely what is happening more and more frequently to so-called borderline patients: misdiagnosis, mistreatment and misunderstanding.
Of course, even when the correct BPD diagnosis is made, being labeled "borderline" has become one of the most stigmatizing diagnoses someone can receive. This is mainly due to the fact that most psychotherapists do not have the courage, patience, skill or know-how to treat Borderline Personality Disorder. I suspect that Sabina Spielrein, who was originally diagnosed by Jung as suffering from "psychotic hysteria," would have been better described by the diagnosis of Borderline Personality Disorder. While variable, BPD's typical course tends, unlike Schizophrenia, to wane with age, especially in those patients availing themselves of psychotherapy. (And not just DBT. Studies suggest psychodynamic psychotherapy can be at least as effective as DBT, and far more so after a five-year followup.) According to DSM-IV-TR, " During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Follow-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of behavior that meets full criteria for Borderline Personality Disorder." This may explain at least part of what happened in Linehan's case: time and maturation. But, as Dr. Linehan herself admits, she still, to this day, struggles with her demons at times. Thankfully, she got to the point in her life where she was no longer so destructively driven or possessed by her inner demons, learning to cohabitate with them creatively. Or as Jung might put it, she, like all of us, may still have her demons (complexes), but they no longer have her. At least, not most of the time.
How much of Marsha Linehan's success in working with severely disturbed and suicidal patients stems from having faced down and overcome or, at least, learning to live with and manage her own destructive demons? Psychiatrist C.G. Jung's psychotic breakdown, the insidious start of which is depicted at the end of A Dangerous Method, didn't happen until mid-life, lasting from his late 30s to mid-40s. (See my prior post on Jung's pictorial journal of this perilous journey, the Red Book.) Though Jung was never psychiatrically hospitalized like Spielrein or Linehan, nor formally treated during that time, and never acted out in the same self-destructive and raging ways Linehan did, he at times experienced visual hallucinations, disorientation, depression, massive anxiety, suicidal despair and was unable to function fully for many years until finally recovering. Actually, Jung did much more than recover: He emerged from his prolonged and painful but transformational journey through Hell a new man, a more whole, conscious, better balanced, psychologically self-aware and insightful person and psychiatrist. And a more spiritual and compassionate one. I suspect this may also be the case with Dr. Linehan.
Here is how Linehan describes a pivotal spiritual epiphany in her own religious life when twenty-three:
"I was sitting in the room right outside the chapel, which I will never forget. Because I was sitting on the couch, and I think I felt complete and total despair. That's the only way to say how I felt. And so this nun walked by, and she turned and looked at me and said, 'Is there anything I can do for you?' And I realized that no one could help me, that just no one could help me. So I said to her, 'No. Thank you.' And she left.
And so I got up and I went into the chapel and I was just kneeling there, and I have no idea ... I doubt I was saying anything. I think I was just looking at the cross above the altar. And then out of the blue - out of the absolute blue -suddenly everything went gold and the crucifix was shimmering and I had this unbelievable experience of God loving me and I jumped up and ran out and ran to my room.
I was standing in my room and I said - I think out loud - I said, 'I love myself.'
And the minute, the very minute the word myself came out of my mouth, I knew I had been completely transformed. Because up to that point, I would have never said that. I would have said, 'I love you.' Because I had no sense of self. I thought of myself as you. And the minute the word myself came out of my mouth, I knew and I've always known - ever since - I would never, ever cross that line again - to being crazy."
To me, it sounds like Linehan had what existential psychoanalyst Rollo May referred to as the "I am" experience. It is an experience of one's self, one's being, one's existence as inextricably and umbilically rooted in the cosmos, in Being, and in the daimonic. It is a rediscovery and reclamation of one's authentic self, described poetically by one of Dr. May's patients as follows:
"What is this experience like? It is a primary feeling—it feels like receiving the deed to my house. It is the experience of my own aliveness not caring whether it turns out to be an ion or just a wave. It is like when a very young child I once reached the core of a peach and cracked the pit, not knowing what I would find and then feeling the wonder of finding the inner seed, good to eat in its bitter sweetness. . . . It is like a sailboat in the harbor being given an anchor so that, being made out of earthly things, it can by means of its anchor get in touch again with the earth, the ground from which its wood grew; it can lift its anchor to sail but always at times it can cast its anchor to weather the storm or rest a little. . . . It is my saying to Descartes, ‘I am, therefore I think, I feel, I do.' " (quoted in The Discovery of Being, 1983/86)
But, at least for the then clearly religiously inclined, Catholic Linehan, it appears to have been more than this. In that moment, she realized, she knew, that she was a lovable person. That if her God could love her, she could love—and accept—herself. So, in that moment, not only had Ms. Linehan found her true self, but began loving that self and feeling loved by God. She could now, perhaps for the first time in her life, accept and feel worthy of love—from her God, from others, and from herself. And this was the start of her dramatic personal evolution. But what does it really mean to be totally transformed by such a harrowing experience? (See my prior post on Scrooge's Christmas "conversion experience.") And what do we mean exactly when we speak metaphorically of dealing with our "inner demons"? What is their psychological, spiritual or biological nature?
My best guess is that until that time, Linehan had never felt loved and accepted by anyone—including, and perhaps especially, by her parents. (See my prior posts on the "love cure.") She had probably been deeply wounded as a child. This can and does happen in the nicest and outwardly most "normal" or "perfect" families. Because such unremarkable family histories seem so benign to both the patient and doctors, there is a tendency (not unlike in Schizophrenia, ADD or Autistic Disorder) to want to attribute affective dysregulation in BPD primarily to biogenetic causes. Statistically, BPD "is about five times more common among first-degree biological relatives of those with the disorder than in the general population" (DSM-IV-TR), though this proclivity could be as much caused by nurture as nature. There is commonly a dark and damaging underside to such family dynamics. Indeed, traumatic childhood experiences such as daily narcissistic injury due to neglect, inadequate empathic mirroring, lack of acceptance, rejection, marital conflict, hostility, narcissism, abandonment, loss, emotional, physical and/or sexual abuse are, in some measure, almost always present, and, in many cases, chronically repressed or dissociated, resulting in childhood amnesia. It is exactly this repressed and unconscious material, these sometimes subtle, pervasive and other times not-so-subtle traumatizing experiences that profoundly influenced the patient's inchoate sense of self, their "myth" of themselves, "guiding fiction" or "core schema" that partly comprise the dangerous inner demons and fragile foundational intrapsychic structure with which they wrestle.
Even more importantly, in my experience, these dynamic inner demons commonly consist of chronically repressed anger or rage. They comprise the patient's unconsciously festering "rage complex," which compulsively drives and motivates much of his or her negativistic, hostile, violent and self-destructive thoughts, reactions and behaviors. Today we know that narcissistic injury (especially occurring between birth and five years) results in narcissistic rage. Kohut, Kernberg and various developmental theorists who have studied pathological narcissism and debated its sources, all concur that it stems from inadequate, insufficient, inappropriate or traumatic parenting during childhood. Later, in adulthood, neurotic narcissism, which is always closely linked to BPD (and from which few if any of us are ever entirely free), masks our lingering infantile anger, resentment, rage and embitterment. And deep-seated, talionic desire for revenge and retaliation for having been psychologically (and sometimes literally) rejected, abused, unloved, neglected or abandoned. (See my prior posts.) As well as, when directed inwardly, tendencies toward self-hatred, pathological guilt, self-mutilation, and suicidality.
In Jung's case, for example, he was still angry with his parents—his mother was mentally unstable, possibly borderline, and his father was a dispirited Swiss parson—as well as with God and reality itself. Jung was prone to fits of fury at times. The early, immature Jung tried, like most of us, to repress these uncivilized, aggressive, angry feelings—in much the same way his sexual feelings were repressed, as suggested in A Dangerous Method. (Freud, unfortunately, for most of his career, theoretically focused solely and dogmatically on the problem of repressed sexuality rather than anger, rage or aggression.) This chronically repressed rage played a prominent role in Jung's psychopathology. I suspect the same may be said of both Spielrein and Linehan. And of BPD sufferers in general. Jung eventually came to recognize that coming to terms with, i.e., accepting and integrating such potentially dangerous, dissociated emotions contained in what he called our "shadow," could paradoxically lead to greater vitality, integrity and creativity. We could say that Linehan's encounter with her shadow led to replacing her intense self-loathing with self-acceptance by embracing the perceived "sinful," "negative," "bad" or "evil" aspects of her personality that so painfully conflicted with her religiously-oriented ego or persona.
The crucial question, of course, is how to most efficaciously deal with these difficult demons during treatment. Cognitive-Behavioral Therapy tends not to focus on these influences as much as on how the patient thinks and how that affects how they feel and behave. Linehan's Dialectical Behavior Therapy is derived mainly from CBT. But, drawing upon her own personal salvation, DBT differs from CBT insofar as its welcome infusion of spirituality. In particular, what Linehan refers to as "radical acceptance." Radical acceptance derives from religious traditions such as Buddhism and Hinduism. Apparently Linehan realized in her own recovery from mental illness that self-acceptance and acceptance of reality is at least as important as changing one's self. Change and acceptance exist in dialectical relationship: though seemingly diametrically opposite to each other, both are essential and complementary attitudes. (See my prior post on change vs. acceptance.) And she incorporated this perennial spiritual principle into her "suped up" and well-structured version of CBT, which has proven to be relatively effective in the treatment of Borderline Personality Disorder.
C.G. Jung, whom some speculate himself suffered from BPD, was probably the first psychotherapist to speak openly of the "wounded healer archetype." (In David Cronenberg's film about Jung and Freud, Jung refers to both himself and former patient-turned-psychoanalyst Sabina Spielrein as "wounded healers.") He based this concept partly on the mythological figure of Chiron. Chiron, a centaur, was the product of his sea-nymph mother's rape by the Greek god Kronos disguised as a stallion. Chiron's early wound resulted from being rejected and abandoned—ostensibly because of his hideous half-human and half-horse body--by both of his parents. Later, he was accidentally wounded in the knee by Hercules with an arrow tipped in the Hydra's poisonous blood. His wound would never heal, yet could never kill him due to Chiron's god-like immortality. So he, like one of his famous pupils, the physician Asklepios, could only search for some cure of his endless suffering while choosing to minister to the suffering of others. As I have mentioned to my students over the years, one of the advantages of being a psychotherapist is that we get to focus sometimes on the suffering of others rather than our own. And we can find meaning and fulfillment in supportively helping others survive suffering. But note that it is the woundedness itself--and not necessarily the fully healed psyche of the psychotherapist--that deepens and intensifies the wounded healer's compassionate therapeutic powers. Indeed, I would say it is partially the psychotherapist's personal acceptance of his or her own (and life's existential) suffering and imperfection that enhances the capacity to heal others. This was true of Jung. And appears, at least to some extent, to be true of Linehan.
Both Jung and Linehan overcame madness. Even made creative use of it. Minimizing the psychotic severity of their symptoms does them both an injustice. For, it undercuts the immense psychological significance of what they achieved. But whereas Jung bravely and doggedly faced down his own demons during his prolonged mid-life "confrontation with the unconscious," and was, in time, profoundly changed by doing so, I wonder whether the same may be said of Linehan as she matured. For if she had, I don't see how she could remain basically a cognitive-behavioral therapist. It seems to me Linehan, who has cited Jung in her own writing at times, would have more likely been drawn to depth psychology, recognizing and respecting the awesome and daimonic power of the unconscious. In my view, CBT, unlike depth psychology, tends to deny the power and importance of what both Freud and Jung referred to as the "unconscious." It reduces our inner demons to irrational thoughts (cognitions) while disregarding the central role of repressed emotions such as anger or rage in both the etiology and healing of mental disorders. This leads me to speculate that Dr. Linehan, whom I admire—and most clinicians attracted to and enamored of CBT—are, to some extent, unconsciously drawn to it precisely because it pretty much ignores, circumvents, denies, downplays and dismisses the daimonic : the affective and irrational component of the psyche or what Jung called the shadow. Both CBT and DBT, and its practitioners, seem to want to steer clear of the unconscious. Professionally and personally. But unconscious demons are at the very core of BPD and many other serious mental disorders. One cannot effectively help patients do what one avoids doing for one's self.
In other words, much of the phenomenal popularity of CBT and DBT is a form of what Freud called "resistance" to the unconscious, to the daimonic. It is an attempt to magically dispel the unfathomably irrational, mysterious and terrifying forces of the unconscious with an almost religious glorification of the healing power of rational thinking and a focus on modifying behavior rather than what truly motivates it. (Though, to Linehan's credit, she does pay some attention to the subjective meaning of suicidal and self-destructive behaviors.) Both CBT and DBT, in effect, set the dialectical principles of Logos against Eros, worshiping the former and denigrating the latter. In this sense, CBT is a one-sided, superficial treatment approach. Even Linehan's DBT, with its supplemental spiritual emphasis, is limited by CBT's inherent superficiality. The research findings supporting DBT's efficacy with BPD are derived mainly from treatment with the more acutely disturbed, suicidal (often hospitalized) spectrum of BPD patients, and based almost entirely on a reduction in frequency of self-harm behaviors and subsequent psychiatric hospitalization. That's valuable, to be sure. (Clearly, one can't do therapy with a dead patient. No matter what one's theoretical orientation.) But highly limited in terms of addressing the potent and pervasive underlying emotional issues borderline patients struggle with. As with the use of psychotropic medications, symptom management or suppression, while having its helpful and sometimes essential place in treatment, is not the same as real psychotherapy. I would contend that, while both CBT and DBT do attempt to address and "exorcize" or "restructure" the patient's cognitive demons, that is, the irrational, negative and self-defeating thought patterns and "schemata" underlying and influencing feelings and behaviors, it fails to adequately address the patient's emotional demons. Indeed, it tends to unwittingly collude with the patient in continuing to repress and avoid these admittedly frightening, overwhelming and potentially dangerous emotions. The problem is that, as Nietzsche knew, what is chronically suppressed eventually returns with a vengeance and turns even more negative and destructive. None of which is ultimately in the patient's best interest.
Like Jung, evidently Linehan learned much from her own hellish suffering, and has made creative use of this hard-won knowledge to help both herself and others. For this she deserves our gratitude, respect, credit and congratulations. Her emphasis on mindfulness, self-acceptance and acceptance of reality on its own terms is something shared with (if not directly taken from) depth psychology and existential psychotherapy. As is her emphasis on learning to pause between stimulus and response, consciously choosing and taking responsibility for one's behavior despite how one subjectively feels. (See my prior post on existential therapy.) There is no doubt that thinking influences feeling and behavior; behavior influences feeling and thinking; and that feelings influence both thinking and behavior. (This is yet another dialectical relationship: thinking vs. feeling, as well as conscious vs. unconscious, though DBT deals almost exclusively with the conscious psyche rather than the unconscious.) And that, especially in addressing severely debilitating and sometimes life-threatening mental disorders like BPD, a clinical emphasis on both thoughts and behavior is essential. In fact, I would argue that DBT and depth psychology themselves represent part of a dialectical polarity. Each tends to be the shadow side of the other.Yet, they are not antithetical: both can complement the other, theoretically and clinically.
I have never had the pleasure of meeting Dr. Linehan. Nor am I familiar with all of her writings. Nonetheless, though I could, of course, be mistaken, I can't help feeling that, deep down, she harbors some strong affinity for fellow wounded healer C.G. Jung. And, that somewhere slumbering in her shadow, longing to be liberated, dwells a budding—or maybe even closeted—depth psychologist.