"Are you one of us?"

A Reader brought this article to my attention and I wanted to share it. It was on the front of the NY Times this past week. Marsha M. Linehan, as I’ve discussed before, is the pioneer of Dialectical Behavior Therapy which is one of the most prominent courses of treatment for Borderline Personality Disorder. I’m going to go through and underline some things I find particularly poignant. Maybe I’ll talk about them tomorrow. Regardless, I think it’s an insightful read.

Expert on Mental Illness Reveals Her Own Fight
By BENEDICT CAREY
Published: June 23, 2011

HARTFORD — Are you one of us?
The patient wanted to know, and her therapist — Marsha M. Linehan of the University 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 and welts 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 Thorazine, Librium 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.”
“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.”
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 super-suicidal 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.”

What causes BPD? Linehan Theory – Part 4

Continuing my 4 Part series of Dr. Linehan’s theory I’ll now explore Unremitted crisis vs. Inhibited grief.
Unremitted crisisuninterrupted; constant, unpardoned (as a sin) feeling that a condition of instability or danger leading to a decisive change which the trend of all future events, esp. for better or for worse, is determined by a dramatic emotional or circumstantial upheaval in a person’s life. Steadily maintained.

Ok, yes. Especially with my depression and trying to hold onto the thought that people care about me and aren’t going to leave, I always feel like I’m struggling to hold on. Everything feels dire or like there’s impending doom whether it’s externally perceived or battling my own internal thoughts and feelings. I NEED to understand what’s happening and what’s more I need those that care for me to understand, intervene, be there for me to lean on if I need.
What’s more I often feel like people won’t forgive me for any small infraction. I get worked up if I’ve done anything wrong and have a nearly fatalistic attitude that people will walk out of my life. Dissolving in a puddle of self doubt until I can prove that I am not a bad person. Again, this has to do with my inability to believe that one action does not negate all previous actions. That people take me as a whole series of our interactions not just single episodes. I can’t say this is completely unjustified though. I have had people, people that I was very close too, walk out of my life at the first infraction (however big), or once a single mistake was made all further actions were then in question and I was made to feel like I wouldn’t be forgiven no matter what I did to make up for it. While this may be true, it’s not entirely unjustified, but now it permeates my experiences with people.
Fortunately my current apartment and roommate are a safe haven for me, I have some reprieve from the constant upheaval. Some, not always, but it’s at least a calm environment.

Inhibited grief – to restrain, hinder, arrest, or check keen mental suffering or distress over affliction or loss; sharp sorrow; painful regret.

Definitely. I’m at constant odds whether I have a right to feel the way I do about any given situation. I don’t understand what I’m allowed to expect or what I deserve from other people so I constantly question whether my emotional responses are appropriate. Do people really owe me anything? What can I actually expect of them? What do I deserve from people when I need help? Do I have a right to impinge on their time and divert their attention from what they were doing? Especially if it’s from a loss. I’m sure things are often my fault, guilt, and I don’t know if I have the right to believe/expect that others should work things out with me. If I don’t have the right, then my feelings aren’t justified and I need to hold them in. But when I know something isn’t entirely my fault, I feel absolutely no remorse if the contributing party isn’t willing to communicate with me. Black or white.
I may want to pursue the topic, push someone to work things through with me but I restrain myself for feeling like I have no right to do so. I hold back and wait. Which only causes me to get more anxious and allows my thoughts to wander down all the possibilities that may be going through their minds and often come to the worst conclusions in my own mind. I feel the loss, sadness, over something that hasn’t even occurred yet. Or may never occur at all. I can’t quiet the distress that it creates and suffer for it in silence being unable to decide if I’m allowed to pursue a solution just to make myself feel better. Then I regret not being able to rectify whatever it was that occurred. This cycles back to making myself feel guilty for something that may or may not be my fault.

What causes BPD? Linehan theory Part 3

Up next we have: Active passivity vs. Apparent Competence

Active passivitythis is defined as: the tendency to be passive when confronted with a problem and actively seek a rescuer. 
 No. Not even a little. When confronted with a problem I confront it right back. I don’t run away from anything. I’m not afraid of people’s reactions in the way that is typical of BPD. I’m hate the thought of negative outcomes but I also believe that as long as a problem can be worked on, talked through, and people are willing to communicate it is possible to get through a problem and not have a devastating outcome. I suspect my Dissociative Disorder acts up in this arena as well. When faced with conflict my emotions turn off completely and I argue with pure logic. I can talk about emotions but not feel them. Then if it becomes inevitable that a situation can not be resolved I go numb to the negative emotions that should come of it. This doesn’t always work. However, I don’t need a white knight, I’ll save myself, thanks.
My personality tends to be too dominant, independent to rely on other people. I can see where some passivity comes into my life, and I guess if I’m really honest, I do hope for someone to come along, see me, and accept me for all that I am. Save me from a lifetime of loneliness. But I’m also not willing to latch onto every shmuck that falls my way. I have standards after all.
Apparent competenceappearing to be capable when in reality internally things are falling apart. Sure. Because I actually am extremely competent. I worked my ass off to be intellectually, logically, mentally competent in some of the hardest fields I could have chosen to pursue. Not to mention some very useful creative fields. I read constantly and I know A LOT about a great many things. That doesn’t mean that internally things aren’t still falling apart for me though.
After a lifetime of rollercoaster emotions I’m disgusted by my own lack of control in this arena. I’ve worked hard to control my emotions. I learned to mask my inner turmoil, not display it, so I always appear calm and rational. In my defense, I am rational. But sometimes it’s too hard to get past the overwhelming emotional upheaval to think straight. I often have the impulse to lash out and say things that reflect how I feel, but I’m sick of being ruled by my emotions, so I hold in my reactions. It doesn’t stop me from experiencing them, but it stops the expression of them. I try very hard not to unleash my emotions publically because the repercussions would only act to alienate me from the people around me. When this happens, I try not to be around other people. I hate anyone seeing me like this. I’d rather them continue to believe the calm, friendly façade. However, underneath the surface little by little it builds up until I can’t control it and I have to either physically vent my emotional frustration or have a self inflicted melt down, alone.
I’m learning how to deal with this though. Through therapy and my journaling I am learning to recognize the emotions that are not … for a given instance. Once you can recognize that a situation is not beyond your capacity to handle, can take a step back and analyze why a feeling is so intense it becomes easier to understand it and thus, manage it and learn to respond more appropriately in the future. It’s not easy, and it doesn’t happen overnight, but it does work. So maybe this field isn’t quite a ‘yes’ for me either because I actually am learning to competently deal with my emotions.

As a side note: I HATE considering myself an emotional person. Anyone that meets me and gets to know me a little would tell you I am one of the most rational women you’ve ever met. Not emotional at all. Just like one of the guys. Crude, funny, outgoing and witty. These certainly are parts of my personality, but they’re parts I put into focus in order to mask everything else beneath the surface.

What causes BPD? Linehan theory Part 2

Continuing on with Dr. Linehan’s theory I’ll take a look at Vulnerability vs. Invalidation
Vulnerability – I detest admitting vulnerability. Over the years I have built defenses and fortresses of walls to keep other people out. Do I have vulnerabilities? Eeeeeeeeeeeeeh, everyone does. I’m loathe to put them out there where others can easily find them and use them against me though. Because they have. So I don’t. I know where my strong points end and my weaknesses begin. That doesn’t mean I need to wear these on my sleeve. Rarely, oh so very rarely, someone will put in the effort to get close to me, really want to get to know me. Slowly, my walls begin to crumble around this person. They can now see into the darker areas of my world. I have no secrets, but there are things I don’t share right away. Every time I open up, reveal something less pleasant about myself, I wait in fear, that their entire opinion of me will shatter and change, and they’ll leave. Every revelation is a wrench to my heart. The closer someone gets to me, the greater the potential that they can hurt me.
InvalidationYes. This especially applies to my emotions. I am constantly questioning whether I have a right to feel the way I do when it comes to other people. Who’s to say what right I have? If the person feels otherwise about something, then my feelings aren’t justified and therefore not valid for the situation. If my feelings aren’t valid or accepted, I’m not valid or accepted. You can’t only accept parts of me, I have to be accepted as a whole. Or not at all. However this also applies to my work, my crafts, my hobbies. I do things, present things to people hoping it meets with approval but looking for criticism that will invalidate my ability, prove that yet again, what I have done, is not good enough. I don’t get defensive with criticism but having become so accustomed to it, I have a tendency to not believe people when they only give me praise with no critique. 
Constantly putting myself out there for others to view and judge exposes my vulnerabilities. Opens me up to the potential criticisms of others, then when I look for those criticisms, expect them, it heightens my feelings of vulnerability because I’ve put myself at the judgment of others. Will I be accepted, or won’t I? Because I have a hard time with object constancy, I often can’t hold onto the feeling that each individual event isn’t the sole basis for a relationship/friendship. Just because something isn’t perfect doesn’t mean that people will leave me or not value me. It’s a self fulfilling cycle of hurt. Emotional masochism.
When you are constantly discredited it’s difficult to hold onto a solid sense of self. Who you are is perpetually in question. It weakens the ability to accept or even understand criticism or praise as something constructive and not necessarily judgemental. The judgement of the self is so impaired that it leaves someone with BPD open to adopting a skewed opinion of themselves based on the views of others.   When a sense of self is not solidly in place, changeable at the influence of others, this leaves a person susceptible to being wounded and hurt. Each word of praise or criticism is taken as a completely separate event, with no context to past interaction. Praise is a beautiful high. Criticism or harsh words a crushing low. This increases the need to be loved and accepted, causing someone with BPD to expose themselves even more, perpetuating a cycle of intense emotional turmoil.

What causes Borderline Personality Disorder?

One theory is presented by Dr. Linehan’s. Linehan has developed a comprehensive sociobiological theory which appears to be borne out by the successes found in controlled studies of her Dialectical Behavioral Therapy.
Linehan theorizes that borderlines are born with an innate biological tendency to react more intensely to lower levels of stress than others and to take longer to recover. They peak “higher” emotionally on less provocation and take longer coming down. In addition, they were raised in environments in which their beliefs about themselves and their environment were continually devalued and invalidated. These factors combine to create adults who are uncertain of the truth of their own feelings and who are confronted by three basic dialectics they have failed to master (and thus rush frantically from pole to pole of):
 
– vulnerability vs. invalidation
– active passivity (tendency to be passive when confronted with a problem and actively seek a rescuer) vs. apparent competence (appearing to be capable when in reality internally things are falling apart)
 – unremitting crises vs. inhibited grief.
So it’s nature and nurture here, or nature and lack of nurture. So let’s see how this applies to me.
“Beliefs about the self were constantly devalued.” I hate to say this is true, because I was raised with incredibly loving parents in a very loving home where both my parents wanted the best for us, for us to be the best. My father however, was an art critic, our coach, our teacher… so everything we did was always capable of being improved upon, never good enough, always something wrong, always could be better. That’s not to say he never praised us, he often did, it was always followed by… “and now you could do this”, “that’s good but this is off, try doing this”, “but this could be improved in this way”, “watch out for this”. For me this translated as, if there’s something wrong with my work, there’s something wrong with me and I need to work harder, to the point of obsession, in order to be the right kind of person. If I’d get hurt or upset, about anything, I was often told to suck it up and deal like a grown up. Crying was not acceptable so I learned to hide my feelings. He didn’t mean to cause these feelings, but I guess being predisposed to this kind of thinking made his critiques all the more impactful.

One of my earliest memories was when I was 3 years old. I had a Little Shop of Horrors coloring book. I did an entire picture all in orange crayon. It was the very first time I had stayed completely in the lines and not messed up. I proudly showed my father. He said good job girl, took my crayon, and decided it was now a good time to show me how to shade my colors. On my current picture. He went outside of the lines. I was heartbroken with disappointment that my painstaking achievement wasn’t good enough and was now ruined. I thought I had done so well, but apparently I hadn’t done well enough. It may not seem like much, but to a 3 year old, it seemed like a big deal. That’s just one example, I could go on with a lifetime of me being pushed to be the best, pushing myself to be the best, but maybe another time.

I will say that as a result of a lifetime of this, it is difficult for me to ever believe that what I do is good enough, that I am good enough. I constantly question and second guess my own sense of self worth and often measure it by what people think of the things I do for them, be it cooking, baking, costuming, gifts, art, work, etc. In an odd twist, I also have a hard time believing people, believe they are telling the truth, unless they give me uneditted criticism. It’s so ingrained in my thinking that I can always improve things, that unless someone tells me how I can do things better the next time I doubt whether the thing that I’ve done was actually ok. So I set higher goals, harder goals, and work my ass off to prove to myself that what I do is valuable. That I am capable of doing things of value. I’ve never set a goal I haven’t accomplished beautifully, and yet, I always wait for someone to tell me how to improve.
Now do I think this is the only theory? or the best theory? No, but it’s interesting to explore.

Coming up next… Vulnerability vs. Invalidation