Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part VI

DBT Challenges The Borderline Diagnosis
Katy Butler, The Psychotherapist Networker, May/June 2001

On the morning of September 21, 1993, a 37-year-old former graduate student named Susan Kandel took an elevator to an upper floor of Duke Medical Center in Durham, North Carolina, where she was attending a day treatment program. She was panicked and miserable: her therapist had recently moved to another state, and she was about to leave agency-supervised housing to look for her own apartment. She went to a breezeway connecting two wings of the building and jumped, expecting to fall 90 feet to her death. She landed instead on a maintenance workers' platform 40 feet down and was taken to the emergency room with three broken vertebrae. A month later, still in a body brace but not paralyzed, she was involuntarily committed to John Umstead State Hospital, an aging two-story brick mental hospital in Butner, North Carolina on the outskirts of Durham. She, the hospital staff and her family all expected her to be there for a long, long time, and she was in deep despair. It was her fourth commitment to John Umstead State Hospital, and her seventh serious suicide attempt. Two years earlier, facing an oral presentation for her Ph.D. in molecular biology at Duke, she had driven to a motel room on the North Carolina shore and swallowed 250 milliliters of chloroform-more than 25 times the lethal dose. Two days later, she was discovered in a coma, with a hole in her esophagus and her liver badly damaged; when she recovered sufficiently, she was committed to John Umstead for her first long stay.
    Kandel had been given the most reviled diagnosis in the therapeutic lexicon--Borderline Personality Disorder--when she was 20. A brilliant but withdrawn college student, she had spent much of the next 17 years turning on a wheel of suffering from suicide attempt to mental hospital to halfway house to suicide attempt. Much like a distressed monkey gnawing its knuckles in a small cage at the zoo, she discovered at 17 that cutting her forearms with razor blades made her feel somewhat better. When she was 19, she was sent to a mental hospital for the first time, and there she took her first pill overdose.
    The years passed, and therapy fashions changed, but no treatment made any appreciable difference: not five-times-a-week psychodynamic talk therapy, nor electroshock, lithium, librium, tricyclics or anti-psychotics. By the time she returned to John Umstead hospital in a body brace, she was like a cat with nine unwanted lives: she had lost faith even in her ability to kill herself. "I had given up on pills because I'd been rescued so many times," she re members. "Guns are foreign to me, and given my history, I knew I couldn't get a license even if I'd wanted one. It wouldn't matter what I did; I would be brought back to the hospital and have to start all over again. I wanted to die, but the powers that be, the gods, were not going to let go of me."
    Then, in November 1993, Kandel was required to take part in a radical new treatment for borderline personality disorder called Dialectical Behavior Therapy (DBT). She left the hospital 10 months later, and in the seven years since, has never come close to being rehospitalized or to killing herself.

A Code Word for Trouble
Long before the ambiguous and insulting term was coined by a male psychoanalyst 60 years ago, the people we now call "borderlines" were public health nightmares, islands of intractable misery, and the bane of many a psychotherapist's existence. A century of shifting diagnostic labels and rising feminist sympathies cannot paper over therapy's signal failure with them.
    Seventy-five percent are women; and about an equal percentage of all clients diagnosed as borderline report a history of childhood sexual abuse--three times the rate of clients given other diagnoses. Many try to kill themselves and.nine percent succeed. Their numbers include the volatile and damaged people that Freud called "hysterics" and treated with little success at the turn of the century, like Dora and the Wolf Man; others who deteriorated in classical psychoanalysis and were described in 1938 by psychoanalyst Otto Stern as "on the borderline" between psychosis and neurosis; and still others treated with equally mixed results in the 1980s by feminist therapists who dropped the borderline label in favor of the less pejorative term trauma survivor.
    Today, the DSM-IV coolly defines Borderline Personality as an Axis II character disorder marked by "instability of interpersonal relationships, self-image, and affects, and marked impulsivity." Listed symptoms include "frantic efforts to avoid real or imagined abandonment"; episodes of depersonalization and dissociation; oscillation between idealizing and denigrating others; suicidality, self-mutilation, loneliness, anger, and inner emptiness; and "impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)."
    But in therapists' private argot, "borderline," accompanied by much eye-rolling, has long been the shorthand for clients who never got beyond the crisis du jour--clients like the fragile and alcoholic Blanche Dubois of A Streetcar Named Desire, eternally dependent on "the kindness of strangers." They are clients reminiscent of Marilyn Monroe (who was removed from the care of a psychotic mother and sexually abused in childhood), ever wandering into exploitative relationships and never able to protect themselves.
    "Borderline" was a code word not for a person but a relationships therapeutic double-drowning. It tagged practically any client who terrified, enraged or repulsed her therapist--like Alex Forrest, the seemingly competent Manhattan career woman played by Glenn Close in Fatal Attraction, who flew into rages, slit her wrists and stalked her married lover when he tried to leave her. Or Bob, the "human crazy glue" played by Bill Murray in What About Bob? who tracked his stuffy psychiatrist to his summer home and drove the shrink so crazy he tried to blow up Bob with dynamite. "Borderlines" were the terrorists of the therapeutic hour, the people with "no boundaries," the experts in the tyranny of the weak.
    "I won't work with them anymore. There was so much effort for so little result," says one psychologist who still remembers two clients who made him tear out his hair at an agency in Maine in the early 1980s. One man frequently threatened suicide and called him collect to say things like You cock-sucker, you don't care about me, this is just a job to you. (That client later threw hot coffee on a therapist's new suit.) Another--a breast cancer survivor--secretly taped her sessions, demanded copies of clinical notes and showed up unannounced at his home office, unnerving him so much that he once told her, You're too mean to die. "You could pay me three times what I make now," he said recently, shaking his head, "and it still wouldn't be enough."

No Emotional Skin
In the decades since, most clinicians who had a choice avoided borderline clients, while agency staff (who couldn't) went through the motions with a sense of futility. Some adopted a psychoanalytic view, blaming the disorder on disturbances of mother-infant attachment or a "constitutional excess of aggression." Therapy consisted of guarding against "manipulation" and mining the borderline's reactions to the therapist for clues to her fragmented inner world. It was hard on clients--and on therapists as well. "We made too much of an assumption that if we directly understood the patients' conflicts and made correct interpretations, they would know how to say no, or stand up to somebody or go through a job interview," says psychiatrist Charles Swenson, a former protoge of psychoanalyst Otto Kemberg. "Role-playing or teaching [a behavioral skill] was considered a no-no, because it would create a different type of transference, where the person would become dependent on you and develop false hopes."
    Other clinicians adopted a feminist, trauma-focused view, concentrating on client histories of sexual and physical trauma--with equally mixed results. "I count myself among the many who thought that by excavating all those stories and memories and feelings we were freeing ourselves and our clients," says psychologist Dusty Miller, the author of Women Who Hurt Themselves. "The truth is, for a lot of people, the pain got worse, the rage got worse and people weren't given coping skills," she says. "Definitely, people got worse."
    Then, in 1991, a study published in the Archives of General Psychiatry (one of psychiatry's most influential journals) challenged this pervasive pessimism. The article reported on a small, NIMH-funded, randomized clinical trial that showed dramatic improvement among 22 borderline, suicidal and severely self-harming women. The lead author and researcher was not a psychiatrist, but a behavioral psychologist and Zen student at the University of Washington named Marsha Linehan; her treatment was called Dialectical Behavior Therapy, or DBT
    All of the women in her study had tried to kill themselves at least twice, and many practiced "parasuicide": they addictively attacked their own bodies in moments of emotional crisis, slashing forearms, tendons and wrists; burned themselves with cigarettes and lighters; and even garroted themselves severely enough to risk death, unconsciousness and hospitalization. But after four months of treatment, fewer than half were still harming themselves--compared with roughly three quarters of a control group of 22 equally self-punishing women given "treatment as usual" by therapists in the Seattle community. Over the course of the year, the DBT women steadily improved, spending significantly fewer days in mental hospitals and engaging in fewer suicide attempts and parasuicides. Tiny as it was, and limited though the improvement had been, the study established DBT as the only treatment for borderline suicidality ever validated by a randomized clinical trial published in a peer-reviewed journal.
    At the core of the treatment was a set of behavioral techniques Linehan called a "technology of change," balanced by a "technology of acceptance"--a soft, almost mystical, Asian emphasis on "radical acceptance" and exercises for calming the mind by following the breath. The women had been taught how to tolerate difficult situations--and their own intense emotions--by using mindfulness-meditation practices and cultivating radical acceptance. Paradoxically, they had also learned assertive Western social skills, such as "interpersonal effectiveness," to get their needs met, and "behavioral chain analysis" to find out exactly what had sparked their desires to kill themselves.
    DBT was no walk in the park: it required team treatment, including weekly individual therapy, a year-long "skills training" class, telephone coaching and supportive supervision for the therapist. But it offered clients and therapists alike a way out of chaos--a systematic clinical package that integrated the technical and analytical strengths of behaviorism, the subtleties of Zen training, the warmth and acceptance of relationship-centered therapies and the often undervalued power of psycho-education.
    Perhaps the most articulate advocate for borderline individuals ever to appear in the mental health field, Linehan turned out to have an uncanny knack for explaining the borderline's inner world in terms that professionals could understand. Borderline individuals, she theorized in a dense, heavily footnoted 1993 text, Cognitive Behavioral Treatment of Borderline Personality Disorder, had "no emotional skin" and had been raised in families where their hypersensitivity had been routinely discounted. This had bred profound self-distrust, a tendency toward extremes and pervasive "emotional, behavioral, interpersonal and cognitive disregulation." Therapy, she wrote, recapitulated the invalidating family environment when it offered insulting interpretations, ignored cries of distress and inadvertently rewarded emotional explosions or suicidality with extra attention or hospitalization. At its worst, therapy had become "iatrogenic."
    Thus, Linehan reconfigured the borderline diagnosis in behaviorist: terms, stripping it of judgment and shame and posing an explicit feminist challenge to the reigning psychodynamic theorists (particularly Otto Kernberg, James Masterson and John Gunderson) who had shaped the field's damning and pessimistic views of it. Borderline individuals had huge deficits in life skills, she wrote--not deficient personalities. Where male psychoanalysts had seen "a constitutional excess of aggression," "primitive thinking" and "manipulation," she saw terror, stress-related difficulties in cognitive processing and despair. Teaching borderline individuals better ways to manage their moods and cope with the world, she wrote, would reduce their self-destructive behavior.
    This could be accomplished, she suggested in her 1993 Skills Training Manual for Treating Borderline Personality Disorder, by teaching a blend of assertiveness and mindfulness. Her book included lengthy quotations from the popular Vietnamese Buddhist monk Thich Nhat Hanh, who counseled "washing the dishes just to wash the dishes."
    These novel and unorthodox clients were, wrapped in research .so solid and language so clear that Linehan's texts drew immediate praise from mainstream psychiatrists and psychologists--and gradually converted people once dismissive of cognitive-behaviorism, ignorant of meditation and fiercely wedded to psychoanalytic or trauma-focused approaches to borderline personality.
    "I was not enthusiastic at first," concedes Dusty Miller, who began teaching DBT at the request of her graduate students at Antioch University in New Hampshire in the mid-1990s. "The borderline diagnosis, as used by straight white men, was very blameful. But Linehan has rescued it from the blame-the-victim tradition, describing it as an understandable response to the way these people grew up. Her model gives clients some great coping skills, and I've learned a lot from it."
    Another convert was Charles Swenson, who had run a borderline inpatient unit under the tutelage of Otto Kernberg. Increasingly disillusioned, Swenson gave up Kernberg's psychoanalytic approach in the late 1980s to train with Linehan and found his practice transformed. "I felt inspired in my work again," says Swenson, who was equally captivated by the woman herself. "She's brilliant, charismatic and articulate," he says. "She's a force, a triple threat. It's no accident that she's transforming the field."

The above text covers the first three pages of this eleven page article. For the remainder, visit the archives of the Psychotherapist Networker at www.psychotherapynetworker.org.



The Empty Couch: What Is Lost When Psychiatry Turns to Drugs?
Joan Acocella, New Yorker- 5/8/2000

In one of the psychiatric wards where T M. Luhrmann did research for her new book, "Of Two Minds: The Growing Disorder in American Psychiatry" (Knopf; $26.95), there was a patient who enjoyed going into the common room in the evening and telling the other patients how she tortured animals: "She told them that she liked to stick pins into rats' eyes and listen to them squeal, that she would chop them up and drink their squirting blood." Once she had all the other patients crying, she would go back to her room and turn in for the night. When the attending doctor spoke to her about this, he did not try to find out if she actually tortured animals, let alone why. He just told her to stop disrupting the ward. "'If you feel like you want to harm animals ... and you need some help controlling those thoughts, tell us,' he said. `Otherwise, don't tell us, because no hospital can legally discharge you if you do."' She stopped, and, in keeping with the current trend toward short hospitalization, probably soon went home. This was a "biomedical" ward, as are most psychiatric units these days, and in such a place the doctors no longer explore with you why you think and act as you do. Biomedical psychiatrists regard mental disorders as "heart attacks in the brain" (Luhrmann's phrase), and they no more expect you to explain such an event than if you had had a heart attack in the heart. On admission to the hospital, you are swiftly diagnosed and medicated. Then, once you have stopped threatening suicide or hearing voices—a process that takes maybe five to ten days—you are given a bottle of pills and discharged. Chances are you will be back soon.
    For about a decade now, since the introduction of Prozac, in 1988, and the articles and books on it in the early nineties, the general public has known about the split between psychodynamic and biomedical psychiatry, which in outpatient terms means the choice, when depression or anxiety returns, of either going back to the psychotherapist for another year or getting your regular doctor to give you a prescription for Prozac or Xanax. People also know, if they have read the Time and Newsweek articles—and maybe Peter Kramer's 1993 "Listening to Prozac," which has sold more than half a million copies in the United States alone—about the philosophical implications of the two approaches: how on the one, psychodynamic hand, you are in large measure stuck with your fate but also responsible for it, and how on the other, psychopharmacological hand, you don't have a fate, you have a system of neurotransmitters, for which you are not responsible and with which you aren't stuck, since, thanks to drugs, you can adjust it. To partisans of the psychodynamic view, the new, drug-based psychiatry is taking the morals, the dignity, the truth out of human life. To the drug doctors, all that is being eliminated is the junk pile of unexamined assumptions descended from Sigmund Freud.
    "Of Two Minds" addresses the controversy differently. Luhrmann, a professor of anthropology at the University of California at San Diego, comes to psychiatry the way Margaret Mead went to Samoa. That is, she approaches it as a culture, a collection of beliefs and practices which young people are socialized into. She follows a number of psychiatrists-to-be through their training and watches how they get "processed" by the contingencies of their culture—how, in the end, what is called theory is actually a canny balancing of conviction with the need to survive. In the process she provides a more nuanced treatment of the moral and philosophical issues than any previous discussion I know of.
    As Luhrmann sees it, almost everything about psychiatric trainees' experience pushes them into the biomedical camp. Medical school, to start with, teaches them to separate their feelings from their patients, and the psychiatric residency drives that lesson home. Residents are given lectures and training in psychotherapy, but there is a none too subtle deemphasis of that part of their education in favor of the biomedical work of diagnosis and medication. Then they graduate and take jobs in places that, increasingly, have nothing to do with psychotherapy. Luhrmann spent a week studying an institution she calls San Juan County Hospital, in northern California. On its psychiatric unit there were two women married to God, and another, pregnant with her ninth child—her previous eight were living with relatives or in foster homes—who called herself Shirley Temple. ("Look," she would say, pinching her arms, "the hospital hasn't helped. I'm still black.") One man, on arrival at the hospital, reported that he had no hallucinations, "except for the Devil." His problem was that he hadn't taken food or drink for six days. This was his fourteenth admission. Many of the other patients were also what the staff called "frequent fliers"—a fact that was unquestionably due in part to the conditions in which they lived on the outside. Most were poor; many, upon release, used crack or alcohol to control their symptoms.
    The staff tried to address these people's "psychosocial" problems; they held meetings with them to talk about substance abuse and living skills, but in the eight days that was the average length of admission there was little they could do. Luhrmann says she once ran such a meeting. When the patients spoke, "which was not so often, they talked about how it was more difficult to get to one prison than to another and how when their son came home on probation they really hoped he wouldn't keep a gun in his car the way he had last time." If social problems are hard to solve in a week, emotional problems don't have a chance. The man who was starving himself reported that his father had died three weeks earlier: "Several times he started a sentence with `My father' but couldn't complete it." The resident who admitted him did not draw him out; she didn't have time. The purpose of the unit was simply containment, for the sickest patients in their sickest periods, and once they were discharged they were not supposed to return too soon. Those who keep coming back may find themselves taking a vacation courtesy of the local authorities. "In southern California," Luhrmann reports, "patients would show up in the psychiatric emergency room and explain that they had been in Minnesota or Illinois and had gone to the bus station and a nice man from the county mental health had bought them a bus ticket to San Diego, which they thought they'd like to visit."
    Many writers who take on the current state of our psychiatric hospitals side with the patients, and demonize the psychiatrists. The wonderful thing about Luhrmann's book is that she demonizes no one. Young psychiatrists, she says, start out idealistic (even more so these days, when managed care has reduced their earning power). Then they start cutting their losses. Diagnosis, which they begin doing as residents, is the first lesson in hospital Realpolitik. Diagnosing means looking at a person who typically presents a complicated, ambiguous picture—"They're sad, they're not sleeping too well, their wife just left them," as one resident summarized it—and, within a matter of minutes, marking him down as having one of the conditions listed in the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders," or D.S.M. These conditions, in keeping with the so-called medical model—which holds that psychological disorders are like, or are, organic disorders—come described as consisting of certain "symptoms," which add up to a certain "syndrome." Then, again in keeping with the medical model, the psychiatrist prescribes medication. These actions have good short-term results. The patient, given the medication, settles down. The insurer, given the diagnosis (it is required), pays for the treatment, thereby keeping the hospital out of bankruptcy. So young psychiatrists go on doing these things, and as they do they come to look for symptoms that fit D.S.M. diagnoses, and for which medications are available. Then they go to work in hospitals where there is no time to do psychotherapy, so why bother even thinking about the matters that psychotherapy addresses—hope, discouragement, truth or untruth to oneself? Thus psychiatrists learn to work within the biomedical system, and to believe in it, if they don't want their lives to be anguish. Touchingly, Luhrmann reports that many of them haven't learned, and that their lives are anguish. They know what it is that they are ignoring, and they feel they have broken trust with their patients. "They feel like bad people."
    Where did the biomedical approach come from? From Hippocrates, at the latest. For a couple of millennia now, the pendulum of psychiatry has been swinging between organic and psychological/spiritual explanations. In the late nineteenth century, organic causation was the dominant theory. Then it was shoved aside by Freud. Psychoanalysis took a while to conquer the United States, but once it did, after the Second World War, its dominance was unquestioned, and its arrogance breathtaking. Schizophrenia, autism, and numerous other disorders were blamed on the mother, with no evidence, just utter certainty. The public accepted this, to the great disadvantage of patients, not to speak of mothers. Then, gradually, it was shown that schizophrenia had a strong genetic component, that autistic children had demonstrable neurological deficits, and so on. In other words, biomedical theory rose because there was science to support it. It also had humanitarian appeal: if mental disorders were biological, patients shouldn't be blamed for them, shouldn't be stigmatized. That the return of the biomedical approach also occurred within the context of the despiritualization of our society after the sixties, that it fit in so well with the abandonment of any value that was not commercially profitable (as psychotherapy apparently was not, and drugs were): these facts were noticed by some but, in the re-scientific atmosphere of those times, they did not amount to a strong argument.
    It was in the late seventies that the first generation of convinced biomedical psychiatrists got out of school. Still, many of them felt that psychological disorders involved both organic vulnerability and learning, and that, whatever the cause, most patients needed both biological and psychological treatment. (Even if a disorder is wholly biological, patients need psychological therapy to repair the consequences—their wrecked marriages, their hiatus-filled resumes.) So in most wards some psychiatrists gave drugs, some gave psychotherapy, and the system chugged forward.
    Then came managed care. Luhrmann is so fair that she is even fair to managed care. By 1990, she notes, expenditures on health care in the United States had exceeded six hundred billion dollars, more than twelve per cent of the gross national product. Something had to be done, but what was done was brutal, above all in mental health. (General medical benefits dropped by 7.4 per cent, but mental health benefits were cut by half.) In the mid-nineteen-nineties, Luhrmann revisited a large teaching hospital where she had done field work a few years earlier. The experience, she says, was like "coming back to a tree-lined London neighborhood after the Blitz." Services had been reduced to a minimum. Psychotherapy was gone altogether, except for certain, very circumscribed groups. (For example, trauma patients. Is this why therapists are now so interested in psychological trauma, and so likely to diagnose it?) Most patients don't have a prayer of discussing their dead father, or even their living circumstances. In all this slash-and-burn, it is not clear that there has been any substantial cost saving, for with the elimination of psychotherapy—and the stepped-up speed of discharge—readmission rates have risen. Especially important in the financial picture, it seems, is the provision of outpatient psychotherapy, as the Champus Insurance Company, for example, discovered when it expanded outpatient psychiatric coverage between 1989 and 1992. It "gained a net saving of $200 million because its customers' hospitalization rate dropped sharply. For every dollar spent on psychotherapy, four dollars were saved." There are few things more expensive than hospitalization, and, strange to say, it can be prevented in many cases by a little talk once a week with an interested person.

The above text covers the first two pages of this six page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.