The other day I was listening to the podcast, “Talking Therapy,” starring Marvin Goldfried and Allen Frances (https://www.youtube.com/channel/UCK-kLrW3koHSlaD2CP9V27w/), which features two old friends kibbitzing and clearly enjoying each other’s company. They are both key players in the psychotherapy integration movement (along with my colleague and friend, Paul Wachtel). Listening to the podcast made me realize that there is a lot we can learn by thinking through the history of our field.
There are two recent episodes that I found especially stimulating to contemplate, one on the evolution of DBT by Marsha Linehan, and the other on the relation between DBT and CBT:
). Goldfried was a colleague of Linehan’s at Stony Brook (SUNY), and Frances served on the NIH committee that first funded her research. Goldfried emphasizes Linehan’s gifts as a clinician and regards her contribution to research as more modest. Frances also appreciates Linehan as a clinician, stressing that she sought to take on the kinds of patients who others were inclined to ignore. Moreover, Frances suggests that Linehan helped him to evolve from having the standard, biopsychosocial perspective, to adopting the perspective—it is a mouthful—that he names as “biopsychosocialspiritual.”
Originally, Frances informs us that Linehan was interested in parasuicidal behavior, and she had to be encouraged to adopt a broader focus on borderline personality disorder, which helped to disseminate her work and meet with a wider reception. Goldfried suggests that it is the notion of the dialectic that is so critical to Linehan’s approach, as underlying the tension between acceptance and change is the capacity for emotion regulation. Both Goldfried and Frances concur that Linehan inspired the field to take on the most challenging patients and to recognize how difficult this is for therapists (thus, encouraging support groups for therapists). And both concur that creating such a new therapeutic approach was a product of her own history and suffering.
Listening to these episodes about Marsha Linehan’s work led me to pick up her memoir, Building a Life Worth Living, which touts the virtues of DBT, which she emphasizes should be regarded as a different animal from traditional therapy.[i] Linehan is remarkably candid in revealing and reflecting upon her own struggles with mental health as a young woman here.[ii] This memoir juxtaposes a person who endured serious mental illness (including cutting, suicidal attempts, and hospitalization) and who then evolves to become a formidable mental health professional, creating one of the most acclaimed new therapeutic approaches.
Linehan begins with a talk that she was about to give at the well-known Institute of Living in Hartford, Connecticut, where, it turns out, she had been a patient many years ago when she was 17 years old. She spends time trying to explain her state of mind at that moment, worrying that she might break down in tears and relieved to overcome such emotionality. Her account of what happened is surprising in that bits and pieces are introduced as factors, but Linehan throws up her hands at trying to understand what went wrong. She cites amnesia about her own history and does not probe further. It would be impossible in terms of the information that she provides to judge whether the memory loss was defensive, serving to ward off painful emotions, or not. If she experienced traumas of any kind, she chooses not to divulge that information.
During her senior year in high school, Linehan started to withdraw from others and to feel depressed. In the background, she informs us several times that she did not fit in, and that she was overweight. There is sibling rivalry, which was exacerbated by Linehan’s mother. It also seems that while Linehan moves to consider her upbringing to have been invalidating, we do not know if this accurately captures how she felt at the time. In a fascinating interaction, Linehan reports her brother’s opinion that their parents were “very judgmental.” She does not weigh in that she had a different experience; at the same time, she is a bit cagey and does not commit herself to affirm (or denying or offering an alternative point of view). She stops short of naming her environment at home as invalidating, although we are left with that as a strong impression.
Linehan is most comfortable acknowledging her struggle with mental illness as forming the motivation for her to help others. In her words, “But I survived. And toward the end of my time at the institute, I made a promise to God, a vow, that I would get myself out of hell—and that once I did, I would find a way to get others out of hell, too” (p. 7). In another passage, she reaffirms this commitment, and tells us that the “vow has guided and controlled most of my life since then” (p. 29). The messianic urge is inspiring, but we are left with the question of how it fits with Linehan’s other passionate commitment—helping psychotherapy evolve to improve its scientific status.
Before I say more about DBT, I want to take a closer look at how Linehan attempts to overcome her mental problems. It does not seem that Linehan feels that her hospitalization was beneficial. Although she does develop a relationship with a psychiatrist, John O’Brien, to whom she felt connected (and later learns that he feels connected to her, his first patient), she is quite condescending about whether he was able to help her. She suggested that he was curious about the unconscious basis of her behavior, which she dismisses as unscientific and fruitless. Along with the belief that he could not possibly help her, Linehan communicates a more vulnerable wish for help in letters she wrote to him (and includes in the memoir). For example, she bemoans the fact that she has never perceived herself as popular with boys (p. 28) and that she became overweight to avoid competition with her sister (p. 32). Linehan astutely observes how her letters reveal a topcoat and an undercoat in her work with Dr. O’Brien. She appreciates him, but she does not hesitate to conclude that he did not really help her, and that, in fact, no one could help her (p. 41).
Living at home in Tulsa, Linehan sees a psychiatrist, Dr. Proctor, who prescribed medication, which led to a suicide attempt. She decides to move to Chicago and developed the ambition to become a psychiatrist herself (also majoring in psychology). Linehan notes that she developed an interest in Freud, claiming to read everything he wrote (Wow!). She saw a psychoanalyst psychiatrist, Dr. Victor Zielinski. Surprisingly, he recommends against continuing the therapy, based upon Linehan’s lack of interest. Her response is to feel joyous. There is some missing element of reflection in this interaction, as it does suggest a lack of openness on her part to be willing to give herself over to the process.
Once Linehan’s interests shift in the direction of behaviorism, she makes the decision to seek out a behavioral therapist, Allan Leventhal. It turns out that they knew each other from a previous encounter: Leventhal wanted to hire Linehan for an academic position. Linehan suggests that this treatment as successful in helping her address her loneliness and absence of a family. Although it is unclear how Linehan acquired the information, she reports a great deal about her therapist’s experience of the case. Leventhal’s countertransference is wholly positive, perhaps even idealizing. Linehan benefitted from the treatment, as it enabled her to take a bold new step: to accept a job at the University of Washington in Seattle.
The narrative shifts away from Linehan in therapy to Linehan developing herself as a researcher and a seeker through contemplative traditions (like Zen Buddhism). The implication of most of Linehan’s experience in therapy is that it was not effective. In one sense, Linehan seems to be making the point that what she really needed was DBT, although it had yet to be invented. In another sense, Linehan seems to be emphasizing that the only therapy that helped her at all was behavioral. More speculatively, there is an implicit hint that as the founder of DBT, Linehan has been able to cure herself. Linehan is comfortable writing off psychoanalysis as unscientific, and at one point, even expresses the hyperbolic fear that it could have made her worse (p. 41). Whatever the merits of DBT, Linehan is slippery in depicting her experience as a patient and as someone who has had a lifelong battle with mental illness.
In raising questions about Linehan’s experience as a patient, I do not mean to doubt or minimize her contribution to the field. DBT is a treatment approach, which differs from traditional therapy in several respects. The aim is to find a balance between acceptance along with change. The “dialectical” aspect of the approach is to welcome and embrace, not to shrink away from contradiction. It is not just individual therapy, as groups are part of the work. DBT is a particularly effective kind of treatment for people who are suicidal. It gives them the tools to contend with affect storms and to find the way to safety.
Linehan offers some reflection on her identity as a therapist. She ridicules how psychoanalysts avoid telling their patients what to do, stating that she tells her patients what they should do all the time. (She does not acknowledge the friction and resistance that are inevitable in dictating to patients; nor whether, it ever turns out, that she was wrong). Linehan is one of most confident therapists I have ever encountered. For example, she tell us: “Maybe that’s why I’m a good therapist: because I understand how my clients feel” P. 32). And another example: “I am a good therapist; I knew that. And I am charismatic; I knew that, too. I also know that DBT was a good therapy” (p. 304). There is no reason to question Linehan’s talents as a therapist. Nevertheless, I do feel an obligation to note that she omits any specific demonstrations of her clinical work that would support her striking claims about herself. I would add that I prefer the style of the mentalizing therapist who adopts a perspective of not knowing and has ample respect for the opaqueness of the mind of the other.
A certain grandiosity permeates Linehan’s memoir. At times, this can seem almost justified, as Linehan has accomplished a great deal in her career and has been able to walk the talk. At other times, she sounds bizarre: expressing the fantasy of inviting all mental patients in the world to dance with her (p. 330). For much of the time, we encounter Linehan as a lonely figure, someone whose relationships are not sustained as long-lasting and satisfying. One major romantic relationship does not work out. Other close relations break down. She has a number of important but murky relationships with spiritual mentors. Linehan does report a rapprochement with her sister with whom she had so much competition. Linehan mentions, but she does not grapple openly with her difficulty connecting with others. Perhaps, it is too private for a memoir in which there is pride in being a researcher and founder of a new therapeutic approach.
One does not have to be psychoanalytically inclined to notice that Linehan felt rejected by her mother and her father. Her mother communicated the wish for her to be someone else: “Mother saw me as a tulip but desperately wanted to make me into a rose” (p. 54). If Linehan was not going to fit into the categories that are most relevant for her mother, she was not going to be recognized. Without a husband and children, “she didn’t `really like or admire the kind of person I was” (p. 243). Linehan also acknowledges the painful experience that her father with whom she had a good relationship when younger, completely distanced himself from her after the hospitalization. We are left to wonder about connecting how these experiences with her parents affected her.
To some extent, Linehan is content to identify as a victim. She does not choose to reexamine relationships to reflect further on her own role in the dynamic. The mentalizing in this memoir is sparse. Linehan opts to put on a brave face in recounting her life and career. It is immensely to her credit to portray herself as someone whose life has been defined by such suffering. There can be no question how much her work has helped other people, as she hoped to be able to do. But the memoir remains full of shadows, with hints of raw, unexamined emotions swelling toward and away from the surface.
DBT is a treatment that allows us to connect with the most difficult, vulnerable patients. We should be grateful to Linehan for her lifelong commitment to work with such patients. A question that comes to mind, however, is whether and how DBT is applicable to other kinds of patients, people who seek psychotherapy who have milder forms of psychopathology. Given that all of us must struggle to regulate our emotions, and to do so flexibly, we might imagine that DBT can be helpful. Where it might fall short, though, is with the role of the therapist as expert, who tells the patient what to do. Not all patients need this; not all patients would feel comfortable ceding that authority to their therapist. I would note a contrast between DBT and MBT (mentalization based therapy) on this point: MBT therapists might disclose how they feel about something patients have said or done but would refrain from assuming that they are right. Some patients benefit from structure and strong support; other patients need more freedom, a light-handed touch from the therapist, and an unspecified sense of direction.
Keeping patients alive is necessary but insufficient; helping them to thrive is what defines the work of psychotherapy. Promoting communication and dialogue are the true aims of psychotherapy, as I see it, regardless of patients’ psychopathology.
[i] M. Linehan (2021). Building a Life Worth Living. New York: Random House.
[ii][ii]Linehan’s history of mental illness was first reported in a New York Times article by Benedict Carey in 2011: https://www.nytimes.com/2011/06/23/health/23lives.html
Gut Gazooked!