On The Borderline

How a Zen-friendly psychologist revolutionized the treatment of patients once thought hopeless.Katy Butler

© Jerry CookeOn the morning of September 21, 1993, a shy and intelligent American woman who had never practiced Buddhism took an elevator to an upper floor of Duke Medical Center in Durham, North Carolina. Her name was Susan Kandel, and she was 37. Panicked and miserable because her trusted therapist had recently moved to another state, she walked onto an open breezeway and jumped, expecting to fall ninety feet to her death. She landed instead on a maintenance workers’ platform forty feet below and was taken to the emergency room with three broken vertebrae. A month later, wearing a body brace but not paralyzed, she was involuntarily committed to John Umstead state psychiatric hospital, an aging brick building on the outskirts of Durham, N.C. 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 hospital and her seventh serious suicide attempt. She had been given the damning psychiatric diagnosis of Borderline Personality Disorder as a teenager and had spent much of her life 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 had discovered at 17 that cutting her forearms with razor blades made her feel somewhat better. At 19, she was sent to a mental hospital for the first time and there she first tried to kill herself.

Nearly two decades passed and therapy fashions changed, but nothing made any appreciable difference—not shock treatment, talk therapy, or psychiatric drugs; not self-medication with sex, wine, or cannabis. At 35, a few weeks before a scheduled oral presentation for her Ph.D thesis in molecular biology at Duke University, she drove alone to the North Carolinia shore, shoved a bureau against her motel room door, and swallowed chloroform, more than 25 times the lethal dose. Two days later, she was discovered in a coma and sent for her first long stay at John Umstead state hospital—the place to which she was returned after she jumped from Duke Medical Center two years later.

By then, 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, “ she says. “Guns are foreign to me, and I knew I couldn’t get a license even if I’d wanted one. I decided that 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.”

That fall, she was forced to take part in a psychotherapy that integrated western behaviorism with Zen, mindfulness practice, and what its developer, Marsha Linehan, a Catholic psychology professor and Zen practitioner, called wise mind and radical acceptance. Ten months later, Kandel left the hospital. In the eight years since, she has never come close to being re-hospitalized or to killing herself.

It is October 5, 2000—an overcast day in Seattle—and the Art Deco ballroom of the Edmund Meany Hotel is crammed with psychotherapy’s ground troops—social workers, psychologists and case managers from agencies and HMOs throughout California and the Pacific Northwest. On the dais stands Marsha Linehan, a psychologist and researcher at the University of Washington and an upright, energetic woman wearing a bright silk scarf over a dark dress. She holds a wooden striker in front of the bronze bowl of a Densho bell used in Zen centers to announce the start of meditation.

“We are going to work on the first mindfulness skill, which is observing,” drawls Linehan, a native of Oklahoma, in a voice equal parts authority and honey. “Usually we think of meditation as relaxation, as feeling better. But it’s not necessary to get calm, comfortable and soothed. The idea is to try to do only one thing at a time. Just notice the sound.” She strikes the bell gently, drawing out a warm velvety hum that vibrates heart and stomach from the inside. Then she rattles her wooden striker across its dimpled surface and strikes again, hard, with a clattering clang, so that people nearly jump. Wake up, wake up, the bell says. Pay attention.

The room is quiet, the therapists focused. But this is no mindfulness retreat: they’re hear to learn Linehan’s Dialectical Behavior Therapy (DBT), now widely believed to be the most effective way to treat people like Kandel, diagnosed with borderline personality disorder.

The term borderline—originally used in 1938 to describe clients supposedly “on the borderline” between psychosis and neurosis—has become a code word for clients that many therapists avoid because of the pity, anger, hopelessness and fear they can arouse in those who try to help them. Think of the people Freud called “hysterics,” like Dora and the Wolf Man; think of the alcoholic, dishonest and fragile Blanche Dubois in A Streetcar Named Desire, eternally dependent on “the kindness of strangers.” Think of Marilyn Monroe—sexually abused as a child and abandoned by her psychotic mother—forever wandering into exploitative relationships, a walking victim. Think of Alex Forrest, the seeming self-sufficient Manhattan book editor played by Glenn Close in Fatal Attraction—careening from seduction to loneliness; from wrist-slitting to stalking and vengeance. On a very bad day—when you are trying more frantically than usual to cling to what you think makes you happy and push away what you think makes you miserable—think of yourself.

Seventy-five percent of “borderlines” have a history of childhood sexual abuse, and others survived other forms of trauma. Seventy-five percent are women. Many try to kill themselves. Nine percent succeed. Psychotherapy had little to offer them until 1991, when the scientifically authoritative Archives of General Psychiatry published a study by Linehan of her federally funded work with twenty-two self-destructive Seattle women. All 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; garroting themselves; burning themselves with cigarettes and lighters. After four months of DBT therapy that included weekly training in mindfulness and interpersonal skills, fewer than half continued to harm themselves, compared with roughly seventy-five percent of a comparison group of twenty-two treated by other Seattle therapists. By the end of the year, they had harmed themselves significantly less than the control group and spent significantly fewer days in mental hospitals.

Since then, more than 100,000 therapists have bought Linehan’s psychological texts, and tens of thousands have taken her introductory DBT training. Perhaps the most articulate advocate for borderline individuals ever to appear in the mental health field, Linehan—previously a little-known researcher—turned out to have an uncanny knack for explaining the borderline’s inner world in terms anyone 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 were raised in families where their extreme sensitivity was routinely laughed at, criticized, or ignored. This had bred profound self-distrust, a tendency toward extremes and pervasive “emotional, behavioral, interpersonal and cognitive disregulation.”

Therapy, she wrote, repeated the pain of the invalidating family when it offered insulting interpretations, ignored cries of distress, or inadvertently rewarded tantrums or suicidality with extra attention or hospitalization. In an unconscious echo of the Buddhist notion that there is no fixed and permanent self, borderline individuals, she wrote, had huge deficits in life skills—not deficient personalities. Teaching them better ways to manage their moods and cope with the world, she theorized, would reduce their self-destructive behavior.

This could be best accomplished, she suggested, by pairing therapy with a weekly “skills training” class that blended Western assertiveness training with Eastern mindfulness. Her manual for the classes (vetted, she says, by two of her Zen teachers) includes mindfulness exercises and lengthy quotations from Thich Nhat Hanh on “washing the dishes just to wash the dishes.”

The work is scrupulously grounded in Western behaviorist psychology, but Linehan, ever an experimental scientist, continues to throw in anything that might work. On the second morning of her workshop in Seattle, for instance, her Densho bell gives way to Greek music and she makes the therapists execute the intricate steps of the hora. “Throw yourself into it!” she urges, as people sway back and forth in more or less graceful lines, practicing “one-mindfulness” and “wholeheartedness.” “Your job is to learn the skills yourself,” she says. “If you can do them, you can teach them.”

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