On the Borderline

An article by Katy Butler which appeared in Tricycle: the Buddhist Review, Spring 2002 issue. (c) 2002 Katy Butler. Excerpt reprinted by permission of the author.

On the morning of September 21, 1993, a shy and intelligent American woman took an elevator to an upper floor of Duke Medical Center in Durham, North Carolina. Her name was Susan Kandel, and she was thirty-seven. 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 Hospital, a psychiatric facility housed in an aging brick building 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 Susan Kandel's fourth commitment to John Umstead Hospital and her seventh serious suicide attempt. She had been given the damning 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 seventeen that cutting her forearms with razor blades made her feel somewhat better. At nineteen, she was sent to a mental hospital for the first time, and there she first tried to kill herself.

Nearly two decades passed. 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 thirty-five, a few weeks before a scheduled oral presentation for her Ph.D. thesis in molecular biology at Duke University, Kandel drove alone to the North Carolina shore, shoved a bureau against her motel room door, and swallowed chloroform, more than twenty-five times the lethal dose. Two days later, she was discovered in a coma and sent for her first long stay at John Umstead Hospital-the place to which she was returned after her jump from the breezeway at Duke Medical Center two years later.

By then, Kandel 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 who had studied Zen, 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 rehospitalized or 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, 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 here to learn Linehan's Dialectical Behavior Therapy (DBT), now widely believed to be the most effective way to treat people who, like Kandel, are diagnosed with borderline personality disorder. The term borderline -originally used in 1938 to describe clients supposedly "on the borderline" between neurosis and psychosis-has become a code word for clients whom 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 seemingly 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 have 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 authoritative journal 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 had been raised in families where their extreme sensitivity was routinely laughed at, criticized, or ignored. This bred profound self-distrust, a tendency toward extremes, and pervasive "emotional, behavioral, interpersonal, and cognitive disregulation."

Therapy, Linehan 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, she wrote that borderline individuals did not have fixed, deficient "personalities"-just huge but remediable deficits in life skills. Teaching them better ways to manage their moods and cope with the world, she theorized, would reduce their self-destructive behavior.

This could best be 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 a mediterranean folk dance. "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."

"The skills" turn out to be a bewilderingly promiscuous gumbo of attitudes, emotional techniques, and psychosocial skills that seem, at first, self-contradictory: behaviorist "diary cards" and folk dancing; radical acceptance of things as they are and assertiveness skills for changing them; "distress tolerance" and "emotion regulation" for facing fears head-on; the measured deliberation of writing out lists of pros and cons before acting. Nobody is playing with a full deck, she suggests, and skills training provides the missing cards.

Linehan sometimes jokes that she could have named her treatment "Zen Behavior Therapy," but it wouldn't have been a good career move. Instead, she called it Dialectical Behavior Therapy, a reference to the propositions elaborated by the nineteenth-century German philosophers Immanuel Kant, G. W. F. Hegel, and Karl Marx. "Dialectics" is a Western description of the notion that there are two sides to every coin, and that the coin cannot exist without them. Every extreme in thought and in the world calls forth its opposite and points the way to a synthesis or reconciliation. Dialectics perceives the world as an eternal dance of related opposites, like the black and white Taoist fish chasing each other on the ying-yang symbol; as in the Heart Sutra, form and emptiness interpenetrate each other and make a single whole. Humorous and wide enough to cope with paradox, Dialectical Behavior Therapy-like a good Zen teacher or life itself-sometimes simply holds contradictions in balance rather than integrating them. "You're perfect as you are-and you've got to change," Linehan tells the therapists, echoing the question investigated by Soto Zen master Dogen: If all beings have Buddha nature, why do we need to practice? (Or the koan: If the wind is always blowing, why do we use a fan?) "That," Linehan goes on, "is the essential dialectic of the treatment." . . .

To read the rest of this article, please see the Spring 2002 issue of Tricycle.

About the article's author: Katy Butler is a journalist, editor, and writing coach in Mill Valley, CA. Her writings on Buddhism have previously been published by the New Yorker, Yoga Journal, the Whole Earth Review, Common Boundary, and the New York Times Sunday Book Review. A version of "On the Borderline" appeared in May 2001 in Psychotherapy Networker magazine. "(c) 2002 Katy Butler.
Excerpt reprinted by permission. "

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