KELLIE NEWSOME: On working days, she was a scientist. After hours, a spiritual seeker. In her youth, she was known as the most disturbed patient in a large psychiatric hospital. We look at how Marsha Linehan built a therapy for borderline personality out of these broken pieces. Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.

KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. On April 30th, 1961, a seventeen year old Marsha Linehan, was brought by her parents to the Institute of Living, a psychiatric hospital in Hartford, Connecticut. Her symptoms were not of the type that would get you into a hospital today: depression, withdrawal, tension, and headaches, but they were a change from her. The girl she was, Marsha, was active and popular in high school, elected to leadership, and voted queen of the junior class ball. Her yearbook speaks of her empathy, good spirits, and high ideals. Now, just weeks from her high school graduation, she found herself in a psychiatric ward, on the outside, a rolling lawn landscaped by Frederick Law Olmsted, the architect of Central Park, but the inside was dark and lonely, and it was about to get worse.

CHRIS AIKEN: Marsha had never injured herself before, but within days of admission, she broke her glasses and cut her wrists. She's not sure where she got the idea to do it. Cutting spreads like a contagion in long-term facilities. It releases endogenous opioids, giving instant relief to the emotional pain, but the hospital had a protocol, and Marsha was carried on a stretcher to the locked ward. It was no longer just dark and cold. She was now surrounded by the smell of urine and feces and the screams of patients who broke out into physical fights. The urge for relief grew, and she broke a window to slash her arms and midsection with shards of glass, burned herself with stolen cigarettes. They moved her then into the seclusion ward, where, with no means to a weapon, she banged her head against the walls and floor.

KELLIE NEWSOME: What was supposed to be a brief stay turned into months, and then years, antipsychotics, sedatives, antidepressants, cold pack therapy, and ECT. Nothing brought relief. She felt compelled to self-harm, as though driven toward suicide by an external force. In her words, “My whole experience of these episodes was that someone else was doing it.” “I felt totally empty, like the Tin Man. I had no way to communicate what was going on. No way to understand it.” After two years of involuntary commitment, Marsha knelt in the hospital chapel and made a promise to God.

CHRIS AIKEN: Kneeling in the hospital chapel, Marsha vowed to “Get myself out of hell and help others get out too”. Marsha Linehan did get out and spent the next three decades developing a therapy that would transform the locked ward at the Institute of Living and similar hospitals around the world. This is her story, much of it drawn from her memoir, Building a Life Worth Living. It gives us an inside view of borderline personality, revealing some of the strengths that we don't get to see much in the treatment setting. And along the way, you're going to learn a few DBT skills.

KELLIE NEWSOME: After leaving the hospital, Linehan lived in hostels and YMCAs, took secretarial jobs, suffered relapses into self-harm, attended regular Catholic Mass, and eventually found direction in the same place that helped her get out of the hospital, the church. While praying in chapel, she felt a golden hue infused the sanctuary as she looked up at the cross. “Suddenly, I felt something coming toward me. 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.”

CHRIS AIKEN: Linehan turned that experience of unconditional love into the core DBT skill of radical acceptance. It forms the backbone of every step in DBT, validation, acceptance before change. Her idea was that borderline personality disorder developed out of invalidating environments. Trauma, by its nature, is invalidating. But Linehan also pointed the finger at smaller invalidations that wear people down over time, like when your parent tells you that you're overreacting or too sensitive, phrases like, “Stop crying about your dead goldfish. It's not like you lost a friend.” “You make yourself miserable.” Or, “Why would you want to go to art school? There's no future in that.” When you've been told not to be yourself your whole life, the last thing you need is a therapist telling you, you need to change. So we start with acceptance, and by accepting the patient as they are, we model a new way of relating to themselves. We say things like, “The pain you're having makes sense. You can let the pain be there without attacking yourself for having it.” Or, “Try noticing the sadness without pushing it away or acting on it. See what happens if you just allow it.” We help patients see that their attempts to end their suffering, to change what cannot be changed, are only making their suffering worse. After acceptance, change becomes possible.

KELLIE NEWSOME: It sounds straightforward, but where Linehan ran into controversy was with suicide. How do you validate someone who's about to jump off a bridge or burn their skin? Critics argued that Linehan was encouraging dangerous behavior by saying things like, “Given everything you've been through, it makes sense that you're having suicidal thoughts at this moment.” To her critics, that kind of validation could reinforce pathology in borderline patients. Psychoanalysts warned that too much empathy is toxic to borderlines, causing them to adopt a victim mentality and become dependent on the therapist. Empathy draws them closer to the therapist, but the closeness is frightening, causing them to explode into rage or self-destruction. But this was a misunderstanding. Linehan didn't rest with validation alone. She was firm with patients, guiding them to take responsibility, face their fears, and live more effectively in the world. Validation came first, but it was paired with behavioral change. DBT therapists pay close attention to the ways that they reinforce their patients’ behavior, in destructive or in constructive ways.

CHRIS AIKEN: Linehan learned this last idea from her own experience in the hospital, where suicidal acts were the only way that she could exert power in that structured environment. It got her the attention of caregivers, and it got her into the seclusion room, where she actually preferred to be rather than the chaotic wards. The hospital structure was reinforcing her problem. Toward the end of her stay, this started to change as she got a new doctor who took a different approach.

KELLIE NEWSOME: “Dr. O'Brien came to see me, sat down and said, ‘We need to have a talk.’ His tone was completely different from what I had grown accustomed to—much sterner in a way. “Well, Marsha, I have finally accepted that you might kill yourself,” he continued, “and if you do, I'm going to have one Mass said for you, and I'm going to say one rosary for you.” “I was aghast. ‘What do you mean? You're not going to come to my funeral?’ ‘No,’ he said. ‘I'm on my way out of town. I'm going to be gone for two weeks, and I hope you're alive when I get back.’ Okay. Then he left. “I became completely hysterical. I cried uncontrollably and had to be restrained.” Dr. O'Brien's emotional withdrawal had a big impact on me. I had been in an environment where no one could effectively help me, so the only thing I could do was try to get them to try harder; trying to kill myself, or obsessively dwelling on it, as I did, had the effect of getting people to help me more. It wasn't a conscious strategy on my part, and I don't think it is a conscious strategy in most people who repeatedly threaten suicide, but I now suspect that my suicidal behavior was likely being reinforced by increased efforts to help me.

CHRIS AIKEN: Linehan put those lessons into action when she first started working with suicidal clients as a young therapist.

KELLIE NEWSOME: “When you become afraid that a client might commit suicide, you become anxious, and as your anxiety increases, your urge to control the client increases too. I eventually learned that trying to control a suicidal person often makes them worse, not better. Instead of reducing dysfunctional behavior, trying to control it can reinforce or promote the behavior.” 

Let's pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes. 

1. How would a DBT therapist respond to a patient who calls after self-cutting? 

A. Reinforcing distress tolerance skills 

B. Exploring the meaning of the self-harm 

C. Directing the patient to the hospital 

D. Increasing the frequency of supportive sessions

CHRIS AIKEN: In 1971, Linehan earned her PhD in psychology from Loyola University in Chicago. Borderline wasn't a concept just yet, so she set out to help severely suicidal patients, borrowing an idea from her behavioral training that fit with her own experience in the hospital: contingency management. It's an awkward term for something better known as shaping. The therapist is constantly aware of what they are reinforcing in the client, seeks to reinforce adaptive, skillful behavior while doing the opposite with dysfunctional behavior. So you reinforce what is effective and don't reinforce what's not, all the while validating the patient's experience. Here's how that looks in practice. When a borderline patient calls you for help after self-cutting, you don't reinforce the cutting. Instead, you focus on the skills, asking, “Let's pause a minute and back up. What skills did you try before you got to this point?” If they didn't put much effort into the skills, you keep the phone call short, reminding them of skills to use for distress tolerance and advising them to call you if they need help troubleshooting those skills.

KELLIE NEWSOME: Linehan's students had another word for this: reinforcement blackmail therapy. Here's how she described its origins: “Once I had a good relationship with a client, I would use it as a reinforcement by increasing warmth toward the participant following effective behaviors, or emotionally withdrawing it as a negative consequence of dysfunctional behaviors. “With suicidal clients, I would generally start by asking if they believed that they would be happier if dead. They seem to think that their suffering would end if they killed themselves. I'd point out that there were no data proving that was true. There are religions that believe if you kill yourself, you will go to hell, and others that believe you will have to live your whole life all over again. That could keep me from doing it.”

CHRIS AIKEN: By this time, in the late 1970s, Linehan was starting to sway from the Catholicism that guided her since childhood, when she tried to emulate the saints, particularly Saint Agatha, the patron saint of rape victims. Saint Agatha chose to have her breasts cut off in prison rather than give up her Christian vow of virginity and sleep with an imperious Roman commander. For Linehan, the breaking point was misogyny. While singing in the Christmas Mass in December 1980, she was struck with the blatant sexism of the Christian songs. The lyrics called on all good Christian men to rejoice, or sang that Mary bore to men a savior. Marsha wrote a letter to the priest calling it out.

KELLIE NEWSOME: “Non-inclusive, male-oriented language, a God only called Lord, Father, or the masculine ‘He, Him,’ liturgies on holy days with an array of ordained men arranged around an altar, suggest little awareness or concern for the needs, cares, rights, and value of women.” Linehan stopped going to Mass, but she had one more lesson to draw from Christianity. Around the time of the break, she studied contemplative prayer at the Shalem Institute for Spiritual Formation in DC, a non-denominational group that was nonetheless steeped in the Christian tradition. She met Gerald May, a psychiatrist who was working to bring meditative practices into his therapy. May told her about willingness, which he defined as saying yes to the mystery of being alive in each moment. The opposite of willingness is willfulness, that stubborn my-way-or-the-highway attitude that tries to control reality. Willfulness demands that you are always right. Willingness accepts reality, goes along for the ride, and is open to what life brings.

CHRIS AIKEN: At this time, Linehan was slowly building the structure of DBT, but she was doing so in halting motions. She would have sudden bursts of insight like the ones we described in the church services, interspersed with long periods of stagnation. Willingness was different. The idea took her further. It created an iterative process that could sustain the kind of transformation she previously had only glimpsed in those moments of spiritual exaltation. Here's how she described this iteration, which she calls Turning the Mind.

KELLIE NEWSOME: “It's a little bit like walking down a road, and you keep coming to forks in the road, one direction, accepting; the other direction, rejecting. Turning the Mind is when you keep turning your mind toward the acceptance road. It can be very hard. You have to practice over and over and over. “It's like walking through a fog, seeing nothing, nothing, nothing, and then suddenly you emergeinto sunlight. The good news is that if you practice turning the mind toward acceptance, eventually you'll practice acceptance more often. And if you do that, what happens? Suffering gets less intense. Suffering goes down to being ordinary pain.”

CHRIS AIKEN: As Marsha practiced willingness, she found herself wanting more, so she reached out to her friends at the Shalom Institute. They recommended Shasta Abbey, a Zen Buddhist monastery in California. It was 1983, and Linehan had little more than a passing awareness of Buddhism. But that was about to change as she drove to the high mountains of Northern California. Next week, we'll learn how she refined the core skills of DBT and confronted the psychoanalytic establishment.

KELLIE NEWSOME: Need a quick way to catch up on psychiatry? The fifth edition of Psychiatry Practice Boosters is out, featuring 66 of the most clinically relevant studies in psychiatry from the last three years, curated and explained by Carlat's research editor, Jesse Koskey.