An open mea culpa to Marsha Linehan

borderline musing part n+1

O Fortuna velut luna
statu variabilis,
semper crescis aut decrescis;
vita detestabilis
nunc obdurat et tunc curat
ludo mentis aciem,
egestatem, potestatem
dissolvit ut glaciem.

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Dear Marsha,

I hope you can forgive me for addressing you by your first name. Just kidding. That’s what everyone does.

Though we have never met, I have long felt acquainted with you. In fact, I have been talking shit about you behind your back for almost 15 years.

I first learned about you in 2010, when I was inside a locked psychiatric unit for the very first time at age 13. My memories of this time are a bit hazy, but I remember the phrase DEAR MAN alongside the acronym “DBT” and the name “Marsha”. I remember being too tired to be as incensed as I would have been otherwise by what I felt to be asinine instructions for self-regulation that read as if they were pulled from the manual to an automaton. I figured I should let it go; this was just some stupid hospital class, anyway.

Upon discharge from the hospital, the social worker assigned to my case strongly recommended my city’s DBT program for my continued treatment. My mother and I took a tour of the facility and got to know the curriculum a little bit. Mutually, we politely declined the prospect of weekly group meetings, family involvement, and phone training.

I went on to be hospitalized many more times for my suicidal behavior over the next many years, culminating in a 9 month stay at a residential psychiatric treatment center when I was 20-21. Each hospital I visited, disparate as they were, wanted me to know all about you and your extra special method of treating crazy people. They wanted me to be mindful. They wanted me to know about opposite action. They wanted me to raise my distress tolerance. I didn’t want to tolerate my distress! I wanted to fucking die!

The treatment program at the residential center I was sent to was based largely on attachment theory and family systems theory (not to be confused with internal family systems—as far as I know, no treatment centers lean heavily on that). As useless as the treatment was for me personally for the most part, I think the treatment helped my family, at least a very little bit. I am so grateful that I didn’t wind up in an environment that made me out to be the villain of my family and the world around me, as so many treatments for very distressed people do. That doesn’t mean that I was never made to understand my distress as my fault, though. In fact, there was a therapist at this program who was quite the DBT devotee, so she ran a DBT group. After all, this therapist told us, Marsha herself was borderline, just like us! She invented DBT based on her own experience being borderline! It was in this DBT group that I saw a video of you, Marsha, talking about how you invented the famous DBT “yes, and”. You said that you were driving across the country, and for entertainment you had brought with you some “comedy tapes”. To my recollection, you thought about how the first rule of improv is to always say “yes, and”, and the profound wisdom of the “yes, and” was revelatory, because “and” is inclusive where “but” is exclusive. It would surely help all the young splitters, the young black and white thinkers, to replace the word “but” in their vocabulary with “and”. This would make room for more possibilities and make us black and white thinkers that much more able to think in shades of gray. After seeing this video, many girls in the program went on to replace “but” in their speech with “and”, leading to some very stilted and confusing speech…that was still rife with splitting. I got a special note from my therapist that said I wouldn’t have to go to DBT group any longer.

So the truth of the matter is that I have never really known your work very well at all. I have never experienced DBT “to fidelity”, as some would put it. I have since learned that true DBT, the kind I would have experienced at my city’s DBT center, is so resource- and time-intensive that it is rarely practiced in this day and age. So, I have been fed regurgitated morsels by overworked social workers and self-righteous wannabe gurus and young girls whose problems were amenable to mending by DBT. My exposure to the fragmented, dislocated shards of your work in hospitals has been as poisonous as exposure to free radicals. And so I have been railing against an unflattering composite rendering of you and your work for 15 years now. (Sorry for the mixed metaphor, but your get the point.)

Mea culpa.

Through a circuitous course of events, last year I found myself in possession of your memoir. I gobbled it up, and I put my tail between my legs. As Kernberg himself saw right away, you’re one of us. Not “a borderline”, though some would so characterize you (mostly post hoc). No: a deeply troubled young girl from a well-to-do but suffocating environment that had no idea what to do with her. A least favorite child. A deeply spiritual, sometime deeply religious person. A long-term psychiatric patient on a locked ward—a chronically suicidal, extremely self-destructive patient. An emotionally underbaked young woman with profound interpersonal problems. A rich girl by birth who lived in or near poverty for years in her early adulthood. You were all these things, and you found your way out, through many further trials and tribulations.

There really aren’t that many of us in the world, by my estimation, who experience such profound distress and adversity (much of it from within) who go on to build rich, full lives. I have known a lot of former psychiatric patients. There are plenty who go on to live lives worth living, to use your parlance, but they usually didn’t have symptoms as acute as yours. There are plenty who have symptoms as acute as yours, but they usually don’t go on to live lives worth living, if they go on to live at all. I am honestly amazed and inspired and moved by your story, when I allow myself to really feel into it. I can so easily understand why you went on to dedicate your life to helping others follow in your footsteps.

And I’m so sorry for talking shit about you when I didn’t know what I was talking about. (Not that you knew I was talking shit or will ever even know who I am, but still…I apologize for sending negative energies your way.)

I used to think, “Wow, the borderline queen Marsha. What, did she yell at her kids or husband or something? How borderline can she really be? She can’t have ever suffered like I am suffering.”

I don’t know why I thought this. I guess people find it hard to believe that functional, competent adults could have suffered the depths of hell. People especially think this way when the functional adult in question is presenting herself as an expert in suffering. And to some degree, they are right to think this, like I said above. But they are not always right. I also think maybe I was so in love with my own suffering that I thought no one else could possibly know it or anything like it—all pain hurts the most.

Plus, Marsha, most of the stuff they make us difficult patients do is SO STUPID. No only is it stupid and unhelpful more often than not, it is often so harmful. You know this better than I do, with your time at the Institute of Living at a time in history when many more physical interventions were common. I have never been plunged into an ice bath to make me stop freaking out, for example. After a long enough time of being harmed in the name of help, you develop a reflexive mistrust of Help, like an abused dog who will bite your face off if you try to remove a thorn from his foot.

Also, I hate to say this, but I think some of your devotees made your modality stupid. My personal conviction, based on observation of various gurus and modalities, is that whatever wisdom is in a given modality is actually mostly in the practitioner. I believe that you have helped patients, I believe that Otto Kernberg has helped patients, I believe Janina Fisher has helped patients, to name a few. I don’t believe that many of their trainees help patients with anything like the frequency or degree of efficacy that the teachers did. (I once had a therapist who was trained by Janina Fisher herself who did some of the stupidest therapy on me that I’ve ever received, and I’ve received plenty. You get the point.) Most people who say they do DBT don’t do the real thing, and this would be true even if DBT to fidelity weren’t so intensive and difficult to practice—something here about maps and terrain. DBT seems, based on the pedestrian knowledge that I have, to be a wise modality based not only on Scientific Evidence, but on your own experience surmounting the insurmountable. Good luck putting that in a manual and having it withstand MSWs who have never really suffered.

Then, of course, there’s the borderline wrinkle. As I have learned in my own public-facing work (to say nothing of my long Mental Health Journey), the minute that the word “borderline” enters the chat, even the sanest people lose their minds. My idea that you set out to treat borderline patients immediately biased me against you—some might even say it split me.

So I find it all the more interesting and poignant that you set out to make a treatment especially for very suicidal patients, and the zeitgeist metabolized that patient group as a borderline group. The only patients who are that dysregulated MUST be borderline!, the story goes. You did not have such a patient group in mind. Borderline personality disorder didn’t even exist as a diagnosis until you were in your mid 30s.

And yet, most of the people I personally know who have been successfully treated with true DBT are not borderline and could not reasonably be considered borderline, nor are they suicidal to a clinical threshold. They are people who have experienced single-event traumas, or people whose cognition is otherwise warped in a way that is easily self-perceived, because those are the kinds of people who are often helped by psychotherapy.

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Sors immanis et inanis,
rota tu volubilis,
status malus, vana salus
semper dissolubilis,
obumbrata et velata
mihi quoque niteris;
nunc per ludum dorsum nudum
fero tui sceleris.

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I will probably never familiarize myself with the right and proper DBT. I think that I have learned a lot of the skills that DBT seeks to teach via other means. I have no interest in trying DBT, and because I don’t know enough about it, I could never recommend it in good conscience. I think the negativity that I still hold toward DBT is the same negativity I hold toward all manualized treatments, and to a lesser degree, toward mind-work and the psy-disciplines as a whole. It’s an ambivalent negativity that’s born of suspicion that I earned goddamn honestly. I know you can sympathize with that. I know that’s at least part of why you eschewed the psychoanalytic tradition of your day and opted instead for the shiny new behaviorism, with its promise of scientific rigor and a strong evidence base. I understand the feeling of rejecting like a bad skin graft everything that harmed you in the name of help, and being so sure that what needs to be done more than anything is to shift the paradigm of the day. In a way, I admire that feeling of conviction, and I miss it. I find myself in a place of resignation, where it feels like the treatments we have now are the best we will ever have, because the kind of serious distress that DBT seeks to assuage are so hard to treat as to be nigh impossible. In other words, as negatively as I feel toward the idea of DBT, I know it helps some people some of the time, and that’s the best we can ask for, and I’m so mad that that’s the best we can ask for, and I don’t like feeling mad, so I just try to let it go.

You built a life worth living. Sometimes I feel like I was dropped from an excruciatingly painful life into a happy one worth living. I feel like I got better almost by accident. I know that the choices I made and the people I surround myself with (and the ones I don’t!) have something to do with it. I have written at great length before about the things that didn’t help me get better. As for the things that did, well, they are somewhat mystifying and mystified. Aside from the commonsensical good circumstances I chose (to the extent you can choose your circumstances), I have to chalk up my recovery to the Wheel of Fortune. This wisdom is actually embedded in DBT. Things just happen, and peace can only come when you really, really accept that. In my case, some good things ultimately happened to me. I recognize that it’s not very agentic of me to put it that way, and some would be eager to see that as evidence that I am borderline and have always been borderline. You and I know that taking things as they come is the only choice we have.

Marsha, I hope you can read these words not in the spirit of harsh criticism, because they aren’t intended that way. I hope you can see that though we are 50 years removed from one another, we are living very similar lives, and such a life includes a fiery temperament, a healthy skepticism, and a desire for the ever-elusive truth. I am ultimately so grateful that you have done the work that you have and have chosen to tell us your story.

Sincerely, and with admiration,

Sorbie Richner

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Sors salutis et virtutis
mihi nunc contraria,
est affectus et defectus
semper in angaria.
Hac in hora sine mora
corde pulsum tangite;
quod per sortem sternit fortem,
mecum omnes plangite!