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2001 May/June (2)

Friday, 26 December 2008 12:00

Revolution on the Horizon

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Revolution on the Horizon

DBT Challenges the Borderline Diagnosis

by Katy Butler

On the morning of September 21, 1993, a 37-year-old former graduate student named Susan Kandel took an elevator to an upper floor of Duke Medical Center in Durham, North Carolina, where she was attending a day treatment program. She was panicked and miserable: her therapist had recently moved to another state, and she was about to leave agency-supervised housing to look for her own apartment.

She went to a breezeway connecting two wings of the building and jumped, expecting to fall 90 feet to her death. She landed instead on a maintenance workers' platform 40 feet down and was taken to the emergency room with three broken vertebrae. A month later, still in a body brace but not paralyzed, she was involuntarily committed to John Umstead State Hospital, an aging two-story brick mental hospital in Butner, 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 her fourth commitment to John Umstead State Hospital, and her seventh serious suicide attempt. Two years earlier, facing an oral presentation for her Ph.D. in molecular biology at Duke, she had driven to a motel room on the North Carolina shore and swallowed 250 milliliters of chloroform--more than 25 times the lethal dose. Two days later, she was discovered in a coma, with a hole in her esophagus and her liver badly damaged; when she recovered sufficiently, she was committed to John Umstead for her first long stay.

Kandel had been given the most reviled diagnosis in the therapeutic lexicon--Borderline Personality Disorder --when she was 20. A brilliant but withdrawn college student, she had spent much of the next 17 years turning on a wheel of suffering from suicide attempt to mental hospital to halfway house to suicide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 discovered at 17 that cutting her forearms with razor blades made her feel somewhat better. When she was 19, she was sent to a mental hospital for the first time, and there she took her first pill overdose.

The years passed, and therapy fashions changed, but no treatment made any appreciable difference: not five-times-a-week psychodynamic talk therapy, nor electroshock, lithium, librium, tricyclics or antipsychotics. By the time she returned to John Umstead hospital in a body brace, 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 because I'd been rescued so many times," she remembers. "Guns are foreign to me, and given my history, I knew I couldn't get a license even if I'd wanted one. 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."

Then, in November 1993, Kandel was required to take part in a radical new treatment for borderline personality disorder called Dialectical Behavior Therapy (DBT). She left the hospital 10 months later, and in the seven years since, has never come close to being rehospitalized or to killing herself.

A Code Word for Trouble

Long before the ambiguous and insulting term was coined by a male psychoanalyst 60 years ago, the people we now call "borderlines" were public health nightmares, islands of intractable misery, and the bane of many a psychotherapist's existence. A century of shifting diagnostic labels and rising feminist sympathies cannot paper over therapy's signal failure with them.

Seventy-five percent are women; and about an equal percentage of all clients diagnosed as borderline report a history of childhood sexual abuse--three times the rate of clients given other diagnoses. Many try to kill themselves and nine percent succeed. Their numbers include the volatile and damaged people that Freud called "hysterics" and treated with little success at the turn of the century, like Dora and the Wolf Man; others who deteriorated in classical psychoanalysis and were described in 1938 by psychoanalyst Otto Stern as "on the borderline" between psychosis and neurosis; and still others treated with equally mixed results in the 1980s by feminist therapists who dropped the borderline label in favor of the less pejorative term trauma survivor.

Today, the DSM-IV coolly defines Borderline Personality as an Axis II character disorder marked by "instability of interpersonal relationships, self-image, and affects, and marked impulsivity." Listed symptoms include "frantic efforts to avoid real or imagined abandonment"; episodes of depersonalization and dissociation; oscillation between idealizing and denigrating others; suicidality, self-mutilation, loneliness, anger, and inner emptiness; and "impulsivity in at least two areas that are potentially self-damaging (e.g. spending, sex, substance abuse, reckless driving, binge eating)."

But in therapists' private argot, "borderline," accompanied by much eye-rolling, has long been the shorthand for clients who never got beyond the crisis du jour--clients like the fragile and alcoholic Blanche Dubois of A Streetcar Named Desire, eternally dependent on "the kindness of strangers." They are clients reminiscent of Marilyn Monroe (who was removed from the care of a psychotic mother and sexually abused in childhood), ever wandering into exploitative relationships and never able to protect themselves.

"Borderline" was a code word not for a person but a relationship--a therapeutic double-drowning. It tagged practically any client who terrified, enraged or repulsed her therapist--like Alex Forrest, the seemingly competent Manhattan career woman played by Glenn Close in Fatal Attraction, who flew into rages, slit her wrists and stalked her married lover when he tried to leave her. Or Bob, the "human crazy glue" played by Bill Murray in What About Bob? who tracked his stuffy psychiatrist to his summer home and drove the shrink so crazy he tried to blow up Bob with dynamite. "Borderlines" were the terrorists of the therapeutic hour, the people with "no boundaries," the experts in the tyranny of the weak.

"I won't work with them anymore. There was so much effort for so little result," says one psychologist who still remembers two clients who made him tear out his hair at an agency in Maine in the early 1980s. One man frequently threatened suicide and called him collect to say things like You cocksucker, you don't care about me, this is just a job to you. (That client later threw hot coffee on a therapist's new suit.) Another--a breast-cancer survivor--secretly taped her sessions, demanded copies of clinical notes and showed up unannounced at his home office, unnerving him so much that he once told her, You're too mean to die. "You could pay me three times what I make now," he said recently, shaking his head, "and it still wouldn't be enough."

No Emotional Skin

In the decades since, most clinicians who had a choice avoided borderline clients, while agency staff (who couldn't) went through the motions with a sense of futility.

Some adopted a psychoanalytic view, blaming the disorder on disturbances of mother-infant attachment or a "constitutional excess of aggression." Therapy consisted of guarding against "manipulation" and mining the borderline's reactions to the therapist for clues to her fragmented  inner world. It was hard on clients--and on therapists as well. "We made too much of an assumption that if we directly understood the patients' conflicts and made correct interpretations, they would know how to say no, or stand up to somebody or go through a job interview," says psychiatrist Charles Swenson, a former prote´ge´ of psychoanalyst Otto Kernberg. "Role -playing or teaching [a behavioral skill] was considered a no-no, because it would create a different type of transference, where the person would become dependent on you and develop false hopes."

Other clinicians adopted a feminist, trauma-focused view, concentrating on client histories of sexual and physical trauma--with equally mixed results. "I count myself among the many who thought that by excavating all those stories and memories and feelings we were freeing ourselves and our clients," says psychologist Dusty Miller, the author of Women Who Hurt Themselves . "The truth is, for a lot of people, the pain got worse, the rage got worse and people weren't given coping skills," she says. "Definitely, people got worse."

Then, in 1991, a study published in the Archives of General Psychiatry (one of psychiatry's most influential journals) challenged this pervasive pessimism. The article reported on a small, NIMH-funded, randomized clinical trial that showed dramatic improvement among 22 borderline, suicidal and severely self-harming women. The lead author and researcher was not a psychiatrist, but a behavioral psychologist and Zen student at the University of Washington named Marsha Linehan; her treatment was called Dialectical Behavior Therapy, or DBT.

All of the women in her study 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; burned themselves with cigarettes and lighters; and even garotted themselves severely enough to risk death, unconsciousness and hospitalization. But after four months of treatment, fewer than half were still harming themselves--compared with roughly three quarters of a control group of 22 equally self-punishing women given "treatment as usual" by therapists in the Seattle community. Over the course of the year, the DBT women steadily improved, spending significantly fewer days in mental hospitals and engaging in fewer suicide attempts and parasuicides. Tiny as it was, and limited though the improvement had been, the study established DBT as the only treatment for borderline suicidality ever validated by a randomized clinical trial published in a peer-reviewed journal.

At the core of the treatment was a set of behavioral techniques Linehan called a "technology of change," balanced by a "technology of acceptance"--a soft, almost mystical, Asian emphasis on "radical acceptance" and exercises for calming the mind by following the breath. The women had been taught how to tolerate difficult situations--and their own intense emotions--by using mindfulness-meditation practices and cultivating radical acceptance. Paradoxically, they had also learned assertive Western social skills, such as "interpersonal effectiveness," to get their needs met, and "behavioral chain analysis" to find out exactly what had sparked their desires to kill themselves.

DBT was no walk in the park: it required team treatment, including weekly individual therapy, a year-long "skills training" class, telephone coaching and supportive supervision for the therapist. But it offered clients and therapists alike a way out of chaos--a systematic clinical package that integrated the technical and analytical strengths of behaviorism, the subtleties of Zen training, the warmth and acceptance of relationship-centered therapies and the often undervalued power of psychoeducation.

Perhaps the most articulate advocate for borderline individuals ever to appear in the mental health field, Linehan turned out to have an uncanny knack for explaining the borderline's inner world in terms that professionals 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 hypersensitivity had been routinely discounted. This had bred profound self-distrust, a tendency toward extremes and pervasive "emotional, behavioral, interpersonal and cognitive disregulation."

Therapy, she wrote, recapitulated the invalidating family environment when it offered insulting interpretations, ignored cries of distress and inadvertently rewarded emotional explosions or suicidality with extra attention or hospitalization. At its worst, therapy had become "iatrogenic."

Thus, Linehan reconfigured the borderline diagnosis in behaviorist terms, stripping it of judgment and shame and posing an explicit feminist challenge to the reigning psychodynamic theorists (particularly Otto Kernberg, James Masterson and John Gunderson) who had shaped the field's damning and pessimistic views of it. Borderline individuals had huge deficits in life skills, she wrote--not deficient personalities. Where male psychoanalysts had seen "a constitutional excess of aggression," "primitive thinking" and "manipulation," she saw terror, stress-related difficulties in cognitive processing and despair. Teaching borderline individuals better ways to manage their moods and cope with the world, she wrote, would reduce their self-destructive behavior.

This could be accomplished, she suggested in her 1993 Skills Training Manual for Treating Borderline Personality Disorder, by teaching a blend of assertiveness and mindfulness. Her book included lengthy quotations from the popular Vietnamese Buddhist monk Thich Nhat Hanh, who counseled "washing the dishes just to wash the dishes."

These novel and unorthodox elements were wrapped in research so solid and language so clear that Linehan's texts drew immediate praise from mainstream psychiatrists and psychologists--and gradually converted people once dismissive of cognitive-behaviorism, ignorant of meditation and fiercely wedded to psychoanalytic or trauma-focused approaches to borderline personality.

"I was not enthusiastic at first," concedes Dusty Miller, who began teaching DBT at the request of her graduate students at Antioch University in New Hampshire in the mid-1990s. "The borderline diagnosis, as used by straight white men, was very blameful. But Linehan has rescued it from the blame-the-victim tradition, describing it as an understandable response to the way these people grew up. Her model gives clients some great coping skills, and I've learned a lot from it."

Another convert was Charles Swenson, who had run a borderline inpatient unit under the tutelage of Otto Kernberg. Increasingly disillusioned, Swenson gave up Kernberg's psychoanalytic approach in the late 1980s to train with Linehan and found his practice transformed. "I felt inspired in my work again," says Swenson, who was equally captivated by the woman herself. "She's brilliant, charismatic and articulate," he says. "She's a force, a triple threat. It's no accident that she's transforming the field."

Everything But the Kitchen Sink

It is October 5, 2000--an overcast day in Seattle--and the ballroom of the Edmund Meany Hotel is crammed with psychotherapy's ground troops: social workers, psychologists and case managers from agencies, V.A. hospitals and Kaiser Foundation HMOs throughout California and the Pacific Northwest. On the dais stands Linehan--an upright, energetic woman in her late fifties, wearing owl-like glasses and a colorful scarf over the shoulders of a neutrally toned dress. She holds a wooden striker in front of a big, bronze Densho bell, ordinarily used in Zen monasteries to signal the start of meditation.

"We are going to work on the first mindfulness skill, which is observing," she says in the almost-Southern drawl of her native Oklahoma. "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 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 Linehan is not a charismatic workshop leader, showing no videotapes of single-session cures. Anyone expecting over-the-top interventions like those of Fritz Perls or Carl Whitaker may well find her work tediously systematic, and so may anyone who remembers watching a woman sobbing, her heart cracked open as she arranged volunteers into a "family sculpture" with the help of Virginia Satir. She does not even show her own training videos of her subtle, unflinching individual work with clients.

Instead, Linehan will spend the next two days showing slides, making the assembled therapists fill out behavioral "diary cards" (recording their activities and moods throughout the day) and doing role-plays up front with those who don't. It is her ninth national seminar in eight months--one of hundreds organized over the past eight years by Linehan and her training organization, the Behavioral Technology Transfer Group. Since her 1991 article appeared, her two books have become professional bestsellers for Guilford Press. More than 60,000 therapists have bought her books (which have been translated into French, German, Italian, Dutch and Swedish); tens of thousands have attended introductory DBT trainings; and more than 400 government and nonprofit agencies have provided intensive DBT training to their staffs.

This two-day session will be the equivalent of the shallow end of the DBT pool: teaching therapists how to run skills-training groups for borderline clients. "The skills" turn out to be a bewilderingly promiscuous gumbo of attitudes, emotional techniques and psychosocial skills that seem, at first, self-contradictory: diary cards and Greek dancing; radical acceptance of things as they are and assertiveness skills for changing them; "distress tolerance" and "emotion regulation" for facing fears head-on; "willingness" to try something and the measured deliberation of writing out lists of pros and cons before acting. The ability to draw on a vast repertoire of seemingly opposite responses is critical for a successful life, Linehan suggests, and equally important for effective therapy.

Much of the training is behaviorist, but Linehan, ever the experimental scientist, will throw in anything that might work. On the second morning, for instance, her Zen bell gives way to Greek music and she makes the therapists entwine their arms and execute the intricate steps of the hora. "Throw yourself into it!" she urges, as people sway back and forth more or less gracefully, practicing "one-mindfulness" and "wholeheartedness." "Your job is to learn the skills yourself," she says. "If you can do them, you can teach them."

In a testament to her intellectual voraciousness, Linehan's name for her treatment, Dialectical Behavior Therapy, is a reference to the philosophical proposition popularized by Immanuel Kant, Friedrich Hegel and Karl Marx. In essence, dialectics presumes that there are two sides to every coin. Every extreme in thought and in the world calls forth its opposite and points the way to a synthesis or reconciliation. Wide enough to cope with paradox, dialectics sometimes simply holds contradictions in balance rather than integrating them. "You have to change--and you're perfect as you are," Linehan explains. "That's the essential dialectic of the treatment." DBT therapists, she says, should continually ask themselves: "What am I leaving out?"

Under DBT's broad umbrella stands a cluster of therapeutic tactics that require a head-spinning degree of gut-honesty, self-assurance and flexibility from therapists--not to mention a secure inner gyroscope. Some are as noncontroversial as Rogerian mother's milk: be warm, genuine and validating. Others require the cheerful use of power. Some therapists are aghast when Linehan describes DBT's "24-hour rule": if a client injures herself or attempts suicide, there will be no extra client-therapist contact for 24 hours so as not to unwittingly reinforce the behavior. "Are you going to get into the ethics of DBT?" one social worker asks her hotly. "It's always ethical to do the most effective treatment," Linehan replies without flinching. "And for the moment, DBT has the most data as effective treatment for this disorder."

She never lets an opportunity go by to wean someone from the condescending, blaming language that clings to the borderline diagnosis like a cheap suit. "DBT doesn't talk about 'splitting,' she interrupts one social worker's question. "To us, splitting just means that two members of the staff disagree on treatment." DBT, the training makes clear, is not just the most tedious, systematic and effective therapy ever brought to bear on borderline clients. It is well on its way to rehabilitating the diagnosis and reconfiguring a broader therapeutic landscape.

Reconfiguring the Borderline Diagnosis

Marsha Linehan is 57 and lives in a pleasant, brightly painted bungalow that is walking distance from her office at the University of Washington. On the edge of a shelf in her kitchen is a row of Post-It notes from her secretary reminding her of back-to-back weekend appointments. On a table in the living room stands a photograph of a smiling, white-haired man in black robes--a German Benedictine monk named Willigis Jager who is also Linehan's Zen teacher. In an interview, she freely describes her intellectual and spiritual life, but presents primarily a public persona. Little is revealed of private vulnerability. Nothing she says really explains what drew her to her life's work.

One of six bright children of a Tulsa oil executive and his wife, she says of her childhood only that she was raised as a Catholic, reading the lives of the saints and dreaming of becoming a nun. As a college student, she continued a devout and prayerful private path, but her professional ambitions secularized.

In the early 1970s, armed with a Ph.D. in social psychology from Loyola University in Chicago, she took on her first distraught and suicidal clients as an intern in a suicide-prevention clinic in Buffalo, New York. She says she came to the work with a blank slate--knowing only that she wanted to work with the most miserable people in the world. She had no idea that most behaviorists avoided clients with these complex problems, nor that psychodynamic clinicians called them "borderlines."

She was in love with psychology as a science and eager to pay attention to observable behaviors rather than speculate about motivation. Never willing to ascribe intents she could not verify, she theorized that cutting and suicide attempts were problem-solving devices and sometimes "communication behaviors," but not manipulations. She assumed that self-punishing responses were learned, and could be unlearned.

Innocent of clinical training and clutching a behaviorist text by Albert Bandura "like a Bible," she tried to get her clients to engage in behavioral analysis--a step-by-step dissection of the triggering events, thoughts and feelings that led them to the moment they tried to kill themselves. It was like trying to build a wall of small stones in a rushing stream: her clients were so raw and sensitive to criticism that they either attacked her for not caring or withdrew. When she soft-pedaled the behaviorism and was warm and validating, her clients relaxed--but continued to lead lives filled with crises.

Stymied, she got more behaviorist training at the State University of New York at Stony Brook, read voraciously, did her own research, created a "Reasons for Living Inventory" to try to figure out why some people resist suicidal urges and read Carl Rogers. Over time, she noticed that her suicidal clients were subtly training her out of doing effective therapy by mercilessly attacking her when she suggested role-plays or topics that frightened them. To make matters worse, she could not teach them the life skills they desperately needed because session time was consumed with current crises.

Still stymied, she taught assertiveness training and wrote a book about it. After some years teaching psychology at Catholic University in Washington, D.C., she moved in 1977 to the University of Washington and began researching therapy for suicidality in earnest. Over the next eight years, funded by a succession of NIMH grants, she added and subtracted therapeutic devices plundered from every conceivable source, while graduate students filmed, watched and encoded her sessions from behind one-way mirrors.

Instead of constructing a grand theory, Linehan broke down the borderline dilemma into bite-size pieces and resolved them one by one until her therapy included everything but the kitchen sink. To stop current emergencies from overwhelming attempts at behavioral change, she separated out a "skills training" class. Hypothesizing that self-injury halted neurobiological cascades of unbearable feeling, she read the research on delayed gratification and asked friends how they got through difficult times.

The result was a handout on "distress tolerance": simple tips for self-soothing and self-distraction like taking a bath, thinking of someone more miserable than you or lighting a candle and watching the flame. When a client discovered that holding ice often quelled her urge to cut herself, that, too, became part of skills training.

Because Linehan found that even her most competent-looking clients often did not know the basics of negotiating with others or acting independent of current mood, her syllabus grew to include sections on interpersonal effectiveness and "emotion regulation"-- observing current emotions, as well as acting despite them.

Her therapeutic package grew more tightly organized, but nothing resolved the central paradox that had tripped her up in the early 1970s: the difficulty of maintaining a good therapy relationship and getting behavioral change at the same time. Then, in 1986, when she was 42 and suffering from a dryness in her own spiritual life, Linehan impulsively took a year's leave of absence to train in Zen monasteries in California and Germany. For the first time in years, this forceful, strong-willed woman followed instructions instead of giving them.

At Shasta Abbey in northern California, she hauled sheep manure, picked green beans, meditated three times a day and submitted herself to bells and schedules. From this experience, she drew the attitudes she later labeled "one-mindedness," "wholeheartedness" and "willingness" and incorporated them into DBT. "The idea was to give up ego every way you could, to do what was called for in every moment," she recalls, sitting in the living room of her Seattle bungalow near her photograph of Willigis Jager.

"We would sit in the mornings and chant, and then file out and get a work assignment and try not to want a particular assignment. When they rang the bell and work was over and you were in the middle of sweeping, you had to stop in mid-stroke, because, otherwise, you were doing it for your own ego."

Easier said than done. After three months, Linehan went to the priest in charge and dramatically told him she was on the edge of a spiritual breakthrough and wanted to meditate nonstop for three days. The monk took her hyperbole seriously, agreeing gravely that he was sure she knew what she needed. But since Shasta Abbey didn't do things that way, why didn't she go to the nearby Holiday Inn, meditate for as long as she liked and then come back? Out on a limb not of her choosing, Linehan quickly backtracked and followed the schedule for her remaining months. She has since integrated the monk's technique into DBT, calling it "extending."

When a suicidal new client told her dramatically, "Either I have to do this therapy or I have to die. Those are my only two choices," for example, Linehan asked coolly, "Well, why not die?"

Taken aback, the woman replied, "If I've got one last hope why not take it?" and Linehan closed in, "So all things being equal, you'd rather live than die. That's good. That's going to be your strength. We're going to play to that."

Next Linehan trained under Willigis Jager in Germany and felt, for the first time in her life, completely accepted and understood. Her relationship with him became a model for her relationship with her own clients. During the intense meditation retreat known as sesshin, she got a letter from her mother, who was slowly dying. She cried in the meditation hall in front of everyone for three days straight, dimly intuiting that her tears were about much more than her mother.

Every day, she would go to a formal teacher-student interview with Jager, bow sobbing, sit down and cry. Jager would say only "Keep going," and ring his bell to signal that the visit was over. After three days, Linehan quit crying. When she told Jager, he moved on to the next relevant topic without comment. "It taught me that everything is as it is, and you don't have to change it," she remembers. "And that has also found its way into my treatment."

Linehan came back to the University of Washington with a deepened ability to accept life as it is. Zen training had made her joyful and happy, and she wanted to share its benefits. "I don't believe anyone is different. Humans are humans. We all have a physiology that's similar, a psychology that's similar. And if it worked for me, it will work for them. If I could learn to walk, they could learn to walk. If I could learn to be happy, they could learn to be happy. All I had to do was figure out how to teach it."

She says she didn't "go around calling it Zen Behavior Therapy--that wasn't going to work out professionally." At first she tried to import elements of Zen wholesale, though, trying unsuccessfully to get clients to take off their shoes and walk meditatively and loosely "like water buffaloes" down the clinic halls. It didn't translate.

What she came up with in the end was Zen denatured of religious trappings, epitomized in one of the two central poles around which her therapy now revolves, which she calls radical acceptance.

Radical acceptance rests on letting go of the illusion of control and a willingness to notice and accept things just as they are right now, without judging mistakes and messiness, listening to self-criticism or succumbing to impatience. Over time, this emotional resting-place helped Linehan and her trainees tolerate their clients' pain without protecting themselves with distance or blame; it transformed their work. At staff meetings, they began to use a second mindfulness bell, ringing it to signal the need to pause and take a breath whenever anyone said anything judgmental about a client, another therapist or themselves.

In individual therapy, she developed an unflinching, oddly humorous style, using Socratic inquiry, talking as though she and the client were involved in a joint process of discovery, reframing their despair in terms that allowed for hope. When one new client said, "I'm a mess. I can't even cope with everyday life right now," Linehan asked a few more questions and then summarized, "So from your perspective, the problem is that you don't know how to do things"--a reframing that implicitly raises the possibility of learning how. Questioning another client who had kept a promise not to kill herself for a week, she asked, "Was it hard?" When the woman said, "Yes," Linehan replied, "Good. Now we know you can do hard things." Yet, she never minimized the torture of her clients' lives.

"If you don't kill yourself, you're going to get out of hell," she told one woman. "Life is not always going to be so painful and you're not always going to hurt so bad. If you can just keep yourself alive, you're going to get to be a more normal person who has a life that's worth living."

In the late 1980s, her confidence growing, Linehan began a clinical trial of her aggregative therapy with a major NIMH grant. She located clients and assessed them for borderline personality, began therapy and collected data. One day in 1989, taught by her years as a researcher to be unsure of her results until the final data analysis, she went to the computer center at the University of Washington and pushed a key. A few minutes later, a set of figures appeared on her screen: Dialectical Behavior Therapy had outperformed treatment as usual with 44 suicidal and self-destructive borderline clients.

Emboldened, Linehan began presenting DBT wherever she could. Shocked by many inpatient units where borderline clients were suspected of hostility for apparently ordinary actions (such as shrinking back self-consciously when faced with a room full of clinicians or leaving a ward without an escort to get to a therapy appointment on time), she appeared at hospital grand rounds across the country, trying simply to get clinicians to "stop hating" their borderline clients.

In the fall of 1991, she spoke at a conference of the North Carolina Psychological Association in Durham. In the audience was Meggan Moorhead, a staff psychologist at John Umstead State Hospital. Moorhead later attended Linehan's first intensive, 10-day DBT training, and in February 1992 began teaching "skills" to eight suicidal borderline women at John Umstead. Joining them, in the late fall of 1993, was a woman in a body brace named Susan Kandel.

Learning the Skills

The women at John Umstead hospital were skeptical. "We hated it," recalls Kandel. "We had these stupid homework assignments, making lists of pros and cons like we were in elementary school. We had come into the hospital with our lives almost gone, and we had tried to kill ourselves in serious ways. Now we were being asked to participate in stretches in the dayroom. Give me a break!"

Then one of her ward-mates took on skills training, blossomed and left the hospital. Kandel began, almost in spite of herself, to pay attention. Her conversion began with a moment of humility at Christmastime when, cold and miserable, she asked Moorhead to help her get through a two-week staff break when activities shut down. Moorhead wrote out a list of ways Kandel could distract herself or practice mindfulness, and Kandel held on to the piece of paper as if it were a map out of hell.

Like many of her ward mates, she had long used self-harm to regulate her emotions. Now, she tried "not making a bad situation worse," and instead watched TV, participated in stretches in the dayroom and followed her breath rather than thinking about cutting herself. When the break ended, she began coming to the group with her diary cards recording her daily activities filled out and sometimes tried to use skills, even though she felt she could only "play at them" in the tightly controlled hospital. She often took two steps forward and one step back. Sometimes, she didn't bother to try because she wasn't in the mood. But Moorhead relentlessly applauded even the smallest move in the right direction, and over time, Kandel's behavior became less mood-dependent.

When she asked Moorhead to be not only her skills trainer but her individual therapist, Moorhead almost "saw stars" imagining the marathon ahead. Nevertheless she said yes. She now describes Kandel as "the patient who taught me DBT," and one of a handful who have profoundly affected her life.

With many a stumble, Kandel embarked on a process of attentional, behavioral and emotional training within an intimate therapeutic relationship. Neither she nor her therapist sought a drenching thunderstorm of sudden change; rather, they hoped that after months and years of plodding across misty fields, Kandel would discover that her clothes had been soaked through.

Working within Linehan's clearly defined treatment hierarchy, Moorhead first zeroed in on "behavioral discontrol"--specifically, Kandel's risk of suicide and self-harm. When Kandel began consistently using "distress tolerance" and other Stage One DBT skills and recording them in her daily diary cards, Moorhead became reassured that her self-destructiveness was under control. In June 1994, after agreeing not to use alcohol for three months or to try to kill or cut herself, Kandel was discharged from John Umstead. She went to live in the only place that would take her--a rest home full of elderly people in a desolate neighborhood of Durham.

Therapeutic work inside the hospital was only a prelude to the real work outside. "Life is the real game," Moorhead says. "This [DBT] is coaching from the sidelines." Over weeks, months and years, she and Kandel stabilized her behavior, reduced her avoidance of emotions and looked forward to creating "a life worth living." Analyzing the chains of behavior that led her to dire states or ineffective actions, they brainstormed alternatives, with Moorhead cheerleading, holding Kandel's hand, encouraging change and yet modeling acceptance.

She reframed Kandel's behavior as the product of a "problematic learning history" rather than mental illness or innate evil; she talked to Kandel weekly on the phone, suggesting skills to try--and Kandel was almost always willing. Living in Durham, still in chronic pain from her back injury, lonely and knowing nobody, Kandel had her first ordinary-life experience of a fundamental DBT skill: "wise mind." "I was standing outside thinking, 'Everything is so bad and hopeless,' and I was starting to think my whole future was bad and hopeless," Kandel recalls. "I remembered Meggan saying, 'Suffer one moment at a time' and 'Don't decide on the future when you're feeling bad. Come back to this moment.'

"So I said to myself, 'Right now I feel really bad, and that's all I have to think about,' Kandel says, illustrating radical acceptance, 'not worry about an hour from now, let alone tomorrow.' And that didn't seem nearly as intolerable. A huge breath of relief just came out of me."

The moment helped her shift away from the self-perpetuating cascade of thoughts and emotions that had so often led her to cut or try to kill herself. "Since it was just this moment, and not the future, then I could more easily problem-solve with a distraction," she remembers. "You can't distract for your entire life, but for the moment, it's okay."

Kandel wasn't the only one who used DBT skills. "I had to radically accept that this individual was in so much pain," Moorhead remembers. "When I had to leave for a conference, I knew Susan was going to work herself into a numbness and stay frozen for seven days. I had to accept that and go anyway--accept that there is that much suffering in the world and in this individual. There were times when we were both verging on hopelessness. I had to accept that and keep trying to make a difference together."

Kandel next learned to counter her habitual avoidance with what DBT calls "participate." She volunteered at a Durham hospital, taking care of babies while their mothers got counseling. She walked and read. She got a job in a gift shop. Out of the scraps of her life, she began the meticulous construction of a self. Like an image slowly developing in the photographic solution in the darkroom, a life began to emerge dedicated to something other than escape, withdrawal and self-injury.

One of DBT's philosophical underpinnings is the notion that therapists need to give voice to their own limits within the therapeutic relationship, as much as their clients do. After Moorhead began experiencing sleep difficulties in her early forties and needed more undisturbed time, Kandel agreed to fax rather than phone sometimes. So as not to demoralize Moorhead, she learned to call to report positive events as well as problems.

Developing a Self

With the first two goals of therapy (eliminating suicidality and overcoming therapy-interfering behaviors) fundamentally met, the pair tackled improving the quality of Kandel's life. Coached by Moorhead in "interpersonal effectiveness" skills, Kandel lobbied her way back into her old halfway house, which had been terrified to readmit her for fear she'd kill herself. She got a better job in Chapel Hill, at a law firm. And she began going to work no matter how she felt.

"As much as I didn't want to go, boy did I feel better by the end of the day. I'd say, 'Boy I did it, man,' and that was 'mastery,' right there," she says. "A lot of suicidal self-destructive stuff started to just leave me. I wasn't putting on a facade. I was plenty scared and plenty depressed, but I was functioning, I was behaving, I was doing okay."

Now, the pair moved to "Stage Two" of DBT--Post-Traumatic Stress Reduction --an exposure-based approach similar to the "uncovering" phase of psychodynamic therapy, in which a client learns to habituate to strong emotions and re-think the meaning of past events.

Using a therapy based heavily on Buddhism, which theorizes that the notion of a fixed, independent and permanent "self" is a convenient fiction, Kandel began to develop a self. At first, she used "the skills" like someone driving while referring to a map; later she developed an inner compass. Once she had seen herself as fundamentally evil and incapable of change--a bad seed, a lunatic. Emotion had regularly driven her into the mouth of hell, without a sense of choice or freedom. Now, she learned to pause and observe and describe her experience, noticing the evanescence of emotions that she neither resisted in panic nor invited in for tea. She discovered a love of horticulture and took classes at the local community college. She found a job in a plant nursery. As her experiences of mastery grew, she found or created a self.

"I've learned the skills, the symptoms have eased and there's been a major structural change," she says now, looking back. "I see my character very differently. I don't see my structure as weak or fragile. Vulnerable, yes, but I don't think vulnerability is a bad thing. I don't feel skeptical or cynical anymore. I used to think that the world was essentially bad, and I don't see that anymore. When I look at the world now, I see the good. I see the connectedness beween all of us, and I don't see the alienation, the disconnection. We're all in this together.

"DBT is mundane, like physical therapy for a person who's broken her leg in 15 places and been told she'll never run again," she goes on. "You do it step by step; it hurts, it's boring. Something changes, but there isn't a single dramatic moment when you throw away your cane."

In September 1995, she moved out of the halfway house and into an apartment with a friend. That year, when deeply discouraged by a setback, she cut herself for the last time, running a razor blade lightly along her ribs. Moorhead imposed the "24-hour rule" and later conducted an exhaustive and tedious behavioral chain analysis. A few months later, Kandel found herself lying on the floor in her room, feeling awful again and wanting to cut herself. But partly to avoid another chain analysis, she got out a piece of paper and listed the "pros and cons."

"The pros were the relief it would give me," she remembers. "The con that I came up with was this: you don't do this to the people that love you. I was becoming closer to my family, to Meggan and a couple of friends, and I thought that self-violence was also violence towards them. After all they had given me, I just couldn't do it."

A Box With 100 Things in It

Meanwhile, in the greater landscape of psychotherapy, DBT continues its rapid spread. In a field bedeviled by fragmentation and warring dogmas, it offers a model for assembling an enormous range of techniques within a well-structured whole.

But what of its limitations? Outcome researcher Michael Lambert, editor of Psychotherapy and Behavior Change, cautions that "the history of psychotherapy is replete with early enthusiasms for name-brand therapies that melt away and we find have been oversold. I don't think you can underestimate the power of Marsha Linehan," he adds. "She's an exceptional therapist. And as outcome research has repeatedly shown, most of the power is invested in therapists and not manuals and name-brand techniques."

Other caveats come from psychodynamic and trauma therapists who see DBT as half a loaf: psychoanalyst Otto Kernberg (whose transference-focused psychotherapy is in a three- to five-year clinical trial against DBT) contends, "It is not clear how it compares with treatments geared to changing the total personality structure of these patients as a precondition for changing symptoms." To Harvard psychiatrist Judith Herman, DBT doesn't emphasize trauma sufficiently. "These clients are this way for a reason," she says, "and when this is made clear, they feel less crazy, less stigmatized and evil."

Meanwhile, even Linehan herself doesn't know exactly where the magic and the limitations lie. She says that DBT isn't nearly effective enough, that it takes too long and that she has no idea exactly which of its interventions constitute the critical ingredients. She continues to tinker.

"It's like finding a box with 100 things in it and not knowing which three are really that good," she says. "That's sort of the spot that I'm in now. Maybe it's more effective than I think," she muses. "It could also be that it just energizes therapists and gives them hope. I don't really know why it works, and that's what I want to find out." As a scientist intimately familiar with Zen notions of nonattachment, she remains more wedded to truth and experiment than to pet ideas. "My greatest fear," she wrote in a successful application for a senior-scientist grant from the National Institute of Mental Health, "is that therapists and patients doing DBT will become attached to the therapy itself rather than to empirical effectiveness."

In the meantime, the current version of DBT is being embraced by many who do the heavy lifting with borderline clients. The Massachusetts Behavioral Health Partnership, which administers the state's public mental health benefits, has structured an expanded reimbursement to cover DBT phone-coaching and consultation groups, as well as skills training and individual therapy.

"DBT came forward with a body of research, and there's nothing that impresses managed care companies as much as research and statistics," says Joe Passenaugh, a masters level counselor and outpatient manager for the partnership. "The results are very compelling and you can't ignore them."

Among the most compelling results are those of the Greater Manchester community mental health agency in southern New Hampshire, which won a $5,000 gold medal from the American Psychiatric Association in 1998 for a DBT pilot project. In 1994, combined mental and medical treatment costs for the agency's 14 most expensive borderline clients fell by 58 percent--from a total of $645,000 annually to $273,000. The clients got more therapy, but the cost was more than offset by a 77 percent decrease in hospitalization days, a 76 percent decrease in day treatment and an 80 percent decline in contacts with emergency service workers. Only two of the clients were employed when treatment began; eight had jobs at the close of the treatment year.

"DBT has given us hope that was not there seven years ago," says counsellor Patricia Carty of the agency, which has since implemented DBT system-wide. "We now have confidence that this population can be effectively treated and we can see people recover from this disorder."

A Life Worth Living

Susan Kandel remains a work in progress. She lives alone in Chapel Hill, spends time with family, sees Moorhead weekly for individual therapy and has graduated from both her skills training group and a DBT process group. She works three days a week in a plant nursery and plans to continue to study horticulture. She copes well with chronic back pain, is making real friends slowly and sometimes contemplates exploring an intimate relationship. She no longer drinks, spends days stewing in depression or cuts herself. She speaks of The Skills in capital letters, the way someone else might quote a sacred text.

It has been eight years since she sat, cold and miserable, in a body brace in a state mental hospital grasping a piece of paper that described how to "not make a bad time worse." She can eat when she's hungry now, take a hot shower when she aches, mend a torn shirt or walk in the woods when discouraged, notice and enjoy the smell of spring leaves and feel the sun against her skin. "When you first begin, all you do is learn the hows of the skills," she says "With more and more time, I started to learn the whys, and that has made the total difference. I was working on making a life worth living."

Her transformation was the result of a normal accretion of small changes, a journey not peculiar to "borderlines," but familiar to anyone who has ever tried to stop biting her lip or become more assertive, less reactive or more kind. "There's no magic to it," Kandel says, looking back. "It's not like being born again through your mother's womb. It's based on things people take for granted, they're so mundane, so obvious. They're things you can find in the dictionary." Thus, she has been brought back within the circle of normal human behavior with the rest of us, where she always belonged. Nobody would confuse her now with a fictional character from Fatal Attraction or A Streetcar Named Desire and she no longer meets DSM criteria for Borderline Personality Disorder. As she puts it, "I don't do borderline anymore."

DBT in a Nutshell

DBT aims to quickly move clients "from a life in hell to a life worth living," according to its developer, Marsha Linehan. Combining behavior therapy with Eastern mindfulness practices, it accepts clients as they are while pushing them to change.

Stage 1: The Components for Behavioral Stabilization

Individual Therapy

One-on-one therapy begins only after agreement on a renewable therapy contract. Clients get a non-pejorative description of the borderline diagnosis and the rationale for DBT's way of tackling it. They agree to stay in therapy, to try DBT tactics and not to harm themselves for the contracted period.

Then, problems are tackled in a strict hierarchy, with top priority given to suicide, cutting attempts and other severe self-harm (parasuicide.) After a self-destructive incident, no extra phone contact or therapy is provided for 24 hours. At the next scheduled session, the incident is analyzed in non-judgmental terms. Self-harm is reframed as a problem-solving behavior. The task of therapy is to:

- Figure out what the problem is

- Find another way to solve it

-Get the client to try it

- Troubleshoot the results

The client's misery is validated as an understandable response to difficulties, but the therapist relentlessly returns to the hopeful theme that things will get better as the client learns new skills. Clients fill out "diary cards" weekly to give the therapist a quick way to check on suicidal thoughts, self-harm, mood, skills and specific issues like binge eating or drug use. Working from the range of perspectives and approaches that characterize DBT, therapists aim to balance "unwavering centeredness" with "compassionate flexibility," and nurturance with "benevolent demandingness."

Second in priority in Stage One of DBT is therapy-interfering behaviors, like not filling out diary cards, missing sessions or being sarcastic. Therapy-interfering behaviors by the therapist (watching the clock, not returning phone calls, insisting on interpretations not shared by the client) are also fair game.

The DBT therapist next zeroes in on behaviors that "interfere with the quality of life," such as homelessness, unemployment, debt, compulsive eating, and alcoholism. Therapy "vacations" may be imposed by the therapist as a last resort until a client makes a specific change (such as getting a job or going to school) that the therapist considers vital to further progress.

Group Skills Training

DBT clients must also attend a weekly, 2-hour class lasting six months or more. New clients join every two months, receiving two weeks of mindfulness training followed by six weeks of:

-Self-soothing, calming, distraction and other reality acceptance tips for getting through painful times without "making the situation worse" by resorting to drugs, self-injury, tantrums, or unsafe sex;

-Emotion regulation--not suppressing feelings but taking "opposite actions" to them, such as confronting fearful situations or avoiding people you're angry with;

-Interpersonal effectiveness--saying no, making requests and deciding how hard to push.

Meta-skills in mindfulness are also taught, like "radical acceptance"; not judging; using "wise mind" (a blend of emotion and reason); and making decisions via lists of "pros and cons."

Focus stays relentlessly on teaching behavioral and emotional skills, practicing them in role-plays and getting clients to fill out their daily diary cards showing if and how they did their "homework." The push for behavioral change is balanced with non-judging acceptance. Emotional processing is avoided, as are discussions of suicide and self-harm--they can be contagious.

The skills trainer can be a case manager or other non-therapist. They coach clients to resolve difficulties with others, but rarely intervene on the client's behalf. Clients who miss four sessions in a row have officially "dropped out" and can't reenter skills training or individual therapy for six months to a year.

Individual Phone Coaching

Clients also learn to ask for help in regular check-in calls to the individual therapist. Calls tend to last 5 to 15 minutes and take place once or twice a week. The client may express distress or present a problem. The therapist validates the feeling and quickly moves on to getting the client to "generalize" her skills in the real world. Excessive calling and not being willing to try a skill are regarded as therapy-interfering behaviors and confronted in the next session. Therapists must be honest about their individual limits (such as hours or frequency of calls) and negotiate changes when necessary. Borderline individuals, Linehan believes, respond well to blunt, "non-fragilizing" honesty.

Consultation Groups

Borderline clients can inadvertently train therapists out of doing effective therapy by attacking when painful emotions are elicited and warming up when the therapist backs off. Burnout can result from the slowness of progress and the client's frightening self-destructiveness. Therefore, DBT requires a weekly team meeting to keep therapists' morales up and keep them on track, non-judgmental and non-punitive. A DBT "team" can be as modest as two private therapists meeting weekly and as elaborate as a dozen agency staff members. According to Linehan, therapists working in isolation are not doing DBT.

Stages 2-4: Moving Toward a Life Worth Living

When "behavioral discontrol" is no longer a way of life, DBT aims to replace "quiet desperation" with a life worth living. In Stage 2, clients learn to experience current emotions without suppressing them. They may also reduce post-traumatic stress due to childhood sexual abuse or other trauma via exposure and cognitive restructuring.

In Stage 3, therapy focuses on improving the quality of life by reducing other psychological and practical issues beyond the borderline diagnosis. Clients may also take part in a "DBT process group" and help each other brainstorm solutions to current challenges.

Clients learn to trust themselves and to self-soothe independently as the therapist gradually steps back from the nurturing role. The goal is dialectical--to learn to rely on others while simultaneously learning to be self-reliant. Self-respect strengthening is a focus. If the urge to self-injure returns, it is treated as a minor relapse.

Since the publication of her book, Linehan has begun to focus on a fourth and final stage of DBT that seeks to amplify the client's capacity for transcendence and joy.

--Katy Butler


DBT Books

Cognitive-Behavioral Treatment of Borderline Personality Disorder (1993)

Skills Training Manual for Treating Borderline Personality Disorder, with handouts that can be photocopied for clients (1993)

DBT Videos

Treating Borderline Personality Disorder: The Dialectical Approach (1995)

Understanding Borderline Personality Disorder: The Dialectical Approach (1995)

All books and videos from Guilford Press, New York. For DBT training, contact Behavioral Technology Transfer Group, 4556 University Way, N.E., Suite 222, Seattle, WA 98105; tel. (206) 675-8588; web address:


Monday, 10 November 2008 11:20

The Anxious Client Reconsidered

Written by Ari Rosenberg


The Anxious Client Reconsidered

Getting Beyond the Symptoms to Deeper Change

By Graham Cambell

Several years ago, my wife and I were at the end of a rather long line waiting to be seated in a popular local restaurant. Tired of standing, we took a seat in an alcove secluded by a large pillar. As we sat talking, a former client strode into the lobby. Sue (of course, this is not her real name) had come to me for treatment of a severe panic disorder. The condition had been impervious to the efforts of three previous therapists and a stress-reduction program, and, since she was pregnant, Sue refused medications. Consequently, I took the case with considerable fear and trembling. We had eight or nine sessions together, but the therapy helped only minimally and she dropped out.

Hurrying to the front of the line, Sue began talking energetically with a man I recognized as her husband. He had been holding their place while she waited in the protective isolation of the car. But Sue had become impatient, and now she had decided to assert herself. In sessions, she was always unassuming, quiet and polite, so I was startled by what ensued.

In a voice audible to everyone in the small crowd waiting for a table, Sue began to argue with the host about where she and her husband would be seated. She wanted a table near the window, and she made it clear that she wanted it now . I glanced in that direction and saw that all those tables were taken.

"No, a second-row seat will not be acceptable," she snapped. "I need to be next to the window. Why can't you seat us in the courtyard? That is where we sat the last time, and it was excellent. That is why I came back here."

The host was calm and seemingly imperturbable, "Unfortunately, the outside area is closed," he said. He could have also mentioned that it was a cold and windy October night, but chose not to. "If you would like to wait until a window seat..."

"No, we have waited long enough," Sue declared. "Why don't you take reservations like most good restaurants do? Perhaps we should just leave."

"If the bitch doesn't want the seat, I'll take it," a man near us mumbled.

I had to agree that Sue was being more than a little abrasive, but as her former therapist, I was privy to information that the other patrons didn't have. It was clear to me that Sue was either in the midst of a panic attack or was trying desperately to stave one off. Her rudeness was simply a means of coping with her anxiety.

"If you can't seat us in a timely fashion..." she continued.

The host interrupted, "Allow me to see if we can set something up outside." He and another staff member cleared the doorway and in a few moments, Sue and her husband were seated in the windy courtyard.

To understand why Sue chose to dine in a stiff breeze, rather than in a cozy restaurant, it helps to examine the situation through her anxious eyes. In the shape she was in, Sue's primary concern was to avoid public embarrassment. The easiest way to do that was to become invisible. Hence, her original desire to be seated near the window. Not only were those seats on the periphery of the room away from most of the other diners, but they came with a reassuring view of the world she could escape into if panic overwhelmed her. But with no window tables available, Sue began agitating for an alternative that offered her even greater anonymity, and the opportunity to depart unobserved if the need arose. Sure it was chilly outside, but a little gooseflesh was a modest price for that kind of security.

Anxiety, as Sue and others experience it, is not only ever-present, it is ever-threatening. It is a phantom that steals their freedom. Living with panic attacks is like belonging to a street gang: one must always be on the alert for personal slights or threatening movements. Combating the phantom of anxiety requires constant vigilance over one's honor, status and territory. Everyday experiences, such as being seated in a restaurant, become crucial battlegrounds.

Anxiety attacks anything and everything in a person's life. Sometimes the targets are the mundane activities that others take for granted. At other times, it attacks more fundamental functions, such as one's ability to work or to love. We are used to thinking of people who are afraid to speak in public or to drive across a bridge as anxious. We are all familiar with a few stereotypical worrywarts. But anxiety influences a much broader range of behaviors. To the ordinary observer, people who are rude in a restaurant, obnoxious at their child's soccer game or overly exacting of their employees might seem simply self-centered. But often, these individuals are dealing with a wide variety of inner phantoms.

The novelist Stephen King understood this. In Delores Claiborne , his novel of domestic violence and sexual abuse, he has Vera explain to Delores: "Sometimes being a bitch is all a woman has to hang on to." An anxiety disorder is not simply an enervating jumble of symptoms; it is an intensely circumscribed way of life.


Treating Anxiety Disorders

When I began working with anxiety disorders 10 years ago, I had little understanding, training or experience with these conditions. But I worked at a mental health clinic that was inundated by people suffering from panic attacks, and I saw this as an opportunity to broaden my skills and experience.

Starting from scratch, I began developing my expertise in obvious ways. I went to training seminars and read everything I could get my hands on. At one point, in the early 1990s, I had read every article about anxiety that had been published in The American Journal of Psychiatry and several other professional journals in the previous 10 years. I also sought supervision, and consulted with colleagues. And, of course, I observed and met with as many clients as possible. For a while, I saw everyone with an anxiety disorder who came into the clinic.

Eventually, I settled on the treatment program outlined by David Barlow in Master of Your Anxiety and Panic . In addition, I found the books Don't Panic by Reid Wilson and Finding Serenity in the Age of Anxiety by Robert Gerzon most helpful. The Barlow-inspired model I employed involved a time-limited, symptom-focused, cognitive-behavioral approach to therapy. It focused on teaching skills that enabled clients to deal with symptoms. Early in the process, I discovered that this model did what it purported to do--something of a rarity in the field. In addition, it placed great emphasis on education. I found that compelling because I know of no condition for which the dictum "knowledge is power" is more true.

Thus, I became an advocate of diaphragmatic breathing, progressive muscle relaxation and self-talk, and an example of an old therapist's (or at least a middle-aged one) learning new tricks. What I did not foresee was that cognitive-behavioral techniques, rather than obviating the need for a more probing therapeutic approach would, in many instances, prepare clients to benefit from deeper work. Developing new therapeutic tools for anxiety has broadened my therapeutic range and, paradoxically, confirmed my faith in my old tools.

Breathing Lessons

In my initial session with clients, we develop a detailed history of the occurrence of their attacks. I also ask them to keep a record of each attack they experience during the first few weeks of therapy. Our goal is to understand what triggers these attacks. Even a partial explanation can help a client feel a greater sense of control and, not surprisingly, a sense of relief.

Early in therapy, my clients and I also discuss their diets in some detail. Because caffeine intensifies anxiety, I insist that they eliminate coffee, tea, chocolate, colas and all other forms of this seductive stimulant from their diets.


During the second session, we usually begin to practice diaphragmatic breathing and progressive muscle relaxation. I also give clients a tape recording of a 30-minute relaxation program. For homework, I instruct them to practice the breathing for five minutes, three times each day, and to listen to the tape daily. We take considerable time during our sessions practicing these techniques, but the clients need to practice at home, too.

If by the third or fourth session a client is not practicing breathing and using the tape, therapy is unlikely to be successful. I have tried numerous times  to explore other issues or confront resistance at this point. It rarely helps. Sometimes clients are simply not ready to do the work necessary to create change.

But clients who commit themselves to learning to breathe and to purposefully relaxing when confronted with anxiety-producing events progress quickly. They begin to believe they can regain control over their lives, and often, they do. In most situations, these clients are usually able to end this episode of therapy after eight or ten sessions.

Anxiety and Medication

One issue that often arises during these early sessions is whether a patient should take medication. I prefer that they do. Obviously, there is no absolute therapeutic consensus on this point. Some writers suggest that drugs may interfere with the impact of the cognitive-behavioral approach. They are concerned that clients may come to rely on medications for success in treatment. This is an interesting theoretical concern, but my experience is that clients who refuse medications often refuse to engage in diaphragmatic breathing, progressive muscle relaxation and self-talk. In a slight variation on this theme, some clients do not directly refuse medications, but take minuscule amounts at irregular intervals. These same clients are very likely to practice relaxation once a week, turning it into an empty ritual.

Dealing with anxiety "naturally" is a wonderful idea that I support wholeheartedly. But the refusal to take medications often indicates that a client is unwilling to confront his or her condition and to make other changes. (This is not always true, but it is very common.) For these clients, control is such a central issue that they refuse to give it up to a pill or to muscle relaxation. Ideally, clients who are established on appropriate medications can begin to gradually cut back on them, with their physician's supervision, as they master coping skills.


Medications are also essential for clients who are simply too rattled to concentrate on therapy. I learned this lesson from an elderly client--feisty, articulate and humorous--who looked me in the eye and said, "Now, Doc, just wait a minute. I believe I'm about to die of a heart attack at worst, or that I'm going crazy at best or probably both. And you want me to sit in a chair and take deep breaths! First, get me something to calm down, and then maybe I'll try it." This client visited his primary care physician, who started him on an appropriate medication. Within three months, he was calm enough to learn breathing, relaxation and self-talk. Within a year, he was tapering off medications, attending a yoga class, meditating daily and heading into a new spiritual phase of his life.

As this case illustrates, cognitive-behavioral therapy, often in conjunction with medications, can produce remarkable results. It is often the only psychotherapy that my clients need. Often, but not always.

Getting to Deeper Issues

In many clients, anxiety obscures deeper issues. It is not uncommon for these people to complete a brief, successful course of therapy for panic attacks and then return a year or two later with related problems. Usually they have become aware of something behind their anxiety, something that drives and intensifies it. Often the problem was present during the earlier therapy, but the client was not ready to deal with it. For example, it is relatively common during the cognitive-behavioral therapy for clients to describe their spouses as supportive, kind and gentle. Upon returning to therapy, however, clients frequently reveal that there have been years of infidelity, domestic violence, financial irresponsibility or a simple lack of support. What was first presented as a fine relationship is now seen as inadequate at best.

But a person who is frequently in the grip of panic is too vulnerable, and feeling too crazy, to confront relationship problems. A woman who can't leave her house without experiencing acute anxiety is unlikely to consider a divorce, no matter how violent her husband becomes. Not until her symptoms are under control will she find the strength to confront the other problems in her life. Clients who return for additional therapy often say things like: "Well, Graham, I'm back and I can't breathe this one away. I faced the panics and now I have to face him."


In these cases, panic was an inner static that prevented reflection and soul-searching. Now that the interference has been reduced, clients are able to face other aspects of their lives. When this happens, I take a much more reflective stance as the therapist. My focus shifts from teaching clients coping skills to helping them explore their values, goals and intentions.

The two endeavors are not entirely dissimilar. In the cognitive-behavioral phase, I am a teacher who listens a great deal. I teach skills that help a person deal with specific symptoms. As a more traditional psychotherapist, I am an empathic listener, but I am still teaching a skill. That skill is inner listening: the ability to hear one's own heart, spirit or soul.

If the issues that bring clients back to therapy are existential, I explain to them that in this phase of their treatment, I will play a different--less directive--role. Sometimes they are disappointed. The previous episode of therapy was so effective that many people come back hoping for more of the same. But this time, there is no ready-made solution to their problems. They have to learn to listen deeply to their own heart and soul.

Fortunately, their disappointment is usually short lived. People who have been faithful to the deep-breathing and relaxation exercises can hear themselves much more clearly than before. Gerald, for instance, originally came to see me for panic attacks. His industry was in the midst of enormous transition. His company was downsizing and his job was in jeopardy. He learned to control his anxieties in the brief cognitive-behavioral therapy and successfully weathered the upheavals at work; however, two years later, he returned to therapy saying, "I survived, but this just isn't what I want to do anymore."

At that point, we entered into a longer, more reflective, therapy exploring what he wanted to do with his life and career. He changed professions and simplified his life. It wasn't easy or always comfortable, but the confidence he gained confronting the anxiety attacks in the early therapy paved the way for deeper work.


The Uses of Anxiety

Over the time I have worked on anxiety disorders, I have arrived at two basic, closely related, conclusions about the nature of these conditions. First, anxiety disorders are a means of keeping the external world at bay.

To understand this idea, it is valuable to contrast this view of anxiety with the perspective of traditional psychoanalytic theory. From a classical psychoanalytic perspective, anxiety is the attempt to repress unacceptable impulses that arise from within the Id. It prevents disorganized thoughts and forbidden urges from invading the consciousness. In this traditional view, anxiety works to keep impulses down within the psyche. Perhaps the best example of this dynamic occurs when a person who experiences homosexual thoughts responds with great anxiety that is expressed through homophobia.

But in my view, anxiety has less to do with repression than deflection. Anxiety keeps new ideas and information out of a person's awareness. It saves overloaded mental and emotional circuits from additional strain. It is a sea wall built against the tide of physical circumstance.

Unfortunately, anxious individuals pay a severe price for this protection. They have trouble accepting feedback or learning from their experiences. They also have a difficult time adapting to new circumstances. Their approach to life may not work very well, but they have difficulty changing it.

As an illustration, consider the dramatic contrast between the way depressed clients and anxious clients respond to a therapist. Most of my depressed clients can take in what I say and consider it. My comment may or may not influence them. It may or may not be accurate. But they take it in. Anxious people usually don't. It is as though feedback and interpretations bounce off them.

With a depressed person, if I say something as basic as, "The opinions of your parents are very important to you," the observation often begins a dialogue about autonomy or dependence or childhood memories. The same comment to an anxious client brings an unproductive evasion: "Oh, yes, they are. I have often thought they mattered too much, but I could never change that."


Depressed people are sometimes helped by supportive comments. They are like a sponge absorbing what is sent their way. But anxious clients wear a Teflon coating and supportive comments just slide off. Depressed people tend to feel guilty and inadequate. Consequently, they feel they must change. Anxious people also feel guilty and inadequate, but they are more likely to feel that something else has to change. They objectify what depressed people personalize.

The handiest object onto which an anxious person can project his internal turmoil is his body. Anxious individuals often view their bodies as failed machines with specific yet undetected flaws that need to be corrected. It never ceases to amaze me that many people with anxiety disorders are somewhat disappointed when tests come back negative. They would rather have a "real" physical problem than a psychological one.

This desire is sometimes fulfilled due to a second trait common to anxious people--their tendency to neglect or even ignore their own needs for the sake of communal tranquility, and compliance with authority figures.

Statements such as "I am a people pleaser," "I come last" and "I have three kids, that doesn't leave much time for me" are very common among anxious people. They are devoted to keeping their environment conflict free, and are more than willing to repress their own desires to do so. Anything that threatens the fragile peace they are trying to maintain is cause for alarm. Since there is little peace in the external world, alarms--in the form of anxiety attacks--go off all the time.

These attacks would be disturbing to anyone, but they are especially disturbing to anxious clients who expect their bodies to be as acquiescent as their emotions. Eventually, however, living in an almost constant state of alert takes a physical toll, and long-ignored needs eventually manifest themselves in physical symptoms. In this way, the desire for a "real" physical problem becomes self-fulfilling.

In therapy I attempt to break this cycle and help clients come to terms with both their internal and external worlds. I try to help them understand that the tranquility they are seeking through repression can only be found by accepting the legitimacy of their own needs. When they grasp this, their Teflon coating begins to dissolve. They can assimilate new information and develop new ways of living. The body can then be seen not so much as something to be controlled but as something to be respected.


Learning to Listen

Once the alarms of the body are silent--once the body component of the mind-body equation has been successfully treated--therapy becomes a reflective process with an emphasis on accepting the importance of subjective experience.

On a concrete level, one of the best strategies for hearing the subjective voice is to continue the practice of diaphragmatic breathing several times a day, until it becomes a natural process: breathing deeply and listening deeply throughout the day. In this way, people can hear their inner voice and weave its wisdom into their responses to the demands of life. In therapy, when people are facing important dilemmas or conflicts, I often encourage them to first be silent and focus on the breath for several minutes. Then, I ask them to listen to what their inner experience says to them about the conflict. I'm often amazed how much more clearly they see their situation after this simple exercise. As they become experts at listening within, they usually discover that the situation is either not as anxiety producing as they feared or that they have the inner strength to handle the problem.

In many clients, the knowledge of diaphragmatic breathing is like a slowly germinating seed. Because it is a physical skill, even those who show little interest in it during therapy can master it later without a therapist's help. A case in point is my former client, Sue.

A year or so after the restaurant incident, I bumped into her on the way into a store. We chatted pleasantly for a while. Things were going very well for her. She had a daughter. The anxiety had receded. She said, "Things are so much better now. It took six months before I took what you or any other therapist said seriously. Then I started doing the breathing and the relaxation tape. I even joined a yoga group last week. I appreciate how kind you were. I didn't listen then, but I do now."

I did not mention the restaurant.

Graham Campbell is a psychologist in private practice with Cedar Associates in Worcester, Massachusetts. His clinical focus is on grieving, terminal illness and the relationship between spirituality and psychotherapy. Address: 9 Cedar St., Worcester, MA 01609; E-mail address: Letters to the Editor about this article may be sent to