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Are You There for Me?

Understanding the Foundations of Couples Conflict

by Susan Johnson

On the first day of a clinical placement in my doctoral program during the early 1980s, I was assigned to a counseling center and told by the director that because of unexpected staffing problems, I'd be seeing 20 couples a week. I'd never done any couples therapy, but I did have considerable experience as a family and individual therapist with emotionally disturbed adolescents--a tough, challenging group of clients if ever there was one! So my first thought when given this new assignment was, "After what I've done, how hard can this be?"

I plunged in and almost immediately was appalled by how hard it actually could be! People who seemed perfectly sane and reasonable often became totally unglued with their partners--enraged and aggressive or almost catatonically mute. I was in way over my head, with no idea what to do with these couples.

I remember one wildly angry pair, whose fight escalated to the point that they threatened to kill each other in my office. What I didn't know at the time was that while I was trying to prevent a double homicide, the clinic's director and staff were poised on the other side of the door, debating about whether someone should come to the rescue. "Do you think she can handle it?" one whispered to another. At that moment, they all heard me break into the melee and shout at the top of my lungs, "Shut up, both of you!!" In the ensuing stunned silence, the director said to the worried assembly, "I think she'll be just fine."

In spite of my complete befuddlement and frustration, I found the dramatic, intricate, baffling dances these pairs did with each other enthralling, and wanted to understand better what was going on. Clearly though, I needed some tool in my toolkit other than "Shut up!" if I wanted to make any headway with them. The drama enacted in front of me by a couple was so powerful, so emotionally compelling, and yet so complex and ultimately confusing, that I felt chronically lost. I desperately needed some sort of map that would help me make sense of what I was seeing.

I remember one woman, who mostly communicated with her husband by screaming at him, sitting in my office one day describing in gruesome detail all the horrible things she was going to do to the husband's body as he lay asleep in bed that night. As usual, he ignored her completely, except to occasionally yell back, "You're absolutely crazy! You belong in a nuthouse!" Sometimes a wife would sob to her husband, "I love you, I love you--you have my heart in your hands." Then a minute later, she'd be screaming at him, "You bastard! I'll never let you touch me again!" Partners wept, made outrageous threats, and sat sunk in depression, all the while knowing perfectly well they were destroying their relationships, but unable to help themselves. I had no idea how to help them, either.



So I began a frantic search of all the books I could find on couples therapy and tried to put into practice some of what I learned. I read books by analysts about collusion, projective identification, and the need for insight. I read books by behaviorists, who defined marriage as a kind of bargain or exchange in which each partner sought to maximize profits and minimize losses. Couples needed to learn communication skills, these books said, so they could better negotiate with each other--so they could become better friends.

But my couples weren't impressed with any of this. They didn't care about insight, and even if they understood what they were doing to themselves and each other, they couldn't seem to stop. Their communication skills were generally just fine--with me--but they couldn't seem to access the skills with each other. They didn't want to talk calmly and rationally about money or sex or children, and doing communication exercises was just going through the motions and made them angrier. They certainly didn't seem ready to become "good friends." In fact, many of them would complain about exactly this. "We're just friends--roommates," they'd say when I asked them what was wrong.

Feeling stuck, I went back to what I had learned from Carl Rogers--particularly his belief in the importance of empathically understanding a client's emotional experience and reflecting it back in a way that orders and distills it. I also reconsidered Salvador Minuchin's insights about how family members engage in patterned cycles of interactions. I took home session tapes and studied them over and over, focusing on the process rather than the content--keeping my eye on the game the couples were playing rather than following the ball, the particular subject they were arguing about. As I watched and listened to all these couples, it became stunningly clear that they'd sought therapy because they were in a state of anguish and terror. Possibly the most important human relationship in their lives--with each other--was dying, and everything they did or tried to do just seemed to make it die faster.

When I quit trying to provide "insight" into my clients' problems or teach them skills, and, in good Rogerian fashion, just followed the emotional currents, reflecting back to them what I saw and heard, and helping them slow down enough to fully experience and explore their own feelings, I'd occasionally make progress. It seemed then that something shifted emotionally within the couple. New emotions would emerge; anger would give way to sadness or fear. For a moment, I could see and hear them tentatively begin to reconnect with each other, and sense the relationship quiver delicately back to life.

With one couple, for example, every time the man--who completely avoided his wife and wouldn't sleep with her--tried, in a kind of embarrassed mumble, to justify himself, she'd respond, "That's ridiculous! You're just so incompetent!" After slowly helping them uncover and experience the emotions beneath their interaction, however, I noticed that he began to talk about his feelings in a different way--more openly, straightforwardly, without his usual awkward embarrassment. For the first time, he was really able to look at her, and say that it wasn't that he didn't care about her, but that he was so afraid of her rejection that he felt paralyzed. Again she responded "That's ridiculous," but her voice was softer, and as he repeated his message, she began to look at him with puzzlement--seeing something that had been invisible before. "I never knew you were afraid," she continued softly, looking him full in the face.

The look she had at that moment I now know well. I call it the "dog and recorder" look. It's named after the cocked-head and deeply nonplussed look my dog sported the first time he heard a human voice come out of a recording machine. Its best translated as: "What new thing under the sun is this?" I knew by that look that my dismissing client had begun to see her husband differently. It was moments like these, in which primary emotions were spoken clearly and pulled out new responses from a spouse, that seemed to make the difference in my sessions. What was going on here? I wondered.

Once when I was still pondering these issues, I went to a conference and got into an after-hours bar conversation with an eminent researcher in the field, who argued that getting and staying married was like entering and sticking to a bargain. I disagreed, saying, "The only time marriages are like a bargain is when the relationship is already as good as dead and all hope of intimacy is gone." Then I heard myself adding, almost without conscious thought, "Marriages aren't bargains. They're emotional bonds."

At that moment, it felt as if a door had suddenly opened in my mind and I could begin to truly see what was happening with my couples. I realized what should have been the most obvious truth of all: marriages were primarily about the emotional responsiveness that we call love; about fundamental human attachment. These bonds reflected deep primal survival needs for secure, intimate connection to irreplaceable others. These needs went from the cradle to the grave. How had we ever decided that adults were somehow self-sufficient?

I then began to be struck by how often the couples I saw talked about their relationships in life-and-death terms, as if they themselves were in danger of dying. Like mountain climbers suddenly caught on a narrow ledge in a stiff wind over a 2,000-foot drop, their thinking brains had effectively shut down--all that was left was raw emotion, mostly fear, and a frantic need to reestablish the safety of their connection, without the least idea of how to do it.

It seemed to me that what I needed to help these couples was what, paradoxically, couples therapy had always neglected: a systematic theory of adult love. But how could anybody even study such a nebulous concept? During the '70s and even into the '80s, in the halls of academic psychology, love was no more than a disreputable four-letter word, and the subject of "emotion" wasn't regarded with any more favor. When I first considered getting a doctorate in clinical psychology, I remember telling the head of the department that I wanted to study emotion, the nature of human connection, and how people change in therapy. He looked at me and said flatly, "We don't do any of that. We do measurements, personality, statistics." So, I went into counseling psychology instead.

And yet, I wondered, if we didn't have a theory of adult love and emotion, how could we truly understand what marriage was all about, let alone help couples make any real changes? Furthermore, even if we began to understand more about how love actually played out in marriage, what could we possibly do, as therapists, to bring it back into the process of therapy with troubled couples?

Relationships that Heal

Today, 20-odd years later, there's been a seismic shift in the way we think about emotion, particularly love. The powerful attachment bonds we form with others are now bona fide subjects for scientific research in psychology, physical medicine, neurobiology, and sociology. We now know how important attachment is throughout the life span for mental and physical well-being.

The scientific evidence is overwhelming: research has shown unequivocally that people in secure relationships have better cardiovascular health, stronger immune systems, lower mortality rates from cancer, and less depression and anxiety, and that they face psychological trauma with more emotional resilience. Research tells us that social isolation is more dangerous for health than smoking or lack of exercise. And when the relationship with our partner becomes distressed, we're likely to become clinically depressed, highly anxious, and more susceptible to physical illness. In short, those closest to us have a direct impact on our ability to regulate not only our own emotions, but our physiological processes.

We've also seen a virtual revolution in the way we treat couples. Once a kind of sideline to the main business of therapy--treating individuals and families--couples therapy focused primarily on getting partners to reduce their mutual bloodletting and achieve a reasonable degree of peaceful coexistence. Today we have a clear, coherent, researched theory of adult love, which provides an extraordinarily informative map to guide us through the otherwise impenetrable wilderness of a couple's relationship. This map enables us to identify the significant emotional moments that define an ailing relationship and, even more important, create in therapy the moments that can redefine and transform a relationship.

In the course of this process, therapists and couples often experience shifts that seem almost magical The power of attachment emotions and needs are such that even partners who've never known safe loving responsiveness from others, or have been violated by those they depended on, will still risk reaching out for care. And even if partners see their lover as scared and vulnerable, they can access a protective empathy that even they didn't know they possessed. But it took us a while to figure out how to create a step-by-step approach, so that we could predictably lead people into these moments of profound shifting with each other.

Emotionally Focused Couple Therapy (EFT), the systemic, empirically supported model of therapy I've developed during the past 20 years, allows us to understand what happens at these key moments of change and make these moments happen. We know how to bring about specific, highly emotional interactions between partners that predictably result in moments of deep bonding between them--bonding that lasts. This means that we can not only heal relationships: we can create relationships that heal. When we help forge new, loving connections between partners, we've found that the clinical depression or anxiety in one or both partners lifts.

EFT work is preeminently a therapy of key moments. Marital therapist and researcher John Gottman argues that marital satisfaction depends on a higher ratio of positive to negative emotional incidents between the spouses. But I believe it isn't the quantity of positive interactions and negative interactions that defines the relationship, but the quality of certain moments, which themselves may seem incidental and relatively unimportant, that reveals the status of the entire relationship. Critical key moments define a failing relationship, and critical key moments can heal it.

Consider a couple who comes into my office for an early session, clearly distant and estranged from each other. As it turns out, he's usually the pursuer-blamer, and one of his tactics is to demand sex from his wife almost daily as "proof" that she really loves him. When she refuses, he gets angry, bangs about, and tells her she's "cold" and "unwomanly." This makes her feel inadequate and hopeless, so she defensively shuts herself down and shuts him out. She becomes the withdrawer-resister in the continual dance they do.

The previous night, the two of them had gone to a party. On the way, he'd brooded about the fact that she'd once again turned him down sexually. He noticed in the rearview mirror that his hair was thinning and that he was developing jowls. He didn't feel very good about himself when he got to the party, so he immediately went to the bar and had a few stiff belts to "calm himself down." Then he set out to find his wife and walked into another room, where he saw her engaged in an apparently intense conversation with an attractive man dressed in a beautifully cut suit and sporting a head of thick, glossy, black hair--"looking like a stupid male model from the front of Esquire. " He marched over to his wife and snarled, "Are you going to flirt and whore around all night with this idiot?" She replied coldly, "Yes, because he's so much more pleasant to talk to than you are." The husband stormed out and drove home by himself in a fury, and they hadn't spoken until they came to the session.

This is a classic defining moment in their marriage--a microcosm of the misery he feels and the resentment she feels. Unable to regulate or honestly express his fear of losing her, he turns to reactive rage, which elicits a response from her that confirms his anguish and fear. In therapy, I frame this event as an example of a critical moment of the couple's negative pattern. Then I slow the process down and help him focus on the event, second by second, including the initial cue--seeing his wife with the glossy-haired guy. What did he see when he looked across the room at his wife? What was his body saying? What was going through his mind? How did he feel?

At first, he doesn't have any answers. "I don't know what I saw exactly," he says. After a few minutes, though, he cops to feeling angry that his wife was wasting time talking to "that pretty boy." He recalls that his heart was beating fast, he was breathing hard, and his face felt hot. Then, slowly, as I softly repeat the questions, giving him cues--"Gosh, you said you remember breathing hard, you must have been upset"--I notice that his eyes are beginning to show signs of tears, and I mention it. "Those aren't tears," he says in annoyance, "my eyes are just watering!"

Gradually, he begins to focus on the memory and what was happening for him. "It was the way she was looking at him," he finally mutters. I follow up this cue. "Could you help me understand what you mean? What was it in the way she was looking at him that made you feel so bad?" Suddenly, his eyes brim over with tears and he says in a choked voice, "She doesn't look at me that way any more."

Eventually, we get to the heart of this defining moment: he saw his wife with the other man, his heart sped up, and he felt deep terror--the basic panic response wired into us at the threat of abandonment and isolation. He saw in a flash of agony that she was lost to him. But a second later, he'd bypassed those terrible feelings and flipped over into a secondary coping response of rage, which left him feeling less frightened and insecure, and perhaps a bit more powerful.

What I see in this little tableau is separation protest. This man is, in fact, terrified that his wife doesn't love him--that he's losing the most vital human attachment in his life. He's reacting in the primal way that frightened, desperate human beings have reacted throughout the entire history of our species: he fights to get her back, becoming ever more aggressive, demanding, and angry. In a much less dramatic but entirely complementary way, she, too, acts out the kind of primal terror that afflicts human beings when their most precious connections are threatened. Of course, she doesn't see his tirades and insults as evidence that he wants and needs her; she experiences them as evidence of his contempt for her as a wife and woman. She feels not only rejected but deeply afraid that, one day, he'll simply leave her in disgust. Rather than engage him, she shuts down, withdraws, and assumes a posture of aloofness to prevent an escalation that'll end the marriage. Its a poor strategy, but like the freeze response of a terrified animal, it's an instinctive, immediate response to impending catastrophe.

Attachment Theory

All of this talk about broken attachment bonds and separation protest probably has a familiar ring to anybody who remembers from graduate school the pioneering work of British psychiatrist John Bowlby, the founding father of attachment theory. Most therapists know his basic premise: the human need to love and be loved is innate, physiologically determined, instinctual, and evolutionarily adaptive.

Bowlby and the attachment researchers who followed him demonstrated unambiguously that babies and young children who didn't get the dependable, trustworthy, attuned response they needed from their mothers became angry and aggressive in an apparent attempt to make the mother respond. Because disconnection, isolation, and loneliness are so unbearable, the children acted as if any response was better than no response--which, in these dire and traumatizing circumstances, is true: any response is better than no response. Children who learned that they couldn't get their attachment needs met finally gave up in despair, becoming apathetic and depressed, sometimes even appearing indifferent, though, in fact, their bodies showed measurable physiological signs of serious stress.

Bowlby's work profoundly influenced the way we think about child psychology. But he believed something that was ignored by psychologists for years: attachment behavior--the biologically based imperative of a young creature to seek and maintain an intimate connection with a dependable, accessible, responsive other--stays with us for life.

After all these years of working with couples, I now understand that the heart of the matter, the central issue in the marriage, rarely concerns the content of a couple's arguments, but almost always concerns the strength and responsiveness of the attachment relationship they have. And the bottom-line test of that relationship is in the answer to a fundamental question each is, in essence, asking the other: Are you really there for me? Do I really matter to you enough that you'll put me first when it really counts--before your job, before your friends, even before your family? Partners in troubled relationships feel that on some basic level the answer to these questions is "no," or at best "maybe." All couples fight, but the fights that really define a relationship are always about the same thing: whether the partners feel they have a safe, secure connection with the other.

So my overriding goal in therapy with couples became to help them regain (and sometimes gain for the first time) a secure attachment bond with each other. But how would I go about this? I'd already tried conventional means--exploring their individual childhoods for clues about their attitudes toward love, teaching them what to expect in marriage, and trying to improve their communication skills--to little effect. Then I realized that if the basis of attachment was emotional cues and responses, than emotion would have to be the royal road to better, more secure marital attachment. Any successful approach would have to focus on helping clients experience, develop, and differentiate their own emotions in the here and now with their partners.

The importance of working with couples at the deepest emotional level can't be overemphasized. Emotional cues and responses are the music of the attachment dance, providing the tones, rhythms, and melodies that suffuse every interaction between partners, defining their relationship. If the underlying music remains a jarring, disturbing cacophony, no amount of skills training will ultimately heal their relationship.

It follows then that the therapist using an EFT approach mustn't be frightened of clients' extreme emotional upheaval, but must learn how to regulate and use it to create new interactions. The EFT therapist is neither a skills coach, nor a wise creator of insight into the past, nor a strategist employing paradox and problem prescription. Instead, we think of ourselves as collaborators with our clients, genuinely curious and fascinated by them, able to feel their sadness, fear, and rage, giving our all to imaginatively inhabit their emotional world. Sometimes I think the key to this kind of therapy is to remember something Bowlby himself believed: no matter how bizarre a person's behavior, it'll seem perfectly reasonable once you understand his or her attachment story.

I grew up in Britain as a pub-keeper's daughter. My mother had an expression for customers, and there were many, who seemed to go a little crazy after a few beers: "He's just having a funny five minutes." I think this kind of gentle tolerance provides a good model for a couples therapist faced with the inevitable, extreme responses people exhibit when facing what feels like the life-threatening loss of an irreplaceable relationship. In a sense, the therapist is almost a surrogate attachment figure, whom both partners can trust to guide them through the shoals of reactivity, risk, and the restoration of trust.

EFT in Action

If the failing marriage is defined by key bad moments, the goal of EFT therapy is to create in therapy key good moments--moments of intense emotional engagement between partners, which become major change events, with the power to transform their entire relationship. Getting the couple to the point at which they can engage in such key moments with each other doesn't happen instantly and easily, but it can happen dependably, even in marriages that might seem lost to all intervention.

The first major step is helping the partners tell their stories to the therapist, rather than to each other. This obviously requires that the therapist forge a bond of trust with each spouse. During this first part of therapy, as a couple grows to trust the therapist, they become more emotionally engaged with each other and begin to explore the fears, sadness, longing, and loneliness that lie beneath the often obnoxious and repellant behavior that fuels the negative cycle of their relationship. After about five sessions, my goal is to help each spouse understand that the "enemy" is the cycle itself, rather than the other person, and begin to "soften" toward the other. By this point, with any luck, they feel a little more hopeful, they've become somewhat gentler with each other, and they're ready for the next, huge step--talking to each other about deeper feelings and attachment needs.

It might be asked why, if the partners have already spilled the beans about their sadness, feelings of failure, and so forth to the therapist in front of the spouse, they must now turn to that spouse and tell him or her basically the same thing. It's because, while it reduces the mutual anger and resentment for one spouse to hear the other reveal such feelings to me, it's absolutely vital that the partners share them with each other--face to face. If a client tells the therapist how much he hurts as his wife stares at the floor, she may feel less angry and a little softer toward him, but nothing important will change. Only a direct emotional connection between the two--eye to eye, face to face--can begin to rebuild a genuine bond of emotional responsiveness between them.

Elvera and Samuel, a couple in their late thirties with two young children, came into therapy with me because both partners had been diagnosed with depression and, after years of individual psychoanalytic psychotherapy, had come to believe that perhaps their rather distant marriage might have something to do with it. Though they considered themselves "good friends," they'd begun to wonder if this "friendship" was enough to sustain a marriage. Beneath their obvious decorum and restraint, I saw the anxiety and sadness in their eyes.

Highly educated and intellectual people, they'd been raised by severely religious and emotionally distant families in Europe. Samuel's parents, who were wealthy and socially prominent, had left their son almost exclusively in the care of nannies and servants. Elvera had been raised to believe that a woman should be a modest helpmate to her husband, a responsible mother to her children, and a dignified figure in society. For her to have, much less admit to, sexual and emotional needs would have been considered entirely inappropriate and shameful by her family of origin.

When I inquired more closely about why they'd come to see me, Elvera dropped her bombshell: this couple was quite literally "out of touch" with each other--they hadn't held hands, hugged, placed a companionable hand on the other's arm, kissed, or had sex in more than four years. It was only after a good friend had told Elvera that it was really quite odd for a couple not to display any physical affection for each other that they'd come to see me.

With every couple, I try to intensify, crystallize, and heighten what I see as the key emotional issue. In this case, I started to talk about the distance and the loneliness in their marriage. We talked of the importance of touch for human beings--playful, loving, safe--and how vital it is for a marriage. I said that I had a vision of a good marriage, and it was one in which warm, loving touch, as well as verbal expressions of love and emotion (which they didn't share, either), played a vital role.

When I began talking about touch and emotion, both partners became quiet and attentive. I've found almost invariably that if I can connect with people emotionally in the process of asking about their feelings, they're fascinated and eager. They may find it scary, but they also love the fact that they're being truly seen and felt. So I asked Elvera, as I was trying to evoke with each in turn the fundamental reality of his or her emotional experience, "Could you please help me understand? Could you tell me how you're feeling as you say these things about your marriage?"

She answered flatly, "I don't know what you mean."

I replied, "When I listen to your voice, you sound calm, reasonable, and detached, but when I look into your face, I'm absolutely blown away by the sadness in your eyes."

At this point, she burst into tears. As it turned out, she'd originally been the "pursuer," demanding more affection from Samuel. When he wouldn't respond, she'd shut down and become increasingly distant and cool. Finally, she'd given up in despair.

After helping them reveal to me, one at a time over several sessions, the feelings beneath their carefully maintained detachment and begin to take small risks with each other, they were ready to turn to each other and, with some guidance from me, begin to talk directly about their deepest emotions. Having gradually put together, made sense of, and expressed their desperate loneliness and neediness to me, they could begin to reveal these feelings to each other.

I always encourage the more withdrawn partner to come out into the relationship first--this is part of the road map of the EFT process. Samuel had been able to piece together his despair at all the apparent rejections he'd experienced and how he'd numbed himself to hold onto his wife and his family. But now he couldn't bear the "emptiness" in the relationship, or tolerate the distance between them, he said to his wife. He wanted to learn how to be close, and he wanted Elvera to take that risk with him. His ability to listen to his emotions connected him with his attachment longings, and he was now emotionally present and reaching for his wife.

The moment in their therapy I remember best was when I pointed out that Elvera was caught between her longing for connection and her fear and shame. It was so hard for her to ask to be touched or held. At this point, she looked at her husband, obviously trembling, with tears in her eyes, and said, "Yes, I can't breathe right now, and I'm shaking. I'm so scared--I can't ask you to hold me." We explored the catastrophic fear she felt and she was able to tell him that one part of her was "sure" that she was too ugly and too difficult to love. If she asked him to hold her then, his face would show the disgust and rage that she deserved. At this point, she was able to put her ambivalence and fear into words, and at the same time, to weep with grief at her sense of loss. She'd never asked anyone to hold her--never.

I asked Samuel whether he could see his wife's desperation, and whether he could help her with her fear. He then looked into her eyes as she wept, put his hand out to her, and said, his voice full, "I've spent four years longing to touch you, and I, too, have been so afraid. If you come to me, I'll be there. I want you so much. I don't want you to be afraid and alone." He then stood up and she reached for him.

We call this type of event, which is the culmination of a hundred little realizations, risks, and new perceptions, a softening. Once this occurs, both partners are accessible and responsive to each other. They can stay with their emotions, tolerate the other's protests and upsets, and formulate their own needs and put them out in an attuned way with their partner--a way that helps their partner respond. Once this occurs, a new safety and a new connection begin to blossom. The couple can do what securely attached partners and children can do in relationships: they can accept and articulate their attachment vulnerabilities; they can ask clearly for their needs to be met, rather than attack or withdraw; and they can take in another's love and comfort, and translate that love into a sense of confidence in themselves and in others.

Of course, EFT isn't the only therapy to encourage partners to talk about their feelings. But with EFT, therapists have a specific approach to help partners discover and engage with key attachment emotions, and to translate this process into compelling enactments that redefine the quality of emotional responsiveness in a relationship. Elvera had never walked around feeling her fear and shame before. She'd labeled these emotions from an emotional distance. She'd never really listened to them and heard their message about how much she needed reassurance and holding. She'd certainly never acted on the longing and grief that accompanied them.

When Samuel and Elvera left my office that day, I noticed from my window that they were walking to their car hand in hand. This is what I expected. These bonding moments are exquisitely reparative because they home in on the most painful and wounding issues in the marriage and, in doing so, heal them by creating new bonding events. Each partner emerges from such an event getting from the other precisely what he or she yearns for and needs most. What we see is that each partner is personally strengthened and empowered by this process, not only in his or her relationship, but in life in general.

Why It Works and When It Doesn't

It's sometimes asked why and how these relatively few moments of marital therapy can actually turn a relationship around after years of marital decline. I think that these critical moments are like laser beams, striking directly into powerful emotions wired into us for millions of years. In therapy, people find the concentrated, distilled experience of deep emotional bonding intoxicating, dramatic, and sufficiently intense to shift the entire relationship off its old axis. The freedom each partner feels at not needing to defend him- or herself against the other, who has now become the source of utmost safety rather than danger, is exhilarating and life-changing. Real emotional connection is like a life-affirming drug for us all.

Of course, there are couples whose marriages just can't be saved by EFT. This method won't work if the therapist can't create a basic sense of safety in therapy for both partners. During the first session with one couple I remember vividly, the husband described his wife in words so full of contempt and hostility that they took my breath away. Over the course of several sessions, before I terminated therapy, I couldn't get him to see what he was doing to her, much less own up to it or stop doing it; nor could I get the wife to understand that his attitude might have something to do with her severe depression. Under these conditions, I couldn't risk drawing her into self-revelations that he'd only use to torture her further.

But even when EFT can't "save" the marriage, it can provide substantial benefits to the marital partners. Late one hot Friday afternoon, a tall woman strode into my office ahead of her wispy-looking husband, fairly yelled at me that I was the eighth therapist they'd tried, and then, pounding on my desk for emphasis, announced that she'd left her whole family in another country and ruined her life to marry a man who was proving to be a terrible husband. He didn't love her, didn't pay any attention to her, didn't care whether she lived or died. Both in their fifties and never married, they'd recently met on a cruise, and married almost on a whim. He, a longstanding bachelor who liked chess, computers, and bird-watching, had fallen into marriage with an emotionally volatile woman who terrified him. He said nothing during her long tirade, but when I looked into his eyes, I saw his mute cry, "Help me!"

At the end of the session, the wife told me that a few nights previously, she'd said to him that, having realized how hopeless both her marriage and her life were, her only course was to commit suicide. Whereupon, she'd gotten a rope, gone down to the basement, thrown the rope over a beam, put the noose around her neck, and made noises as if she were hanging herself. While doing this, she'd timed him to see just how long it would take him to come "save" her. It took him a full six minutes to make it down the stairs. She, of course, wasn't dead; on the contrary, she was very much alive and in a state of near-psychotic rage.

This first session with them wasn't my finest hour. It'd been a long week, I was tired and hot, and as she shrieked and banged on my furniture, I found myself mentally thumbing through possible DSM diagnoses and wondering why I'd taken up this line of work. That evening, over a drink (when EFT fails, I turn to gin), I berated myself for not responding with the kind of empathy and compassion my own model demands, and vowed that the next time I saw the couple, I'd do better.

When the couple came in the following week, I said I felt I hadn't really heard them last time, and I was sure they'd picked up on that. "I just remember," I said, "a story about a strange-sounding drama that might have had to do with testing a spouse, and I didn't know what to make of it. Could you help me understand?" To the woman, I added, "I think perhaps you were telling me that you were doing something that took incredible courage--courage I don't think I'd have had under the circumstances. Really, it sounds to me as if, in your actions, you were framing a vital question to your husband: ´If I were dying, would you come to me?''

The woman began to cry and said, "Yes, that's what I was doing." She wept for about 20 minutes, dried her eyes, and then said sadly, "I know he can't be my husband. He's a good man, really, but he's not ready to be anybody's husband. I just can't find a way to accept that. And I needed somebody to hear me."

In a sense, this is the fundamental story of our lives--we all need someone to really see us, to hear us, and to be there for us when it really matters. When we can't make sense of our own experience, we desperately want somebody who can make sense of it for us. In good, secure relationships, we get all this from our mates, or some other beloved figure, and it saves our lives. But when we've lost those connections, the power of a therapist to offer validation--to be the eyes and ears and receptive heart for the deepest emotional yearning of each partner--can help them learn how to do the same for each other. To be seen and affirmed, by the therapist and by one's partner, is often a life-transforming event. It's the corrective emotional experience that we were all once taught was the heart and soul of change in psychotherapy.

Susan Johnson, Ed.D., the main proponent of Emotionally Focused Couple Therapy, is professor of psychology at the University of Ottawa and director of the Ottawa Couple and Family Institute and Centre for EFT. She's also a research professor at Alliant University in San Diego, California. The EFT website is www.eft.ca. Contact: soo@magma.ca

 

 

 

When Three Threatens Two

Must Parenthood Bring Down the Curtain on Romance?

by Esther Perel

Sex makes babies. So it is ironic that the child, the embodiment of the couple's love, so often threatens the very romance that brought that child into being. Sex, which set the entire enterprise in motion, is often abandoned once children enter the picture. Why does parenthood so often deliver such a fatal blow?

The transition from two to three is one of the most profound challenges a couple will ever face. It takes time--time measured in years, not weeks--to find our bearings in this brave new world. Having a baby is a psychological revolution that changes our relation to almost everything and everyone. Priorities shift, roles are redefined, and the balance between freedom and responsibility undergoes a massive overhaul.

Eventually, most of us come to recognize ourselves again within this new context of family. For some of us, this is when romance starts to work its way back into the fabric of our lives. We remember that sex is fun; it makes us feel good, and it makes us feel closer.

But while some couples gravitate toward each other again, others slowly wander off on a path of mutual estrangement. Reclaiming erotic intimacy is not always easy. The case is often made that American parents today, regardless of class, are overworked and overwhelmed. We constantly sort conflicting demands into their appropriate hierarchical slots: The Crucial, The Important, The Dreamt of, The Ought-to. Sex often remains firmly at the bottom of the "to do" list, never fully relinquishing its last-place status to other, more mundane tasks.

Why is it that our erotic connection with our partner winds up so demoted? Does it really matter if the dishes aren't done, or is there something more beneath our mysterious willingness to forego sex? Perhaps eroticism in the context of family is simply too difficult for anyone to embrace.



Parenthood, Inc.

Safety and stability take on a whole new meaning when children enter the picture. For children to feel confident enough to go out into the world and explore on their own, they need a secure base. Parenthood demands that we become steady, dependable, and responsible. We plant ourselves firmly on the ground so that our kids may learn to fly.

We do it for our kids, but we also do it for ourselves. Facing the great unknown of parenthood, we try to establish as much security as we can. We seek to contain the unpredictable by creating structure. In the process we cast aside what is frivolous, immature, irresponsible, reckless, for these clash with the task at hand: building family. "I got rid of my motorcycle when Jimmy was born. I'm not allowed to die in a bike crash anymore." "It was all spur-of-the-moment for us before the kids. I'd call Dawn at the office at 5:15 to tell her about a band that was playing at 9:00, and she'd always meet me there. Now we buy season tickets but wind up giving half of them away."

Family life flourishes in an atmosphere of comfort and consistency. Yet unpredictability, spontaneity, and risk are precisely where eroticism resides. Eros is a force that doesn't like to be constrained. When it settles into repetition, habit, or rules, it touches its death.

Many of us become so immersed in our role as parents we become unable to break free, even when we might. "I knew we were in trouble when I couldn't even think about having sex until all the toys were put away," my patient Stephanie reluctantly admits. "And then there are the dishes, the laundry, the bills, the dog. The list never ends. If someone were to ask me, What would you rather do, mop the kitchen floor or make love to your husband?' of course I would pick sex. But in real life? I push Warren away and grab that mop." It's easy to disparage the mop. Like a lot of mothers, Stephanie resents cleaning, even while she feels compelled to pursue the tidy household as an icon of successful motherhood. She finds herself irresistibly drawn to cleanliness, as if order on the outside can bring peace on the inside. And, to some extent, it does. These are activities with immediate and measurable results, far more manageable than the open-endedness and terrors of childrearing.

Children are a blessing, a delight, a wonder. They're also a minor cataclysm. These cherished intruders fill us with a profound sense of vulnerability and lack of control. We dread the thought of something terrible happening to them or worse yet, of losing them. They hold us hostage to constant anxiety. We love them so much, and want to protect them at all costs.

Before Jake was born, Stephanie worked as an office manager in an international shipping firm. She had always planned on returning to work after her maternity leave, but Jake's birth changed that. She couldn't bear the thought of leaving him and, after doing the math, realized that most of her paycheck would go to the babysitter anyway. Five years have passed and Sophia has come along. "With a five year old and a two year old, I'm on mother duty 24/7. If I have any time left, I just want it for myself. When Warren approaches me it feels like one more person wanting something from me. I know that's not his intention, but it's how I feel. I don't have anything left to give."

"When did sexual intimacy become his need only? Do you miss the connection, too?" I ask her.

She shrugs. "Not really. I keep thinking that it will come back, but I can't say I miss it."

While Stephanie's desire has remained stagnant, Warren's frustration has risen exponentially. "I've tried everything," he tells me. "She asks for help, I give her help. I do the dishes, I let her sleep late on the weekends, I take the kids out so she can have some time to herself. But, you know, I work, too. I'm meeting deadlines all day long. It's not like I'm having a picnic. She thinks all I want is to get laid, but that's not it. I want to come home and be with my wife sometimes. But all I get is a woman who's become all mother."

"Have you seen the movie Before Sunset ?" I ask him. "At one point the main character, Jesse, says that he feels like he's running a daycare with someone he used to date."

"Exactly!" he snaps.

Eros Redirected

Stephanie bursts with creativity: art projects, nature walks, trips to museums and fire stations, puppet shows, cookie-cutting, cookie-baking, cookie-parties. If we think of eroticism not as sex per se, but as a vibrant, creative energy, it's easy to see that Stephanie's erotic pulse is alive and well. But it no longer revolves around her husband. Instead, it's been channeled to her children. Regular play-dates for Jake but only three dates a year for Stephanie and Warren: two birthdays, hers and his, and one anniversary.

Which brings me to another point. Stephanie gets tremendous physical pleasure from her children. Let me be perfectly clear here: she knows the difference between adult sexuality and the sensuousness of caring for small children. She, like most mothers, would never dream of seeking sexual gratification from her children. But, in a sense, a certain replacement has occurred. The sensuality that women experience with their children is, in some ways, much more in keeping with female sexuality in general. Female eroticism is diffuse, not localized in the genitals but distributed throughout the body, mind, and senses. It is tactile and auditory, linked to smell, skin, and contact; arousal is often more subjective than physical, and desire arises on a lattice of emotion.

In the physicality between mother and child lies a multitude of sensuous experiences. We caress their silky skin, we kiss, we cradle, we rock. We nibble their toes, they touch our faces, we lick their fingers, let them bite us when they're teething. This blissful fusion bears a striking resemblance to the physical connection between lovers. In fact, when Stephanie describes the early rapture of her relationship with Warren--lingering gazes, weekends in bed, baby talk, toe-nibbling--the echoes are unmistakable. When she says, "At the end of the day, I have nothing left to give," I believe her. But I also have come to believe that, at the end of the day, there may be nothing more she needs.

The Cult Status of Children

The sensuous pleasure of caring for small children is natural and universal. It is also wise from an evolutionary standpoint--the mother's bond to her child is a powerful physiological response that has been selected for since humans were apes. The infant's survival depends on it. However, I'd like to make a distinction between the parent-child bond, on the one hand, and a recent culture of childrearing that has inflated that bond to astonishing levels on the other.

Stephanie's intense focus on her kids is not a mere idiosyncrasy of her mothering style. In fact, this kind of overzealous parenting is a fairly recent trend that has, one hopes, reached its apex of folly. Childhood is indeed a pivotal stage of life whose future repercussions are indelible. But the last few decades have ushered in an emphasis on children's happiness that would make our grandparents shudder. It's a far cry from the days when children were considered principally as economic assets to the collective, and women gave birth to many in the hope of keeping just a few. We no longer get work out of our children; today we get meaning.

Meanwhile, American individualism, with its emphasis on autonomy and personal responsibility, has left us between a rock and a hard place when it comes to family life. On one hand, we have children vested with sentimental idealization and a culture of childrearing that demands considerable emotional and material resources. On the other, we have a society notably lacking in the public support necessary to complete this fundamental project. We are left with isolated domestic units: overworked parents deprived of extended families, kinship networks, or real institutional assistance.

The magnitude of childrearing, coupled with the scarcity of resources, affects mothers in particular, who carry the majority of the burden in heterosexual couples. And it doesn't end there. For this unprecedented child-centrality is unfolding against the backdrop of romanticism that underscores modern marriage. Not only do we want to be perfect parents, to give our children everything, we also want our marital relationships to be happy, fulfilled, sexually exciting, and emotionally intimate. Indeed, in our culture the survival of the family depends on the happiness of the couple. But cultivating the ideal relationship requires care and attention, and this competes directly with the "full-contact" parenting many of us embrace.

Warren Wants His Wife Back

Stephanie and Warren embody a common marital configuration: she is wrapped up with the kids, exhausted, and uninterested in sex; he is frustrated and lonely. Warren feels displaced, and claims he's been fed a litany of excuses for years. By the time they come to see me, they're locked in a pattern. He initiates, she rebuffs, he feels rejected and withdraws, she feels emotionally bereft and even more distrustful of his sexual motives. They blame each other for their sexual unhappiness, and each holds the other responsible for making it better.

I am worried about them, and I let them know it. I am worried not because I think that a couple without sex can't have a viable relationship--the absence of sexual desire, when it's mutual, is not necessarily an indicator of dissatisfaction. However, and this is a big "BUT," if one partner really misses sex, and can't engage the other, a pernicious downward spiral is set in motion.

What Stephanie fails to see is that behind Warren's nagging insistence is a yearning to be intimate with his wife. For him, sex is a prelude to intimacy, a pathway to emotional vulnerability. She responds to him as if he's one more needy child, and doesn't realize that this is not just for him but for her, too. She's so mentally organized in terms of what she does for everyone else that she is unable to recognize when something is offered to her.

What Warren finds intolerable is that his approach is having the opposite effect of what he intends. He is desperate for a flicker of desire from Stephanie, but he wants it just to be there, sudden and whole, the way it is for him. I explain to him that expecting our partner to be in the mood just because we are is a set-up for disappointment. We take their lack of desire as a personal rejection, and forget that one of the great elixirs of passion is anticipation. You can't force desire, but you can create an atmosphere where desire might unfurl. You can listen, invite, tease, kiss. You can tempt, compliment, romance, and seduce. All of these help to compose an erotic substrata from which your partner can more easily be lifted.

Even before having children, Stephanie's sexuality was always more receptive than initiating, and she rarely experienced spontaneous desire. In those days, Warren's role was lavishly complementary: her coyness was dissipated by his assertiveness. He not only made her feel desired and desirable, he also made her feel desirous. He would entice her slowly, gradually awakening her senses, and she would eagerly respond. This responsiveness, so marked in the early days of their courtship, temporarily masked her long-standing lack of sexual agency (a characteristic shared by many women). I point out to him that she might be more receptive today if he paid attention to cultivating her desire rather than simply monitoring it.

"Stephanie needs you to take the lead, but you can't just buy her a ticket, you have to get her interested in the trip." I tell Warren." You play an important role as the keeper of the flame. Right now, all she feels is pressure. She experiences your come-ons as abrupt and intrusive. She thinks all you want is sex. Prove to her you don't."

Looking for Stephanie

It was harder for me to reach Stephanie, for neither she nor I could easily separate ourselves from the abundance of ideological pressures that lurked beneath the surface of our conversation. Validating her husband's needs could easily be construed as denying hers. How to invite a woman to reconnect with her body and her sexuality, separately from her children, when she's completely uninterested in either, or when she feels undeserving or too maxed out? How to avoid the pitfall of swinging back and forth between her children's needs and her husband's needs, leaving her own perennially unattended?

What I said to her was this, "You'll never hear me say that you should force yourself. Nothing is more deflating erotically than sex on demand. But I do believe that sex matters: for you, for your marriage, and for your kids. I am puzzled by your willingness to forego such an important part of yourself. How did it come to be that, on the extensive list of things your children need, parents who have sex isn't one of them?"

Together we probe the elusiveness of her sexual agency. We explore her sexual history, how sexuality was expressed in her family growing up, and what her earliest experiences were like. She tells me how awkward her own mother was around the subject of sex, never speaking frankly but only making veiled references to morality and sin. She has never conceived of her mother as a sexual being, and it doesn't escape me that history might be repeating itself.

We talk about how her sexual identity changed as the result of pregnancy, childbirth, nursing, and motherhood. Putting her personal experiences in a broader cultural context, we discuss how the politics of motherhood, the chastity myth, and the medicalization of pregnancy and childbirth all conspire to denude motherhood of its sexual elements. I recommend the gem of a book Sexy Mamas by Cathy Winks and Anne Semans, which discusses the topic of sexuality and motherhood in an accessible, down-to-earth, and sex-positive way. I suggest she leave it in plain view on her bedside table.

Together we explore how she might reclaim a right to pleasure, with its inherent threat of selfishness, in a way that doesn't leave her feeling like a bad mother. One upshot of these discussions is that Stephanie does something radical (for her)--she goes on a weekend retreat with her sister, leaving Warren and the children to their own devices. Getting to that point took a lot of work, but I sense that before she can open herself to sex, she needs to expand the domain of personal pleasure altogether.

I'm not big on homework in therapy, especially when the list of domestic tasks is already endless. At the same time, action is a prerequisite for change. So I ask Warren and Stephanie, at the end of one session, to each do one thing differently in the next few weeks. They need not talk about it, for their effort will not be measured by its success but only by its intention. "I'd like you to stretch, to do something, anything, that takes you a step further than usual." To Warren I say, "At one time you pursued Stephanie with great creativity, but no more. There's an assumption--and you're not alone--that we need only pursue what we don't yet possess. The trick is that in order to keep our partner erotically engaged we have to become more seductive, not less."

At this point, sex has been relegated to what Warren wants and what Warren misses. Stephanie has shifted from being receptive to being reactive. It is a passive stance in which her main power is that of refusal. To her I suggest, "Keep in mind that there's something limiting about an absolute no. What really hurts him is categorical rejection. You might find more freedom in "maybe" or "let's kiss" or even "talk me into it." Warren, more than anyone else, can help you to reconnect with the woman inside the mother. Can you imagine recruiting him rather than pushing him away? Invite him to invite you, and see what happens."

Stephanie, consumed by motherhood, was too quick to dismiss the inherent value of Warren's persistence. With him, and through him, she potentially can begin to disentangle from the symbiotic bond with her children and transfer some of her energy back to herself and her relationship. When the father reaches out to the mother, and the mother acknowledges, redirecting her attention, it serves to rebalance the entire family. Boundaries get drawn and new zoning regulations get put in place delineating areas that are adult only. Time, resources, playfulness, and fun are redistributed, and libido is rescued from forced retirement.

My work with gay and lesbian couples has led me to recognize that this dynamic is replicated whenever one parent takes charge of the kids, gender notwithstanding. What I see over and over is that the person who takes on the role of primary caretaker almost always undergoes changes similar to Stephanie's.

The role of the more autonomous parent is to help the primary caregiver disengage from the kids and reallocate energy to the couple. "Leave the toys for now, nobody is going to give you a medal, go take a nap." "The nanny is here, let's sit down for ten minutes and share a glass of wine before she leaves." It's a different approach to the traditional "division of labor," one which emphasizes shared responsibility and mutuality and honors the interdependent agency of both partners.

Lifting the Erotic Embargo

When Warren asks, "Want to?" and Stephanie finally answers, "Convince me," their dynamic begins to shift. It puts a halt to the grinding antagonism and introduces an overdue mutuality. The couple is headed in the right direction, but the forces of eros are not yet aligned. Warren's most elaborate seduction rituals are thwarted, repeatedly and pitifully, by an unaccommodating home life.

If Warren and Stephanie are going to get their groove back, they need to free themselves from the disproportionate focus on their kids, both emotionally and practically. As much as spontaneity is desirable, the reality of family life demands planning. Couples without kids can initiate sex on a whim, but parents need to be more practical. Be it a regular date night, a weekend away every few months, or an extra half-hour in the car, what matters is that the couple cordons off erotic territory for themselves. When Warren and Stephanie balk at the idea of premeditated sex, I respond, "Planning can seem prosaic, but in fact it implies intentionality, and intentionality conveys value. When you plan for sex, what you're really doing is affirming your erotic bond. It's what you did when you were dating. Think of it as prolonged foreplay--from twenty minutes to two days."

Not only do their rendezvous help maintain the emotional connection so critical for Stephanie, they also help her to make the transition from full-time mom to lover. "For so long, my thinking about sex was about how to avoid it. Knowing that Warren and I have a date has helped me to anticipate it instead. I pamper myself. I take a shower, shave my legs, put on make-up. I make a special effort to block the negativity and to give myself permission just to be sexual."

My work with them isn't finished. Things have definitely improved, but for this couple, and for this woman, caring for small kids doesn't agree with eroticism. I suspect that when they reach the next life stage--when the kids are both in school full-time and Stephanie is back at work as she plans--new energies will be released. In the meantime, thinking of it as but one phase in a life-long relationship helps them remain patient and hopeful.

Sexy Mamas Do Exist

The liberation that so bolstered women's sexuality has yet to cross the threshold of motherhood, which has not lost the moralistic aura of sanctification it always had. The desexualization of the mother is a mainstay of traditionally patriarchal cultures, which makes the sexual invisibility of modern, Western mothers seem particularly acute. Perhaps it's our Puritan legacy that strips motherhood of its sexual components, convincing us that lustfulness conflicts with maternal duty.

Of course, there is not one America, and cultural differences abound within this vast country. My friend June is quick to remind me that not all Americans came here on the Mayflower. "Black people are certainly not spared our share of sex problems, but we're definitely a lot less hung up than you white folks," she says. "Sex is a natural part of life, not some big dirty secret. My kids know I have sex; I knew my parents had sex. They'd put on Marvin Gaye, shut the bedroom door, and tell us we better not knock." My Argentinean girlfriend jokes about how her husband calls her "mamita" in bed--what better way to co-opt the taboo? My Spanish colleague Susanna tells me that, in Madrid, her greatest sexual asset is her beautiful three-year-old son. "In New York it's my accent, my hair, my legs, but definitely not my son." My American patient Stacey, a white woman who lives in Brooklyn with her daughter, knows her demographics. "The only men who flirt with me are the West Indian pediatrician, the Russian dentist, the Italian baker, and the Puerto Rican grocer. The white guys? Forget it. If I'm with my kid, they look right past me."

Despite the pervasiveness of this mindset, there are plenty of women who mount daily insurrections against the denial of eros. For them, motherhood heralds a newfound sexual confidence, a womanliness, and even the restitution of a wounded body. One day, I had back-to-back sessions, first with Stephanie, then with Amber. The realities of their daily lives shared an uncanny resemblance, but their experiences couldn't be farther apart. Amber told me, "I used to say no to sex as a matter of course, who knows why? Denial of any desire, even hunger, was modeled for me by my 105 lb. mother. Before I had kids, whenever my husband asked me if I wanted to eat, I also said no. I refused out of habit, before actually registering the question.

"Now I know far more profound reasons to say no to sex: the desperate fatigue of new motherhood, the seemingly bottomless rage at my 2 1/2-year-old for waking up his sleeping infant brother, the bitterness of feeling unsupported, a workhorse for our home and children. And yet I am the one who feels hungry for sex, who demands it, or mopes about not getting it. I give all day in very physical ways: nursing, cooking, stooping to pick up toys, carrying children, changing diapers. After a few days of peanut butter sandwiches and Wiggles CDs, when I am a participant in my children's world to the exclusion of my own, I want my glass of sherry, my music, and my man."

For Renee, pregnancy ushered in a self-acceptance she had never felt. "Pregnancy was a healing experience for me. I was sexually abused as a child, and had always loathed any signs of womanliness in my body. I'd been at war with my thighs for twenty-five years. I was hospitalized for an eating disorder the year before I got pregnant. In fact, I was so skinny I didn't even think I could get pregnant. I hadn't had a regular period in years. But the minute I saw that plus sign in the ept everything changed. It was the first time in my life that food became decontaminated. I relished watching my body grow ripe. For once in my life my breasts were naturally round and I was so proud. Most of my friends complained of the discomfort and weight gain. But for me, I felt like it was finally okay to look like a woman. I gave birth naturally; it was powerful. I was amazed by what my body could do and what it could endure. I was capable of so much more than I thought. Ever since, when I make love, I pursue that intensity."

When Daddy Sings the Baby Blues

For every man like Warren, who feels sexually abandoned when his wife becomes a mother, there is a man like Leo, whose libido makes a break for it on the way home from the delivery room. Dwindling desire in mothers is, in some ways, old news. We might not like it, but we can at least make sense of it. But what are we to make of the father who can no longer eroticize the mother of his children? This story, though just as common, is admitted far less frequently.

When Carla and Leo came to see me, she was at wit's end. They'd been together seventeen years: the first six a frenzy of the flesh, the next four the chaos of babyhood, the last seven a sexual desert. She went from talking to pleading to screaming to compensating. She had a number of flings and then a serious affair. He found out, she threatened divorce, he suggested therapy, and here they are.

She says, "I am so sick of the excuses. It's his work, it's the stress, it's his dying father, his back hurts, it's my breath, it's my weight, it's his weight. I took it personally for so long, but now I'm done. I love this man, I'm prepared to stay, but I can't live like this."

He says, "I always considered myself to be very competent sexually. We kid around that we broke furniture when we first started dating; there was a lot of passion. I never looked at the kids as a defining moment in my life sexually, but obviously something switched somewhere deep inside."

I learn that Leo had begun to withdraw physically when Carla became pregnant with their first son, and they had no sexual contact at all during the last trimester. Leo just came home later and later from work. Carla knew something was up, though they never discussed it openly.

"What changed for you when she became a mother?" I ask.

"Her significance," he answers. "Her whole being turned from being my lover, my partner and wife, to being the mother of my son. And then the mother of my other son. For a while they needed her completely, and that was really okay with me. I thought it was the most awesome thing in the world to have our babies sleeping next to us, for her to nurse them through the night. I wasn't jealous at all. I'm a very loving, nurturing father myself."

"What's it like to suck the breast of a woman who's been nursing a baby?" I ask him.

"It was weird," he answered. "The whole physical thing was a little weird. I watched her give birth, twice, and I gotta say it was not so great for our sex life."

"I know it's supposed to be this magical moment, the miracle of life and all that, but no one seems to want to acknowledge the yuck factor," I reassure him.

"I became different with her, more cautious, not as free. I guess it stopped me from being aggressive or passionate or desiring her in that way--really giving myself to her, or taking her, when normally that's how we were together. It was definitely a shift."

"Couldn't do that to the mother of your children?" I ask.

"Apparently not," he answers.

"Let's talk about this whole Madonna/ whore business," I continue. "It has deep psychological roots. A lot of men find it difficult to eroticize the mother of their children. It feels too regressive, too incestuous, too Oedipal. What you need to remember is that she's their mom, not yours. At this point, I recommend anything that can introduce a little healthy objectification. Anything that might distinguish her from The Mother."

Carla had been quiet for much of the session, but the following week I had no doubt she'd been paying attention. Laughing, she told me the story.

"I really wanted to let go with Leo. I wanted to give him an involved, prolonged, great blow job. Not just the compulsory head, not just the polite head. But I knew there was this thing with the wife, The Mother. Would he let me? So I initiated this game and said, [bullet]You know, we can have a couple different kinds of sex and you can call it what you will, but if you want this blow job to continue it's gonna cost you.' I said, "A hundred bucks if you want that kind of head. A hundred bucks." I thought the money would be fun, but I was really into seeing if Leo could de-role that mother. Well, you don't pay the mother of your kids for a blow job, do you? You don't pay your wife for a blow job. It was a lovely experiment, that's all I'm going to say."

"Maybe you could start taking credit cards. Keep a credit card machine by the bed," Leo jokes.

Carla's playful erotic intervention has stayed with me for years. In one gesture she cleverly captured and subverted the whole dilemma: how to retrieve the lover from the mother. Leo feared expressing the rawness of his desire to the mother of his children, a woman too worthy of love and respect. Carla took a risk, interrupted the pattern, and invited him into an erotic complicity.

Escaping the Siege of Family Life

Having a child is a pure, life-affirming act. How cruel it is to see it erode the force that brought it into being.

There is no question that children make the erotic connection more difficult to sustain.

For many parents, the idea of a secret garden inspires everything from acute guilt and anxiety to the more benign gradations of embarrassment. We are afraid that our adult sexuality will somehow damage our kids, that it's inappropriate or dangerous. But whom are we protecting? Children who see their primary caregivers at ease expressing their affection (discreetly, within appropriate boundaries) are more likely to embrace sexuality with the healthy combination of respect, responsibility, and curiosity it deserves. By censoring our sexuality, curbing our desires, or renouncing them altogether, we hand our inhibitions intact to the next generation.

There are so many reasons to give up on sex that those who don't are champions in their own right. The brave and determined couple who maintains an erotic connection is, above all, the couple who values it. When they sense desire in crisis, they become industrious, and make intentional, diligent attempts to resuscitate. They know that it is not children who extinguish the flame of desire: it is adults who fail to keep the spark alive.

From Mating in Captivity by Esther Perel. Copyright © 2006 by Esther Perel. Reprinted by permission of HarperCollins Publishers. Esther Perel, M.A., is on the faculties of the New York Medical Center, Department of Psychiatry, and the International Trauma Studies Program, New York University. She's a visiting faculty member at the Minuchin Center for the Family and is in private practice in New York City. Contact: eperel@earthlink.net

 

 

 

From Research to Practice: Scoreboard for Couples Therapies

Which are the Winners in the Latest Research?

by Jay Lebow

Couples therapy is on a roll. Whereas a mere 20 years ago, surveys showed that consumers didn't think much of it, today it's become increasingly accepted by the general public. Indeed, to end a marriage without benefit of some sort of marital therapy or counseling is now widely viewed as somehow irresponsible--as if the couple were remiss for not making that last-ditch effort to put themselves back together again. And whereas, two decades ago, the most prominent models of therapy focused almost exclusively on individual work, today as many as 70 percent of therapists here and abroad treat couples as part of their practices, according to a study conducted by prominent psychotherapy researcher David Orlinsky of the University of Chicago and his colleagues around the world.

Yet the research about couples therapy, as well as research about couples themselves--why some marriages succeed and others don't--hasn't kept pace with the growth of couples therapy. The slow pace of research on couples is partly due to the fact that relational distress isn't considered a "mental disorder" by DSM-IV, and thus doesn't usually qualify for government funding. In addition, researchers and clinicians have only recently recognized how important couples therapy can be in the treatment of such individual mental health problems as depression and anxiety. Even now, those researching the behavior of couples and couples therapy treatments have been limited to a small group of investigators dedicated enough to continue their work despite sporadic funding.

In spite of these handicaps, a considerable body of information has emerged that tells us a great deal about what works and doesn't work, both in couples' relationships and in couples therapy. The two strands of research inform each other: learning the specific differences between the ways couples interact in satisfying and unsatisfying relationships serves to pinpoint helpful behavioral, cognitive, and affective skills that therapists can encourage in their clinical work.



Research on Interactive Processes

What do we know from research about interactions between spouses that either promote or undermine good marital relationships? One fact that's been established is the not entirely surprising finding that satisfied couples manifest in their exchanges much higher rates of positive behaviors than of negative ones. Researcher John Gottman, now of the Gottman Institute in Seattle, Washington, one of the leading authorities on couples' behavior, who's meticulously documented the interactions of couples for more than 30 years, has been famously quoted saying that the ratio of positive to negative behaviors is at least 5 to 1 in satisfied couples. The types of behavior to which he's referring vary--remarks to each other, body language, helpful vs. challenging acts, and so forth. But this finding from his research with Julian Cook and several other colleagues in 1995 has been widely replicated in studies since then by him and others.

Gottman reports that if this ratio falls below the 5-to-1 level, couples are likely to be dissatisfied with their marriages. In those likely to divorce, the ratio hovers around 0.8 positive acts for every negative one. Gottman adds that really happy couples typically have ratios of positive to negative behaviors even higher than the 5-to-1 level.

This research has made therapists more aware of the importance of helping couples understand the long-term impact of their everyday, moment-to-moment interactions. They can then be taught to monitor their own remarks and behaviors and find ways of increasing the ratio of positive to negative exchanges with their mates. In fact, teaching this skill has become an essential ingredient of a variety of couples therapies, such as Douglas Snyder's Affective Reconstruction Treatment and Mona Fishbane's dialogical approach.

Satisfied couples communicate well and approach problems in a spirit of collaboration rather than antagonism; unhappy couples just continue being angry about the same old problems, while new ones accumulate. Numerous studies have pointed to the relationship advantages of direct communication and developing successful methods of problem-solving. Most couples therapies therefore build in a didactic-experiential set of interventions to help couples learn or regain their abilities to communicate and tackle problems. For example, couples are taught to clearly state their desires and complaints, to listen even when emotionally aroused, to brainstorm potential solutions that bridge differences, and to be sure to follow through on decisions.

Gottman reminds us, however, that even in satisfied couples, many problems are never actually "solved" throughout the duration of the marriage. Arguments often arise over the same issues throughout the course of a 40-year marriage. Spouses may never share the same interests, political perspectives, or social proclivities, and may repeatedly revisit differences over such issues as neatness and promptness. Nonetheless, the couple can learn how to "agree to disagree"--accept each other and certain differences, show respect, friendship, and love, and work around their problems without undue conflict, even if the issues in question never are finally resolved.

Another hallmark of satisfied couples is that they argue successfully and have ways of resolving differences. Gottman's research is especially relevant here since the general public often believes that happy couples simply don't argue. Not at all! In fact, being able to argue effectively--express differences in a way that doesn't sidetrack the discussion into old grudges and conflicts, or devolve into personal attacks--seems to be an essential skill of satisfied couples. Those lacking this skill fall prey to the accrual of unresolved issues and resentments, leading to patterns of defensiveness and contempt that undermine connection.

This research into the importance of knowing how to argue has generated treatment interventions that teach fair fighting and authentic repair--how to make up with each other. One means of making arguments fairer and less toxic to a relationship is the process of "softening," highlighted by couples therapy researcher Susan Johnson, psychology professor at Ottawa University. Teaching couples to achieve a moment by moment opening up and lowering of defenses in the face of conflict, which Johnson believes is critical for putting antagonistic relationships back on track, is a key component of her Emotionally Focused Couple Therapy.

Not ambushing the other person also makes fighting more productive. Gottman's couples therapy helps partners find alternatives to the overly rapid start-up of disagreements, in which one partner, more or less without preamble, blasts the other with his or her grievance, which generates emotional flooding and overwhelming states of arousal in the other.

Another feature of satisfied couples is that they accept each other and display what Gottman calls "positive sentiment override," referring to the overall positive regard they have for each other. This well of positive feeling shapes the way they approach potentially difficult marital issues and tends to immunize them against automatic patterns of blame and counterblame. Following the implications of this notion, several recent approaches, such as Integrative Behavioral Couple Therapy, developed by the late Neil Jacobson and Andrew Christensen, now emphasize mutual acceptance more than behavior change. In this model, couples are taught to distinguish between problems that can be changed and those that can't, or aren't worth the effort. Partners are helped to find ways to live with the unchangeable issues by engaging in self-talk that emphasizes the other's positive intent and the feeling of love that overrides the annoyance of the problem--that he or she can never learn to be less messy, for example.

Satisfied couples have secure attachments with each other that still allow room for the other to be him- or herself. Research indicates that those with secure attachments earlier in life are more likely to be able to create such attachments in marriage. Susan Johnson has found in more than 20 years of couples research and therapy that good marriages are based on deep, mutually dependable, responsive, accessible connections between partners--reflecting the secure attachment bonds of a mother and infant. Such bonds, she argues, give couples (and very young children, for that matter) a safe emotional base from which they can freely and without anxiety explore their own individual personalities and pursuits.

Satisfied couples share expectations, but only to a "good enough" extent. What matters for marital happiness is that the two partners share some overlap in their expectations of what a successful marriage "should" be and of what each owes to the other. But beyond that basic agreement, happy couples can be close or relatively distant from each other--passionately involved in each other's lives or living almost separately. Individual partners may be high powered and success oriented or low key and laid back--oriented to material rewards or spiritually inclined.

By contrast, the most distressed couples display high levels of defensiveness, criticism, contempt, belligerence, and stonewalling with each other. In the longitudinal research of Gottman and his colleague Robert Levinson, these characteristics during interactions between spouses, often displayed nonverbally in expressions and gestures of one partner toward the other--rolling eyes, disdainful sneer, arms folded across the chest, sarcastic tone, tight lips, narrowed eyes, etc.--emerged as the best predictors of divorce and of intractable marital distress.

Research Assessing Couples Therapy

The research on couples' relationships has helped identify the key focal points in marriages that should be the targets of therapeutic interventions. In parallel, a second set of investigators has begun to develop a significant body of work assessing whether couples therapy works and, if so, which interventions work best. The findings from these studies show that couples therapy is generally effective in reducing distress in relationships. The metanalysis produced by William Shadish and Scott Baldwin, for example, finds effect sizes for couples treatments to be in the same range as those for individual therapy--typically helping three out of four couples.

Couples therapy, both alone or in combination with other interventions, also has been demonstrated to be effective for treating several individual disorders. such as depression, anxiety disorders, and substance abuse. Two quite different factors appear to account for this result. First, partners can play a useful role in encouraging and supporting treatment in a partner. For example, Barbara McCrady of Rutgers University and the team of William Fals-Stewart from the Research Institute on Addictions in Buffalo, N.Y., and Timothy O'Farrell from Harvard Medical School have shown that one partner can help the other more fully engage in treatment, and encourage him or her to behave in ways that reduce the likelihood of substance abuse. The second factor stems from the remarkably high rates at which marital distress occurs along with individual disorders. In a recent national study of comorbidity, Mark Whisman of the University of Colorado found that 28 percent of individuals in distressed marriages also suffered from anxiety disorders, 15 percent met criteria for a diagnosis of depression, and 14 percent for

substance-use disorder. Thus, for a subset of individuals with these disorders, it's an open question whether the more pivotal problem is the individual disorder or the marital distress.

Following this logic, two different research groups--Steven Beach and Daniel O'Leary, then of the State University of New York, Stony Brook, and Neil Jacobson and colleagues--each found that a behavioral form of marital therapy was an effective treatment for individual depression affecting partners in distressed marriages. And whereas individual treatment in these studies also was shown to have an effect on individual depression, only the marital therapy had any effect on the marital distress. Marital therapy thus emerged as the treatment of choice for those with both depression and distressed marriages.

Research has shown that vastly different forms of marital therapy have a positive impact, and each has an overall level of impact similar to the other treatments. As in every form of treatment research, there have been demonstrations of the effectiveness of cognitive-behavioral approaches, but there also have been numerous studies demonstrating the impact of Susan Johnson's Emotionally Focused Couple Therapy. Additionally, two of the best studies in this field have focused on the psychoanalytic-intergenerational treatment called Insight-Oriented Marital Therapy, developed by Douglas Snyder, and a treatment focused on acceptance of one's partner, Andrew Christensen and Neil Jacobson's Integrative Behavioral Couple Therapy.

The cognitive-behavioral therapies accentuate learning and engaging in more skillful marital behaviors, such as communication and problem-solving. Emotionally Focused Couple Therapy centers on building secure attachment between partners through uncovering and nurturing the soft feelings of vulnerability and connection that lie beneath conflict. Insight-Oriented Marital Therapy helps couples understand partners' experiences in their families of origin, and how their family background affects or promotes difficulties in their relationships. This mode of therapy ultimately challenges engrained patterns of interaction. Integrative Behavioral Couple Therapy accentuates developing skills for living with one's partner and accepting the aspects of the other's behavior that can't be changed. Each method shows success in approximately 75 percent of couples. As Alan Gurman of the University of Wisconsin has suggested, it seems clear that there are many routes to the goal of changing the experience of being a couple.

Another finding is that aspects of treatment related to the process of therapy, such as the generation of a positive therapeutic alliance, play a crucial role in the treatment's success. Couples therapy is notoriously difficult. Clients often seek help only after problems have become nearly intolerable. By the time a clinician sees them, one of the partners may have pretty much written off the entire marriage, which undercuts his or her motivation to establish a strong, working relationship with the therapist. Thus, alliances between clients and the therapist are fragile early in treatment.

Studies by Lynne Knobloch-Fedders and William Pinsof of the Family Institute at Northwestern, like other investigations, demonstrate that early alliance predicts treatment outcome. Their findings suggest that therapists must be especially sensitive to what Pinsof calls the split alliance, in which one person feels allied with the therapist and the other doesn't.

In general, research data--even from a small body of studies--make a powerful case for the effectiveness of couples therapy. Yet the same data provide clear indications of its shortcomings.

Most studies show that the impact of these therapies on couples can be limited. When the treatment is successful, couples frequently don't reach a level of genuine marital well-being characteristic of genuinely happy unions, even though they're less dissatisfied, and their marriages work somewhat better. Then treatment isn't always successful, so the relationships of a significant percentage of couples in most studies simply don't improve at all. It appears that with enough bad feeling and erosion of John Gottman's "positive sentiment override," couples have a hard time making real progress in therapy. In addition, even when couples experience a positive outcome, the effects may not last. The few studies that have conducted follow-ups of clients over several years frequently find regression in levels of marital satisfaction over time. This has been the case particularly with Behavioral Couples Therapy, the approach with the most follow-up studies. These findings suggest that long-term marital distress has many of the properties of a chronic condition, and may be similarly resistant to treatment.

Yet some approaches show promise of generating positive outcomes that do last. The study by Snyder and Wills of Insight-Oriented Marital Therapy showed remarkable stability in the positive effects over a five-year period. This suggests that spouses who develop insight into their problems may have better results over the long haul.

Others approaches appear to be effective even with couples who have a long history of unhappiness in their marriages. The study of Integrative Behavioral Couple Therapy by Christensen, Jacobson, and colleagues showed a clinically significant impact on an extremely distressed sample of couples. Couples included in this study displayed a high degree of marital distress in a three-step screening process and had experienced marital discord for many years. Surprisingly, 71 percent of these couples improved following treatment, moving into the range of couples in nondistressed marriages on the Dyadic Adjustment Scale, the most widely used measure of marital satisfaction.

Despite these findings of effectiveness, surveys sometimes have shown a low regard for couples therapy. In a 1995 survey conducted by Martin Seligman, Consumer Reports asked readers who'd undergone therapy, either individual or marital, for their opinion of its impact on their lives. The results demonstrated that individual psychotherapy clients were almost universally satisfied, while clients of marital counselors had the highest rates of dissatisfaction--approaching 50 percent of the sample.

It may be that this finding reflects the results for clients who'd simply entered marital therapy too late and/or under duress, for whom treatment probably would have been short-lived and unsuccessful. It also may be that what respondents described as marital counseling may have little connection with what we now think of as marital therapy. However, to the extent that such negative attitudes are still held today, the field needs to find ways to make even those couples whose marriages aren't helped feel that seeing a marital therapist is worthwhile on some level--if only because they learn something about themselves individually or about why their marriages failed.

In sum, there are now four empirically supported methods of practice for which positive outcomes have been demonstrated: Behavioral Couples Therapy, Emotionally Focused Couple Therapy, Integrative Behavioral Couple Therapy, and Insight-Oriented Marital Therapy. We also should highlight, as Al Gurman has for many years, that there are many forms of couples therapy, such as Bowenian and narrative therapy, which may be effective but haven't been studied yet.

The totality of this body of research offers us the security of knowing that what we do as couples therapists truly does make a difference. However, there's a great deal that we still don't know about what can help couples improve their relationships most effectively and about how to foster changes that last.

Resources

Gurman, Alan S., and Neil S. Jacobson (eds.). Clinical Handbook of Couple Therapy. 3rd edition. New York: Guilford Press, 2002.

Jacobson, Neil S., and Andrew Christensen. Acceptance and Change in Couple Therapy: A Therapist's Guide to Transforming Relationships. New York: Norton, 1998.

Johnson, Susan M. The Practice of Emotionally Focused Couple Therapy: Creating Connection. 2nd edition. New York: Brunner-Routledge, 2004.

Snyder, Douglas K., A. M. Castellani, and Mark A. Whisman. "Current Status and Future Directions in Couple Therapy." Annual Review of Clinical Psychology 57 (2006): 317-44.

Whisman, Mark A. "Marital Dissatis-faction and Psychiatric Disorders: Results from the National Comorbidity Survey." Journal of Abnormal Psychology 108, no. 4 (November 1999): 701-06.

Jay Lebow, Ph.D., is a contributing editor to the Psychotherapy Networker and clinical professor at Northwestern University. He's also senior therapist and research consultant at the Family Institute at Northwestern University. Contact: j-lebow@northwestern.edu. Letters to the Editor about this department may be e-mailed to letters@psychnetworker.org.

 

 

 

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


Resources

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: www.behavioraltech.com.

 

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