Panning for Gold

Michael White is the Ultimate Prospector

by Mary Sykes Wylie

 

ACCORDING TO AUSTRALIAN THERAPIST MICHAEL WHITE, a disconcerting effect of his new celebrity on the international therapy conference circuit is the recurrent experience of getting off a plane, being met by a workshop sponsor and told something like, "We sure have a real humdinger of a family for your live consultation. Oh, and by the way, about 500 people have signed up to watch." Whereupon White, the most visible representative of what is loosely called the "narrative method" of therapy, is plunked down in front of an impossible situation, while the audience waits breathlessly for a therapeutic miracle. White, who finds the hoopla attached to his new status puzzling, denies that there is anything magical about what he does. He says he is just very "thorough," very painstaking, and that "it's silly that people expect to get a good idea of this kind of work by setting me up in one meeting with the most complex situations they can find." Then he adds, "Certainly, the idea that I've got all the answers doesn't fit the spirit of the work."

Nonetheless, over the past decade, White has developed a worldwide following of both senior therapists and neophytes on several continents who insist he has something vitally important to say that the field needs to hear. But it can hardly be his therapeutic style that explains his elevation to the ranks of the illuminati. Watching him in session is a far cry from seeing one of the recognized lions of clinical performance sweep grandly into the middle of a dysfunctional family circle and in one session transform it into a little kingdom of love and harmony, while being wildly entertaining in the process. Far from it. His pace is measured, even monotonous some find it maddeningly slow the therapeutic persona respectful, solicitous, inquisitive, slightly donnish, almost deferential, the circuitous language an eccentric mix of the folksy and the politically correct. It is hard to imagine the following questions appearing in any psychotherapy textbook: "Do you know how you got recruited into these habits of thought that have been so capturing of your life?" "What skills have you developed as a couple that allowed you to hold on to your relationship in the face of adversity, and in spite of the politics of heterosexist dominance and ageism that marginalize your ways of being?" "What's it like for Anorexia Nervosa, which has been pulling the wool over your eyes, to witness these recent, more positive developments in your life?"

During sessions, White hunches down in his chair over his notes he seems almost to recede from view. He almost never asserts anything, rarely utters a declarative sentence, just patiently asks questions, hundreds of questions, often repeating back the answers and writing them down. Like an archaeologist, White sifts through the undifferentiated debris of experience for minuscule traces of meaning the tiny, precious shards of struggle, defeat and victory that reveal a life all the while doggedly taking notes, even occasionally requesting the speaker to slow down so he can take it all in.

At the same time, there is a startling tenacity about the process, a kind of polite but unshakable insistence on participation, a refusal to let people off the hook, even after hours and days of non-response long silences, embarrassed shrugs, parrot-like reiterations of "I don't know." White will not allow the people who consult him to slip away into the sad night of their misery. He simply will not give up.

In one session, for example, the parents of a deeply shy and isolated pre-adolescent girl, are trying to coax her away from her perch in front of the television and go walking with her father. But the girl's reluctance is such that even when she does consent, she dawdles so that her father says he must then take a second walk in order to get any exercise for himself. He is disheartened and wonders if the effort is worth it. In this segment, White tries to get a statement of feeling from the girl herself. It is uphill work. White asks, "Do you have different paces of walking? A snail's pace? A tortoise's pace?... Are you faster or slower when you go walking with your dad?" After a long pause, she murmurs, "Probably slower." "Probably slower," volleys White. "That means you do have more than one gear. [Do you walk more slowly] because you don't want to go walking with him?" "I don't want to do it," she says finally.

Ignoring this response, he asks her how she could help her dad work out what to do abandon their walks together or persist. She yawns hugely. Building on a microscopically tiny advance in the girl's life emerging earlier in the session (when he had elicited from her a barely spoken acknowledgement that she might like to be "taking more initiative in life, rather than being a passenger") White asks, "What would you like to do with your dad that would fit with this new direction of yours?" a "new direction" that would have been invisible to anyone but White. She mumbles "Go walking." "Going walking would that fit this new direction?" he pushes. "Fits," she barely murmurs. "It does fit," White continues enthusiastically, "So would you like him to keep on trying to go walking, or would you like him to stop?" "Hmmm, hmmm, hmmm," she replies. "You have to say what you'd like," says White the closest he comes to making a demand. "Keep on walking," she finally answers. It is an achievement, says White, because she has determined that the decision to keep on walking "fits more with self-care than self-neglect." By the end of a later session, while she doesn't exactly seem as "bright, open, chirpy, communicative, chatty" as White suggests to her, she is clearly much more engaged. She looks at him out of the corner of her eye and smiles shyly, and even produces some whole, unequivocal answers (short ones) to his questions, obviously delighting her parents. Their daughter, who had rarely been able to identify any of her own likes, dislikes, desires, interests, purposes, who had rarely even talked to anybody, has begun, however hesitantly and timidly, to say out loud what she wants for her life.

This kind of work may look to some practitioners like cutting grass blade by blade, but it is probably more like panning for gold in an overworked stream long since abandoned by other prospectors. Slowly, meticulously, steadfastly, White sifts through the sandy deposit, patiently extracting almost invisible flakes until, by imperceptible increments, he has amassed an astonishing mound of precious metal. Clearly, White's reputation rests less on therapeutic bravura than on the extraordinary, transfiguring moments that occur in his practice epiphanies that take place with people most therapists would write off as hopeless.

Mary, a young woman horribly abused as a child, appears in White's office anorexic and bulimic to the point of near death, suicidal, actively hallucinating, unable to leave her house or talk with anybody except her husband. Discharged from her last psychiatric hospital with the medical prognosis of death by starvation within a few weeks, she is brought in to therapy by Harry, her despairing husband, and spends the session curled up in a fetal position, rocking to and fro on the floor in the corner of White's office. "She would not answer any questions, and I did not get to see her face for the first three sessions," says White.

When Mary does not respond to his gentle, persistent probing, he asks her husband to pose the questions to her, and when she still remains silent, White wonders aloud if Harry would like to "speculate" on what her answers might be. At the end of the third session, after one of White's typical questions what did Harry think her answer might be if he asked her how she had been recruited into such self-hatred she moves a little and whispers something into her husband's ear. "For that one instant, hateful-ness did not speak to Mary the truths of her identity," says White, "and from then on, she began to speak more and more in a different voice for herself."

With time, this almost unbearably fragile woman has acquired a small puppy and talks about how sweetly the dog licks her chin in the morning at first, she had thought she was so hateful the dog would perish in her care. Once terrified into paralysis by the possibility of personal rejection, some months later she has organized an outing for herself, her husband and her in-laws. She has reestablished a relationship with her mother and, mir-abile dictu, she has gone, by herself on the train to a shopping mall, walked into a coffee shop, ordered a cappuccino and drunk the whole thing. When White asks what this event tells her about her life and her identity, this woman, who has believed she was worthy only of death, says in a small, frail, but unwavering voice, "I would like to do something for my own self."

In Mary's life, these ordinary events are miracles, of which nobody who views the tape can have the least doubt. Still mysterious, however, is what White has done that has made the difference. By now, the theories and methods that have given White and David Epston, his New Zealand colleague, an international following are well-known, and they clearly figure in Mary's case. Through "externalizing conversations," for example, White has helped Mary think about her anorexia nervosa and the attendant "self-hate" as hostile, outside forces in her life, not at all intrinsic to her nature and personality "When you were drinking the cappuccino," he asks her, "did you or Anorexia and Self-hate have the upper hand?" "I had the upper hand," she answers softly, but with something that sounds very like pride. When anorexia and self-hate are no longer inherent to her very being, she can fight them without fighting herself; she does not have to die in the act of resistance.

White and Epston also look for evidence of what they call the "unique outcomes" in people's lives and the "counterplots" associated with them seemingly ephemeral, often forgotten experiences that contradict the dominant story of abnormality, deficiency and failure. "There is always a history of struggle and protest always," says White. He finds the tiny, hidden spark of resistance within the heart of a person trapped in a socially sanctioned psychiatric diagnosis "anorexia nervosa," "schizophrenia," "manic-depression," "conduct disorder" that tends to consume all other claims to identity. White liberates little pockets of noncooperation, moments of personal courage and autonomy, self-respect and emotional vitality beneath the iron grid of lived misery and assigned pathology.

Even in Mary's history, for instance, in an almost unimaginably bleak and brutal childhood, he finds the saving remnant of another, untold story. "In her darkest hours," he says, "at a time when she was being sexually abused by several people, she used to run away into the woods to the same tree whose trunk she could just stretch her arms around she said she could hear the tree speak to her. She had found a living thing that didn't abuse her, a simply fantastic achievement." Such heartbreaking moments of spiritual valor are hints, in White's credo, of Mary's subtle, half-forgotten, almost unrecognized dissent from the dominant story of abuse and self-hatred, official psychiatric labeling and social ostracism. When people like Mary remember and speak about these tiny saving fragments of formerly lost experience, says White, they also relive and perform them as well transforming meaningless autobiographical aberrations into the palpable material of new stories, new lives.

IN EVERY KNOWN CULTURE, PEOPLE give meaning to their individual stories (what happened to me as a child that affects me now, how I met my husband, why I got sick and why I got well) by organizing them according to a time-line with a beginning, middle and (perhaps hypothesized) end. In this way, we create our personal history. White's therapeutic method may depend more on exploring people's history than any other current approach, barring psychoanalysis but with a profound difference. Whereas practitioners of the latter delve into personal history like surgeons looking for hidden tumors, a lump of pathology in the far distant past, White seeks out the healthy tissue, the protective antibodies, which he always finds. For White, people's present lives cannot be reduced to their diagnoses, which are much too tight, too confining to contain the capacious possibilities revealed in their histories.

And, unlike other therapists who may take history into account, but only as individual case histories, White both brings history with a capital 'H' into the lives of the people he sees and, in turn, brings them into the broad current of historical time and place. He might be described by an Eriksonian therapist as breaking the "trance" imposed on people by the powerful forces of history and culture, making visible the invisible pattern of ordinary humiliations and terrors, routine tyrannies and acts of violence that comprise much of "civilized" life.

John, for example, a therapist in training, came to see White because, says White, "he was a man who never cried" he had never been able to express his emotions and he felt isolated and cut off from his own family. As a child, John had been taught, both at home and at his Australian grammar school, that any show of gentleness or "softness" was unmanly and would be met with harsh punishment and brutal public humiliation. White asks John a series of questions that are at once political and personal, eliciting information about the man's "private" psychological suffering and linking it to the "public" cultural practices, rigidly sexist and aggressively macho, that dominated his youth. "How were you recruited into these thoughts and habits [of feeling inadequate, not sufficiently masculine, etc.]? What was the training ground for these feelings? Do you think the rituals of humiliation [public caning by school authorities, ridicule by teachers and students for not being good at sports or sufficiently hard and tough] alienated you from you own life? Were they disqualifications of you? Did these practices help or hinder you in recognizing a different way of being a male?"

Having clarified the social context of John's alienation from himself in the "dominant men's culture," White helps him acknowledge and appreciate his ability to resist it and "reclaim" the other stories of his life, the other selves and ways of being gentle, kind, loving that he had managed to keep alive, though hidden, in spite of his tormentors. White asks what it would have been like for John, as a young boy, to have himself as a father. That little boy would have loved it, John replies. It would have meant having a father who talked with him, who showed him love, gentleness, kindness; it would have meant being accepted for himself; it would have meant having more fun. "I try to do that with my kids, now," he says.

Then one of those White epiphanies occurs. While John is still in a kind of reverie about the little boy he had been and the father he had needed, thinking aloud about his own sons and the father he tries to be affectionate, emotionally open, warm, playful White asks him what is happening to him right then, in the session. A look of wonder comes over John's face, and he says, "It's okay . . . It's okay to be that way. It's alright," and for the first time in his adult life, he begins to cry. "Yeah. Wow. Whew," he says over and over, blowing his nose. "Yeah, thanks. That's really strong, that's really powerful. Yeah, I did resist it somehow. This is rare. Yeah." And it is rare, to see two trajectories meet the abstract knowledge about the power of cultural conditioning, and the gut realization of what that conditioning has meant in one's own life.

Even more striking is White's ability to cut through the maze of social opinion, psychiatric ideology and individual indoctrination that reinforces the very symptoms of people labeled "chronic" mental patients. Often, these people, particularly diagnosed schizophrenics, have what sociologist Erving Goffman referred to as "spoiled identity," and, says White, "perceive themselves to have failed rather spectacularly in their attempts to be persons," that is, in their attempts to force themselves to behave, feel and think along stereotyped lines considered "normal" and "healthy" in the dominant culture. The cost is often excruciatingly high for people already particularly vulnerable, for biological and/or psychological reasons, to emotional stress.

According to White, the hallucinatory voices heard by people diagnosed as schizophrenic, telling them they are sick, helpless, crazy, deranged outcasts, bear an uncanny resemblance to common negative cultural stereotypes. Men's voices, for example, tell them they are wimps and weaklings, while women's voices attack their sexuality calling them sluts and whores. In both cases they harp relentlessly on the hearer's stupidity, worthlessness, social unacceptability and failure to measure up to social norms and rules. All-knowing and opinionated, the disembodied, magisterial voices speak in tones of great authority the voices of correct opinion and unimpeachable judgment (one imagines a malevolent Dan Rather or Peter Jennings) that the hearer would have heard repeatedly in the "real" world.

What perplexes White isn't the odd parallelism between the "internal" voices and "external" social messages, but the difficulty most people have seeing the connection. "Although it seems relatively easy for us to entertain the idea that much of what we think and believe, and much of what we do, is informed by culture," he said in a recent interview, "for some reason it seems rather more difficult for us to entertain the idea that psychotic phenomena are similarly informed; that regardless of etiology, the content, form and expression of psychotic phenomena, such as auditory hallucinations, are shaped by culture."

In his own terms, White "deconstructs" the dominant authority by taking people's voices very seriously accepting their validity as hostile forces "out there" collaborating with the person to unmask them as the lying scoundrels they are and develop strategies that will undermine their power. "What is it that the voices are trying to convince you of?" he asks. "What are they trying to talk you into? Are these voices for you having your own opinion, knowing what you want, or are they against you having your own opinion? Does the confusion caused by the voices contribute to their goals for your life, or yours?"

Jane, for example, steadily regressing at home with a diagnosis of schizophrenia, heavily medicated, unable to leave her parents' house for years, has recently moved into her own home, after working with White. She says that the six hostile voices that used to harass her constantly have been reduced to one, which seems to be on the defensive. "They used to dominate my life totally," she remembers, "told me I had to stay in bed all the time, that I was queer, that nobody liked me, that I didn't deserve to have any company." As he does ordinarily with people who have experienced psychotic episodes and suffer hallucinations, White equipped Jane with transcripts of their sessions together, along with various other "documents of identity" (i.e. written "charters" celebrating the person's strengths, capacities and current progress and intended to be shared with family and friends), which protect her from her hostile auditory ensemble. Whenever one of the voices threatens to have a "tantrum" or otherwise attack her, she reads a transcript and "I get a picture of what I really am like ... a much better picture than the voices [give me] . . . and I'm not so scared. [I can see] that I'm a nice person, attractive, good personality, independent.. . [It] shows through." The action of reading the transcript makes the voices just "go away," says Jane, though they go with much grumbling, in ill grace and it is hard not to envision a swarm of evil, wrathful little trolls retreating before a determined woman wielding a particularly effective magic talisman. Together, Jane and White have transformed a hopeless story with a foreordained ending into a dramatic epic, in which Jane is not a victim, a defeated mental patient, a crazy lady, but a hero engaged in a valiant struggle against a formidable enemy.

White has been roundly criticized by the psychiatric profession for reinforcing hallucinations and failing to help people "own" and "integrate" the voices to recognize that they are part of themselves, and take responsibility for having, in effect, invented them. White rejects such criticism because he rejects the foundation on which it is based that every human being comes outfitted with a single, unitary, core-personality, the center and source of all human meaning. Those who admit to hearing tyrannical voices coming from "somewhere else" break all the rules of self-containment, self possession, self-definition, self-control, self-determination that are the earmarks of "healthy personality development" in our culture. This view, White contends, is far less an objective description of human nature than a culturally determined prescription for the way people should be, not to mention an implicit damnation of people who don't measure up. "This work is not about people discovering their 'true' nature, their 'real' voice," says White, "but about opening up possibilities for people to become other than who they are."

For White, the personal is, and must be, deeply embedded in the political. The stories of the people he sees John, Mary, Jane are of personal struggle and transcendence, no doubt, but in White's eyes they are also unmistakably tales of power politics, the "politics of local relationship," as well as the larger social politics of gender, class, professional and institutional dominance. Mary's anorexia is both the result and the expression of the damage done to her by the misuse of power by her family, by a society that countenances male domination of women and children, and also by the mental health establishment that defines her life, reducing her to a kind of psychiatric object a "case" of anorexia.

White's thinking is legions away from the clinical Zeitgeist suggested by the standard family therapy metaphors of cybernetics or systems theory, suggests Gene Combs, codirector of the Evanston Family Therapy Center in Evanston, Illinois. "You have to think more in anthropological, sociological metaphors; you need to have pictures and ideas in your mind about how social and moral values, political and intellectual practices are transmitted in a culture, and how they influence the way people are. When Michael talks about stories, he's not just talking about individual anecdotes, but the story of Western civilization and how it has already 'storied' our lives for us before we were born."

WORDS ARE SO IMPORTANT," White said in an interview with The Family Journal last January. "In so many ways, words are the world." Yes, but so are the people who utter them. And it is hard to avoid the sense that the White persona is a very powerful element in the therapeutic equation. He dislikes the terms "client" and "intervention," which suggest to him the sort of expert domination of people in therapy that reproduces the social control and disqualification they already experience outside. And yet, in spite of a distinctly unshowy clinical manner in sessions, he is clearly the director of the ongoing drama.

Sometimes, the stream of formulaic questions intended to elicit externalization and re-storying can seem relentless, almost conveying the impression of a benevolent salesman hammering away at a hesitating customer: "Come on, you know you are better than you think you are, more than this paltry story you've been given, so when are you going to get with the program, take the deal, sign the papers, buy the product?" It's as if he is trying to convince them not only to buy themselves but to consider the sale as good a deal as he does. He clearly believes in the people who consult him more than most others do more, probably, than many of the therapists observing and certainly more than they believe in themselves. In one live interview with the family of an 18-year-old boy involuntarily hospitalized by the legal system for setting fires, he spends a major part of the session following a line of questions apparently aimed at building a greater sense of personal agency in both the boy and his 12-year-old sister (herself hospitalized for suicide attempts), while helping the two of them get along better. It is not an easy job even getting the siblings, both following their own eccentric and antagonistic orbits, to respond to a line of questions about their accomplishments, much less focus on what they might have in common. Nonetheless, White pries from each (buttressed by appeals to the parents) admissions of small, but legitimate "new developments" related to their increasing maturity: Mike now takes a shower "at his own suggestion," and helps his mother with kitchen chores; Debbie keeps her room neater and can handle more school classes.

In a segment that looks like the equivalent of pulling seriously impacted wisdom teeth, White manages to get from brother and sister, syllable by syllable, grudging concessions that each notices the changes in the other, and approves of them, sort of. As usual, White is only asking questions not, presumably, "imposing expert knowledge" on the people he is interviewing. But, he is generating the lion's share of talk, energy and conviction, and it is hard not to see at least the shadow of an unflagging preacher cornering the town sinner and extracting from him an admission that, yes, he probably does feel an attack of salvation coming on.

In the question-and-answer period that followed this live interview, one observer said he had found White "directive" and "suggestive" in his questions and noticed that he had "blocked" Mike from saying things and "interrupted" him on several occasions. Was this an important part of the narrative method as White practiced it? White answered that what looked like direction, suggestion and interruption was, in fact, a form of differential attention. He was not "blocking" some material as much as he was "attending to" other material the "sparkling facts" and "unique outcomes" that had been totally ignored or quashed in the family's dominant story of sickness and failure. As powerful coauthors and coconstructors of the realities that people forge in the process of therapy, White suggested, clinicians have a rigorous responsibility for what they choose to select from the multitudinous possibilities given them in session, and for whether the stories they help create are newer, more helpful, more healing or just regurgitated chapters from an old chronicle of despair: "Old dominant, problem-saturated stories are not good for you there's not one old story that's good for you, despair is not good for you."

But old stories sometimes die hard people have been imprisoned in them too long. Coming into the light of a new story can be blinding at first It isn't likely, suggests White, that people will always be able to leap immediately to a new possibility, to instantly invest old, half-forgotten, devalued experiences with new meanings. If therapy with White is a process of coauthoring new stories, many of the people he sees could be said to suffer from paralyzing writer's block they sometimes need to be nudged out of their immobility, persuaded to fit those first awkward words to experience, embarking on the reflective reverie that begins with "Once upon a time . . ."

The therapist who wishes to be coauthor, or creative agent and impresario, cannot hide behind passive silence or pretend neutrality. "There is no way of asking neutral questions," says White, "and you can't just drop a question when they don't answer right away and go on to something else. I'm very much the coauthor at first, but gradually, the person becomes far more active about articulating what these new developments mean in their lives. They become fascinated with neglected elements of their own stories, and as they step into that fascination, my role diminishes. I ask fewer questions, while they come up with ideas, notions, solutions I never would have imagined, unravel mysteries in a way I never could do." As the "alternative plot" gets rooted in people's own memory and imagination, says White, the story "runs away from me, it takes over, it has no end . . . and I can't know in advance whether the story will be beneficial or not. Only the people with whom I am working can determine this, and I keep encouraging them to do so."

Although White claims that Western ideals of individualism, self-determination, personal authenticity have become tyrannical measures of human worth in our society, he seems particularly good at producing these old-fashioned, perfectly unexceptional therapeutic outcomes. In fact, the people he sees seem to believe that his practice of nurturing a freer, more robust feeling of personal agency and individual identity is what distinguishes his therapy from the multitude of other treatments they have had.

Diane, for example, hospitalized several times for anorexia nervosa, compares the repressive, distrustful hospital environment with her experience of being treated by White. In the former, where food intake was rigidly watched, toilets were locked so that food couldn't be flushed away, rooms were searched if inmates didn't gain weight and therapists tried to extract from her admissions that she must have been sexually abused as a child, she felt degraded, brain-washed and rebellious "The way they treated you made you feel as if they had all the answers and you were nothing." White, on the other hand, "helps me along the way, but I'm the one who chooses what I want to eat; I'm the one who's got control. In the hospital I was forced to eat, and [when I gained weight] I wanted it off as quickly as possible, whereas with him, I did it myself, when / was ready, and it will stay on." If this isn't self-determination, what is? White words it differently, arguing that such responses "are the outcome of people stepping into ways of being and thinking that bring new options and possibilities for action." Still, a rose by any other name ...

Even people considered to be chronically psychiatrically ill and particularly at the mercy of the Western cult of individual selfhood, according to White, seem to emerge from his therapy with a much expanded sense of... individual selfhood! They also have a greater sense of community, White points out, because they have begun to engage family members, friends and others in the "renegotiation" of their life-stories making them witnesses, so to speak, to their changed realities. Still, White seems to have an inside grasp of the profound demoralization felt by people who are not only denied agency for their own lives, but told constantly that they are unworthy of having it so they become nonpersons to themselves. "I used to try to be everyone's [else's] person," says James, who holds a handful of diagnoses, including schizophrenia, schizo-affective disorder and manic-depression, and has suffered, as he puts it, from the judgmental, unrelenting "expectations" of others (including his own tyrannical voices) to get a job, to exercise, to give up smoking, to act "normal," to behave, to be the person others "expected" him to be. With White's help, he says, he could learn to say "no . . . Michael hands it over to me to decide what I want. He empowers me, he doesn't take over the reins for the management of my case. He's somehow very clever in allowing me the freedom to be the person I need to be, while also managing myself so I don't go overboard."

Gene Combs describes a tape in which a woman diagnosed as schizophrenic compares the hospital chart that had accompanied her for years on a mental ward with White's case notes based on his sessions with her. "When she read the hospital chart, she said she felt like a chronic, medicated schizophrenic, like someone stuck, with no hope, not worthwhile in the eyes of other people," says Combs. "When she read what Michael had documented, she saw clear movement in her life. She felt like a valuable person who lived a meaningful life that she was making even better. She said she felt respected." What really impressed Combs, however, was the difference on her face, in her voice and in her bearing when she talked about the hospital chart on the one hand, and White's notes, on the other. "When she talked about the former, she looked like a chronic mental patient; when she talked about Michael's story, she looked like a person."

This transfiguration seems at bottom a mystery, which challenges notions of the "unitary self" certainly, if that self is predetermined by culture and politics, and if it is a static, hard-wired entity of predictable operations and predilections. Is this newly transfigured "self" more "real," more "true" than the old one? Will this new self be more successful than the old? "I don't know what these stories are going to bring with them," says White. "I can't know whether they will be beneficial or not all I can do is keep on asking the person what the effects of the story are, asking him or her to judge it. I can't assume anything there are always lots of surprises."

In "The Power and Culture of Therapy," White quotes social philosopher Michel Foucault's words, which probably come close to White's own views on the issue of selfhood: " "The main interest in life and work is to become someone else that you were not in the beginning. If you knew when you began a book what you would say at the end, do you think that you would have the courage to write it? What is true for writing and for a love relationship is true also for life.'"

WHITE'S IMPACT ON THE PEOPLE he sees cannot be explained solely as the product of an interesting theoretical worldview that makes its way into some interesting new techniques. His work, perhaps like that of any gifted therapist, any inspirational spiritual leader, any talented artist, depends upon something like what 18th-century English evangelist John Wesley called "the heart strangely warmed." In White's case, there is no question that he is literally "warmed" by the people he sees, that there is a degree of devotion and loyalty to the people who consult him, a vital faith in them and their possibilities, and he insists upon their knowing it. When Mary tells him how she accomplished the triumph of her solo trip to the coffee shop she "took Michael and the team with her" in her mind, she says, when she boarded the train for the mall his own emotional response is as vivid as her narrative. "What do you think this does to my life, to know you have invited me and the team into your life this way, and to hear about you going to the coffee shop how do you think I'm feeling right now?" "Happy?" Mary asks faintly, after a pause. "More than happy," says White. "Joyful."

Probably all therapists worth the title feel privileged to be doing the work they are doing; many also feel gratitude, occasionally even awe, at the willingness of vulnerable and defensive people to trust their lives and sorrows to virtual strangers. Few, however, can have such a radical sense of solidarity with the people who seek their help, can consider the therapeutic relationship with them so profoundly sustaining and transformative of their own lives as does White, with every person he sees, regardless of how apparently unreachable and disturbed, how ground down by years in the psychiatric mill. "Inevitably, we change each other's lives, often in ways that are hard to speak of," White said in a recent interview. "These interactions are life changing for me ... In saying this, I am not talking of anything ingratiating,.. . And I am definitely not proposing something that has some strategic aim, like a one-down position for therapists, which I believe to be ingenuine, patronizing and disqualifying."

This attitude tends to raise skepticism, partly because it suggests an almost superhuman single-mindedness and integrity. Doesn't he ever fake it? No, according to colleagues who have worked closely with him. His vision of the people he helps, of the work he does, is apparently uncorrupted by the normal doubts, exasperation, weariness, disappointment and ordinary ill-temper about clients vented by even the most dedicated therapists from time to time. It is, for example, a point of deepest honor and professional integrity with him not to speak differently in private, entrenous with other therapists, about the people he sees than he will in front of them. This is part of the famous White "congruence" that his colleagues describe, which is not only a matter of political correctness undermining professional hierarchies, equalizing the relationship between therapist and client but a matter of utmost importance to the morality of the entire therapeutic enterprise.

"There is nothing about him that turns on and then turns off," says David Moltz, medical director at Shoreline Community Mental Health Services in Brunswick, Maine. Moltz recently attended a three-day workshop featuring White, who did a live consultation with a family in which the father, thought Moltz, was "completely impossible." But there was never a moment, Moltz said, when White indicated any remote difference between his apparent feelings about the family how he appeared to them and his "real" feelings; there was no moment afterward, says Moltz, when he let down his guard and said something like, "Oh, my God were they something else!" Says Moltz, "He has no guard to let down; there are no hidden corners or agendas ... no second order of business, no waiting for the family to leave before you say your real feelings." What you see is what you get.

A particularly revealing story about White and his work is one he tells himself. As a young man, before formally taking up the profession of social worker, he worked as a gardener for what was then politically incorrectly called an "old folks home." Paying no attention to official instructions from the institution's administrator, he collaborated with the elderly inhabitants to create the gardens they wanted in front of their units. "They would come out and tell me where they wanted to plant shrubs, and how they wanted things pruned," he recalls. "It was great because I didn't know much about gardening and they were teaching me." Eventually, White was fired for what might be called "client-centered gardening," but he remembers the experience as at least as important as other more personal or professional biographical tales.

In a sense, White has remained a gardener in the work he does now; doing therapy, like planting and tending a garden, is a matter of methodical attention, small steps and hard labor digging, spading, pruning, watering, mulching. Good gardeners are both practical and visionary. They don't expect to turn the desert into a Garden of Eden, at least not overnight, but they are optimistic enough to believe that with time and effort, and the blessings of rain and sun and decent soil, they can collaborate with nature to transform even quite desolate spots into little oases.

Good gardeners are forced to be modest. They can provoke and prompt and support nature in certain directions, but they can't control it they can't make anything happen. An acceptance of their own limitations is perhaps part of the ethic of gardeners, along with a renunciation of grandiosity and a respect for the self-created, self-sustaining rhythms of living things. In a sense, White's ethic of therapy is not dissimilar. It is an ethic that eschews the grand therapeutic gesture implicit in the myths of the one-session cure, the personality makeover, the eradication of mental "disease" through biochemical wizardry. Like a gardener who knows that even the most elaborate landscape must be tended step-by-step, plant-by-plant, square foot-by-square foot, White carefully nurtures the small triumphs in the lives of the people he sees, honors the transient moments of competency, initiative, resoluteness.

These marginal stories are usually neglected in the grand schemes of psycho-pathology as accidental, insignificant epiphenomena that are too small to count, but they are the seeds and the soil of human transformation. "People neglect the landscapes of their own lives they think they are uninteresting and dull," says White, "but I'm very curious about them, and I always find it interesting to hear people talk about themselves in ways they've never done before. I often find myself up against the limitations of my knowledge and vision, when I don't feel equal to the task, but the questions I'm faced with become the impetus for further explorations that extend the limits of what I know. I don't have any grand account of the work I do I don't think it is so fantastic, it's not heroic it just addresses a few things. We don't need to teach people anything new, just help them reach stuff that's already there."

Mary Sykes Wylie, Ph.D., is senior editor of The Family Therapy Networker.

 

2005

 

From Jim Foreman, Symposium Director

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Visionary or Voodoo?

Daniel Amen's Crusade Has Some Neuroscientists Up in Arms

by Mary Sykes Wylie

Psychiatrist Daniel Amen is a trim, elfin figure with a puckish smile and the staccato delivery of a stand-up comic. The winner of a Distinguished Fellow Award from the American Psychiatric Association, a clinical professor of psychiatry and human behavior at the University of California, Irvine School of Medicine, the author of 20 books and as many peer-reviewed papers, and a hugely popular public lecturer and workshop leader, he sounds, somewhat paradoxically given his own sum, a bit like a wiseacre underdog impudently challenging a reactionary establishment. He cheerfully rails against the self-satisfied stuffed shirts from the worlds of academic psychiatry who, in defiance of reason and good sense, don't accept his view that a brain-imaging method called SPECT is an invaluable tool for understanding and treating psychiatric disorders.

"I just don't get it. Why are we the only medical specialists who never look at the organ we treat?" he asks, his voice rising in exasperation before a jam-packed audience of 500 therapists drawn to a full-day workshop on his work. "Why is it controversial to get more information on people who suffer? The images are really easy to understand. What's the problem with having more data?"

And then the "piece de resistance". We're always being told that the brain is so terrifyingly, irreducibly complex that nobody except Nobel-caliber neuroscientists could ever begin to understand how it works. But Amen says, in effect, that it really isn't that hard for anybody--with a little training--to get a good sense of what all those brain modules are actually up to. "The images are really easy to understand--you don't need to make it any harder than it is," he says, as if explaining a new recipe to an insecure cooking student. "All SPECT does is measure three things--areas of the brain that work well, areas that are underactive, and areas that work too hard. Then you just gear the treatments to rebalance these areas."

So why not just take a look? What's the harm? His case is helped by the elegant, crisply articulated, brain images he shows that, in concert with his simple explanations, seem to luminously reveal what's actually going on upstairs.

Amen flashes two computer-reconstructed, three-dimensional, exquisitely tinted color scans, each of a different brain. One, a "healthy" brain, is a smooth ovoid shape, with some softly modulated rises and depressions; if it were a landscape, it would be a gently rolling pastoral scene. The other brain looks an awful mess. With its deep fissures, crevices, and "holes"--areas of severely low activity--it looks as if uneven chunks of it have been eaten away by a voracious rodent. This latter brain, Amen dramatically announces, is the brain of Kip Kinkel, the 15-year-old boy from Oregon who, in 1998, shot to death his mother and father and then drove to his high school, where he shot 24 more people, killing two.

Kinkel, Amen explains, had been seeing a psychotherapist and taking both Ritalin and Prozac, which only made him worse--more volatile and unreachable. His demoralized parents had taken him off his meds, after which he went on his murderous spree. "If a scan had been done on him before the killings, it would have shown an extraordinarily abnormal brain," says Amen. On the SPECT scan, he tells the audience, Kinkel's prefrontal lobe--associated with impulse control, judgment, and planning--exhibits extremely low activity. At the same time, his temporal lobe, controlling such functions as temper and mood stability, also showed abnormal patterns of blood flow, which can make a person more prone to aggression, emotional volatility, and violent suicidal and homicidal thoughts.

"If his therapists had actually seen his brain, they could have put him on mood stabilizers, and the odds are they'd have diminished his violent thinking dramatically." Amen pauses to let this sink in. "But because the current 'state of the art' in psychiatry is not to look at the brain, his doctors were simply throwing darts in the dark. Today you can try to kill yourself or kill other people, and nobody will look at your brain. But if your brain's not right, you won't be right."

Amen has a vast fund of salvation stories about people misdiagnosed and mismedicated, often for years, whose real problems are only finally revealed through the combination of intense clinical detective work--the kind any good therapist would do--and the nuclear magic of a SPECT camera, which, literally, casts light into the hidden recesses of the brain. "Giving a diagnosis of 'major depression' or 'ADD,' is like giving a diagnosis of 'chest pain,' or 'belly pain,'" says Amen with some asperity. "These are symptoms with many, many possible causes. And one treatment will not fit every person with similar symptoms. We need to start looking at the brain, to begin seeing the underlying physiology of what's going on. Scans aren't the answer, but they're certainly part of the answer. A psychiatric profession that doesn't look at the brain is archaic, dated, and stupid."

Amen now has the audience in the palm of his hand, laughing at his jokes, moved by his stories of troubled little kids whose lives were either saved or ruined, depending upon whether their underlying brain problems were discovered and treated. He seems to be as much on a personal crusade as a professional quest. But, periodically, a note of unabashed salesmanship and self-promotion intrudes--the repeated references to his "cool" books and their worldwide distribution; his bestseller, Change Your Brain, Change Your Life ; his column for Men's Health ; his media appearances on The Today Show, The Leeza Show, CNN ; his recent gig at the National Security Agency. For some in the audience, it's enough to induce emotional whiplash: are we hearing from a fearless pioneer dedicated to transforming the mental health field or a salesman whose most important product is himself?

To be sure, Amen has acquired a small, but growing, crowd of supporters and colleagues in psychiatry, psychology, and nuclear medicine--he says more than 1,000 professionals refer to him--who consider him a trailblazer and believe SPECT scans will revolutionize the practice of psychotherapy. "I think he's a real pioneer, making an enormous contribution to the field of psychiatry and helping to change the paradigm of how people think about the brain and psychiatric symptoms," says Joseph Wu, professor of psychiatry and clinical director of the brain imaging center at the University of California, Irvine. "Daniel Amen introduced me to a whole new universe of subcortical brain structures that we in nuclear medicine had only looked at casually before. He helped me realize that SPECT can be very useful for evaluating complex, difficult cases in which comorbidities are present," notes Dan Pavel, professor of radiology and nuclear medicine at the University of Illinois. "I came away from Amen's clinic convinced there is a place for SPECT in clinical psychiatry," writes AD/HD expert Edward M. Hallowell, coauthor with John J. Ratey of the bestselling Delivered from Distraction: Getting the Most Out of Life with Attention Deficit Disorder. "It is obviously helpful to be able to look at the brain before you try to treat it. Perhaps SPECT will prove to be the most practical way for psychiatrists to do that."

But utter the name Daniel Amen to some of the leading members of the psychiatry and neuroscience research community and the reaction ranges from dismissal to derision and denunciation. "He's made a mountain of money doing scans [a two-scan evaluation at one of Amen's clinics costs $3,250, which also includes, a history, physician evaluation, and follow-up visit], but never, to my knowledge, published any data, or provided one shred of evidence that an independent investigator would be able to reproduce," says George Bush, psychiatry professor at Harvard Medical School and psychiatric neuroimaging researcher at the Martinos Center for Biomedical Imaging. "Amen is extremely successful, has many franchises and is a wickedly good salesman, but what he's doing isn't supported by scientific evidence. Where's his data? What does he know that all the other practitioners and researchers don't know?" asks Helen Mayberg, psychiatry and neurology professor and brain-imaging researcher at Emory University. In fact, so exercised is much of psychiatric officialdom by Amen's approach that, last January, the American Psychiatric Association's nine-member Council on Children, Adolescents and Their Families felt moved to issue an independent position paper opposing the use of SPECT in the clinical practice of child and adolescent psychiatry.

It seems strange that a person so disarming and apparently eager to please, who's clearly distressed by the uproar he's caused and seems like the last person who'd mount a Rambo challenge against entrenched power, would arouse such hostility. Or that his cause--the incorporation into psychotherapeutic and psychiatric practice of SPECT scans, a technology that's been around for decades--should be so contentious. So what is it about Daniel Amen and his mission to get therapists to use brain imaging, and SPECT in particular, as an aid to diagnosis and treatment that makes him such a lightning rod?

The Man Behind the Cause

Daniel Amen's personal and professional biography is a palimpsest of the odd and extraordinary, which may help explain why he's never found a home in the clubby atmosphere of the psychiatric and research establishments. His entrepreneurial success seems to particularly gall them--it adds insult to injury that he's not only doing something totally beyond the scientific pale, but making pots of money at it.

His talent for business seems almost foreordained by his background. His parents, the children of poor Lebanese immigrants, went to the West Coast during the 1940s. There, Amen pere began clerking in a relative's grocery store and then, embodying both the American dream and the ancient Phoenician talent for trade, worked his way up to become chairman of the board of Unified Grocers (a position he still holds), one of the largest wholesale grocery businesses in the country. Amen's family was large (five sisters, one brother), loving, but strict and Roman Catholic, headed by a tough, authoritarian paterfamilias. "I grew up with an extraordinarily successful father, who always expected the most from us," says Amen. "Our family honored work, and our lives were centered around work--I worked from the time I was 10. And nobody ever thought it was a bad thing to be successful."

Amen joined the Army at 18, partly because he had a low draft number, but also because his father told him not to. It was 1972, and the Vietnam War was in full swing, but Amen believed the recruiter who told him he'd be assigned as a vet's assistant. (He'd always loved animals and, as a teen, considered becoming a vet.) "I thought that the odds were good that nobody would be shooting at a vet's assistant." Instead, he ended up as a combat medic in Germany, where he got himself retrained as an X-ray technician, mainly so he could work in a nice, warm dispensary, rather than a chilly tent. But he became fascinated by X-ray technology and found that he loved studying the ghostly images of people's insides. "I looked at kidneys, lungs, skulls, thigh bones," he says now with remembered relish. "That's where the imaging story really begins."

Because of his religious background, Amen had seriously considered becoming a priest, but, as he says sardonically, "I couldn't stand the idea of being called 'Father Amen.'" He declined the priesthood, but certainly not religion. In Germany, he found himself drawn to the wholehearted, emotional expressiveness of Pentecostalism--shouting, praying in tongues, healing ceremonies, and all--so different from the restrained solemnity of the Roman Catholic mass. He was sufficiently moved by his new religious tack that, when he returned home, he got off the plane dressed in a "Jesus loves you" T-shirt and carrying a Bible, much to the consternation of his blindsided mother. By this time, 1975, he knew he wanted to go to a small school, and a religious one, so he finished his college education at Vanguard University, a small Christian college. Then, in 1978, he became a member of the first class of a newly opened medical school (since closed) at Oral Roberts University.

The nexus between capitalism and religion appears to have shaped Amen's life. In Healing the Hardware of the Soul, his book about the connection between a healthy brain and the capacity for morality, conscience, and faith, Amen writes that he felt "led by God to pursue this [SPECT] work." These days, he uses his training and skills as a kind of reverse mission to churches, in an effort to persuade Christians and Jews that much "sinful" behavior may be due to brain problems, rather than evil motives. Some of his critics haven't looked kindly on this sense of religious mission. "He's a true believer, and evangelical medicine is scary," says Mayberg.

After medical school, Amen took a residency in psychiatry at Walter Reed Army Medical Center. In 1987, the Army sent him to Fort Irwin, California, as the chief psychiatrist--the only psychiatrist in the middle of the desert for thousands of soldiers and their families--a population rife with drug abuse, depression, anxiety, domestic violence, psychosomatic ailments, and stress. This new gig would have been a daunting job for any psychiatrist, let alone a young, newly minted, and relatively untried one.

Serendipitously, in the old World War II building that housed his office, he found an antiquated biofeedback machine (an instrument that measures physiological responses, via electrodes or sensors attached to various parts of the body) left by his predecessor. He found that, even as a novice, he could use the machine to train people to warm their own hands by using their imaginations--thinking about burying their hands in hot sand, for example. He could also use it to help them reduce their anxiety or relieve their migraine headaches, while gaining a sense of self-control and personal mastery. Enthusiastic about his new toy, Amen convinced his dubious commander to pay $30,000 for an up-to-date model and send him for 10 days' training in biofeedback.

The biofeedback training program in San Francisco was, Amen remembers, a revelation: "The best, most exciting, training I'd ever had. I was just stunned by what I learned." It was the first major introduction he'd yet had to the powerful interaction of brain, body, and mind, and he was hooked. He discovered that people could learn how to control their own autonomic nervous system--relax their muscles, calm their breathing, reduce their sweat-gland activity, lower their blood pressure and heart rate--to relieve both physical tension and mental anxiety. Moreover, through neurofeedback (a form of biofeedback in which electrodes are attached to the scalp), they could learn to change their own brain-wave patterns, and thus their mental states. "I was so excited to have this cool new technology that I went back to Fort Erwin and started using it on everybody."

Amen was particularly anxious to try out this new brain-mind technique on kids with AD/HD. "Standard psychotherapy, as I'd been trained to do with AD/HD kids, made me crazy--they just never got any better," he recalls. Medications helped, but not nearly often enough, and there was no way to predict whether or not they would work. So Amen began using neurofeedback with his AD/HD patients to encourage more normal brain waves and reduce their symptoms. While not exactly the fast-track cure he'd have liked (it could take from one to two years to produce significant improvement), neurofeedback did work encouragingly well, with the side benefit of helping many kids avoid or lessen medications. In 1989, when he opened his private practice in northern California, he equipped it with his own biofeedback equipment.

Amen's clinic was an immediate success, no doubt partly because of the workaholic habits, business acumen, and marketing skills he says he inherited from his father; but also because he was the only child psychiatrist for 300,000 people in the county. During this period, he worked six- and seven-day weeks, building up his practice, directing the dual-diagnosis unit of a local hospital, lecturing in the local community, and writing a news column (he'd already published two self-help books on getting ahead in school and in work).

In March 1991, Amen attended a lecture on SPECT imaging at the hospital where he worked. If learning about neurofeedback had been a revelation to him, seeing SPECT scans was an epiphany. SPECT is the acronym for single photon emission computerized tomography, a nuclear-medicine imaging technique that measures an organ's blood flow or activity level--its function . An MRI, by contrast, looks at brain structure or anatomy, just as an ordinary X-ray does (but provides far more detailed images). A patient being SPECT-scanned is injected with a "radiopharmaceutical" and then lies on a table for about 15 minutes while a multiheaded camera rotates around his or her head picking up gamma rays (which are like pulses of light) from the radioactive material taken up by the brain cells. The data obtained by the camera are processed by a supercomputer to produce a series of two-dimensional cross sections of the brain. Different activity levels--relative blood flow--show up as shades of different colors or gray tones, depending on the color scale of the software program chosen by the imager.

These cross sections are then reconstructed into three-dimensional images. Notwithstanding Amen's suggestion that brain scans "aren't that hard to read," it's definitely not a simple process, requiring real skill and judgment to do well. To a lay viewer, the cross sections that first come out of the computer look like a meaningless kaleidoscope of colors and patterns. It takes an expert in reading, understanding, and manipulating the scans to tweak them into an accurate but elegant form--the dramatic, 3-D pictures of the kind Amen shows his audiences.

The Society for Nuclear Imaging officially recognizes only four common indicators for the clinical use of SPECT: to detect and evaluate strokes, brain trauma, and suspected dementia (a recent article says that brain scans like SPECT can predict Alzheimer's disease nine years before people have symptoms), or to locate focal points of epileptic-seizure activity. But SPECT has been used in a huge and highly eclectic number of research studies on almost every conceivable psychiatric and neurological condition, as well as some nonpsychiatric studies, like measuring the impact of meditation and prayer on blood flow to different brain areas.

The lecturer at Amen's hospital, a local nuclear physician named Jack Paldi, showed brain images of patients with depression, dementia, schizophrenia, and head trauma, comparing them with normal brains. Using these amazing images, Paldi tried to demonstrate that one could actually see the differences between brains that worked well and those that didn't, see how medications changed the way brains functioned and where those changes occurred. In this rush of graphically astonishing images, Amen thought he could begin, finally, to understand why some of his patients just couldn't seem to benefit from therapy or get their lives in order, no matter how hard they tried. It wasn't psychological resistance or personality type or deep-seated unconscious motives that kept them from getting better: it was simply that the software of their brains wasn't up to speed!

"I was absolutely blown away," remembers Amen, who took up Paldi's offer to do no-cost SPECTs on interested physicians and, six months later, got one himself. Shortly after the lecture, however, he ordered 10 scans on particularly difficult patients, which, according to Amen, resulted in "literally miraculous changes" in five of them. One patient was a 12-year-old boy with a nasty temper, a history of aggression, and school failure, who'd been hospitalized three times, prescribed assorted drugs (including Ritalin, which made him hallucinate), and treated with two years of psychoanalytic therapy. The scan showed low temporal-lobe function (associated, as in Kip Kinkel's case, with anger, violence, and mood swings), as well as frontal-lobe problems (which kept him from being able to concentrate in school). Amen placed him on mood stabilizers and a different stimulant, and voila! Within three weeks, he became milder tempered, began making friends, and, says Amen, "turned into the sweetest boy you'd ever want to meet." His school performance improved dramatically as well.

Another woman had been diagnosed with Alzheimer's after she'd nearly burned down her own home and lost her driver's license. Amen scanned her and found no signs of the characteristic abnormalities associated with dementia. But he did see that her deep limbic structures were "on fire" (a favorite bit of Amen-speak to describe brain areas of severe overactivity). This suggested depression, which can sometimes mimic Alzheimer's symptoms of memory loss, apathy, indifference, and disorientation. Amen prescribed Wellbutrin--an antidepressant and stimulant--and voila` again! Within weeks, she'd regained her memory, and her mood was much better. Within six months, she got her driver's license back.

"How many experiences does a psychiatrist have like these in a whole career?" Amen asks. "I had five of them in the space of a few weeks."

By Amen's lights, SPECT was not diagnosing new conditions. The scans didn't remotely correlate with DSM diagnostic categories, but they often revealed the inaccuracy of previous diagnoses and suggested functional anomalies that shed light on otherwise unexplained symptoms. Nor were his treatments miraculous, radical, or novel; they apparently just hit the target better than earlier interventions. In short order, he was a true believer in the modality. "I thought, 'How can I do psychiatry in good conscience without using scans when I don't really understand what is going on? How can I just continue to rely on guesswork when I have this tool at my disposal?'"

Between 1991 and 1995, he became something of a SPECTomaniac, reading everything he could find, attending meetings about SPECT, and ordering SPECT scans on hundreds of patients at the local hospital. He was asked to talk about SPECT at hospitals and at the University of Colorado medical school. He wrote a research paper comparing SPECT brain images of ADD children to those of normal children. He became an enthusiastic promoter of SPECT.

But there were signs of smoke from an impending firestorm almost from the beginning. In 1992, at a meeting of the American Psychiatric Association (APA), where he attended an all-day course on the use of SPECT in child psychiatry, he went to a lecture by National Institute of Mental Health child-psychiatry researcher Alan Zametkin. This would-be colleague used PET scans (a form of nuclear imaging with higher-quality resolution than SPECT, though more difficult and expensive to use) in a groundbreaking study of what ADD brains look like. Zametkin, says Amen, was one of his heroes, so he went up to him after the talk in the spirit of a fan approaching a star. "I told him that, partially based on his work, I was using SPECT in my own practice," remembers Amen.

But if he'd expected an avuncular smile of approval, he was mistaken. Zametkin angrily barked at Amen that these techniques were strictly for research and in no way intended for clinical use. In no uncertain terms, he told Amen, in effect, to cease and desist what he was doing.

"But why do you do these studies if you don't intend this technology to be used clinically?" Amen asked, baffled.

"I do them just to learn more; it's interesting basic science," Zametkin replied loftily.

This is an attitude foreign to Amen. "I really have no interest in science for science's sake," he admits. "I'm a clinician through and through--it's my reason for living. I get my juice from my practice, from relationships with patients, not from research."

Back home in California, the natives were also getting restless. A local pediatric neurologist, after calling three or four researchers around the country and hearing that SPECT wasn't ready for clinical prime-time, complained to hospital officials about Amen's heterodox behavior. "The neurologist told me that my reasons for ordering scans weren't empirically proven, and that I should quit doing them. He said, 'The brain is for neurologists, not psychiatrists,'" Amen recalls, even now incredulous. "I told him he was nuts." At a meeting of the hospital authorities, Amen was given permission to continue getting SPECT scans for his patients, but he was now required to have the medical director sign off on his requests.

In 1993, he was asked to help teach a brain-imaging course at the APA annual meeting, but when the program came out, a Dallas SPECT researcher wrote the APA program chairman demanding to know why such a controversial figure was included. The program committee chair sat in on the presentation and supported Amen's work, but many others were openly hostile to him, making a point of telling him he was a fraud and a mountebank and ought to be drummed out of the medical profession. It had gotten to be too much, so he decided to retreat from the public field, help his patients in the relative privacy of his clinical practice, and let other people do the research and fight the battles.

It's hard to imagine as restless and driven a figure as Amen ever really settling for a quiet, low-profile practice in suburban California, so he'd probably have taken up the gauntlet again sooner or later. But a crisis involving his 9-year-old nephew, Andrew, launched him back into the fray.

Amen's sister called him in tears one day early in 1995, telling him that her son--his nephew and godchild--had attacked a little girl on the baseball field for no reason. Over the preceding year, this friendly, active, outgoing little boy had become surly, angry, mean, and depressed, and had begun drawing pictures of himself shooting other children or hanging from a tree. Amen told his sister to bring the boy in the next day and, after a lengthy interview, personally took him to the hospital to be scanned. "When I looked at the image, I saw he had no left temporal lobe at all!" recalls Amen. This was, again, a part of the brain associated with violence, aggression, and suicidal and homicidal feelings. Andrew was almost immediately given an MRI scan, which showed a cyst about the size of a golf ball where his temporal lobe should have been.

But Amen couldn't find anybody willing to remove the cyst. Three pediatric neurologists--one at Harvard--told him that Andrew's behavior was probably not related to the cyst and that they wouldn't remove it until there were "real symptoms." Amen was beside himself. "Hearing this made me nearly psychotic, I was so angry." He remembers shouting, "What do you mean, 'real symptoms?' You don't think suicidal and homicidal thoughts and behaviors in a 9-year-old are real symptoms?" Real symptoms, the Harvard neurologist coolly informed him, meant seizures and speech problems. Period.

Finally, he located a pediatric neurosurgeon at UCLA who said he'd operated on three other children with the same problem--a temporal lobe cyst resulting in aggression. This doctor performed the operation on Andrew. When the boy finally woke up after the surgery, he smiled at his mother--the first smile from him she'd seen in more than a year. Shortly afterward, he became, once again, the youngster he'd been before his problems began.

This event changed Amen's life, he says. "From that moment on, I felt I could no longer be shy, or allow myself to be hurt by criticism, or fearful that people wouldn't like what I was doing. I just thought of all the kids who are in residential treatment facilities or end up in prison because they've done terrible things, and nobody ever even knows whether or not it's because they have something terribly wrong with their brains."

Now a newly energized Amen charged full-steam ahead. He completed the 1,000-hour training and supervision program to obtain the license in handling radioactive material that's necessary to do scans, bought SPECT equipment, and became, as far as he knows, the only psychiatrist in the world who had then incorporated brain imaging in his own practice. He once again took up the SPECT gospel and began spreading the word, and once again was met with virulent attacks.

In 1996, after Amen gave the State of the Art Lecture in Medicine at the Society of Development Pediatrics, a San Francisco pediatrician stood up and excoriated him for using brain imaging to justify giving drugs to children for AD/HD--in effect, accusing him of shilling for Big Pharma. Shortly after the meeting, he was anonymously reported to the California Medical Board for practicing outside the generally accepted standards of care. The state medical board began an investigation, which took a full year--of lawyers, interviews, questions, reviews of his articles, office visitations. "The worst year of my life," Amen calls it. Finally, after his work was sent to the departments of neurology and nuclear medicine at UCLA, he was exonerated and became an expert reviewer of psychiatry for the California Medical Board.

Amen and His Critics

Today, about eight years later, Amen has no doubt succeeded as a medical entrepreneur. He has two clinics in California, one in Washington State, and one in Reston, Virginia. By any measure, he's a huge success. Besides founding his clinics and cranking out books (another is on the way), he's produced a "Clinician's Toolbox" of brain-related materials for therapists, a brain-scan atlas, and assorted CDs and videos. He's given more than 100 presentations in the United States and abroad, written or been the subject of numerous articles in the popular press, appeared on scores of radio and television shows, testified at numerous trials, and developed a 12-week high school course on the brain to be piloted in 30 schools this fall. There are perhaps 15, mostly for-profit, psychiatrist-run clinics around the country that now use SPECT--a fair number of the proprietors trained by Amen himself. In addition, an indeterminate number of psychiatrists around the country quietly, but regularly, refer their own patients for brain scans.

Nevertheless, most of the research community and the psychiatric establishment remain deeply unimpressed. Indeed, there isn't anything about Amen or what he does that his critics do like. Following the back-and-forth between them and him is like watching a bunch of increasingly infuriated boxers all trying to knock down an inflatable punching doll--the harder they hit, the faster he bounces back. They argue that Amen isn't competent to use scans because he's not board certified in nuclear medicine, didn't train in radiology (his several hundred hours of imaging training don't count), and doesn't follow science-based methods of differential diagnosis (using appropriate tests to differentiate systematically between distinct diseases with similar symptoms). He counters that he has the proper licenses to do his studies, teaches SPECT at a major medical school, has written or cowritten chapters about SPECT in three professional textbooks, has produced nearly two dozen peer-reviewed papers, instructs nuclear-medicine doctors who come from far away to spend weeks at his clinic, has chaired workshops on SPECT at the APA annual meeting, and, finally, just a year ago, received a Distinguished Fellow Award from the APA. "I have more experience with SPECT than anybody else in the world, and there are mountains of scientific literature backing up my clinical work--1,500 such studies are on my website alone."

They argue that he sits on a proprietary stash of 27,000 scans, like a miser sitting on a pile of gold bullion, and won't give researchers access to his data because he's afraid an independent look will undermine his claims. He contends that researchers are perfectly welcome at his clinic, to talk to his doctors, see how they interpret scans, and look at his database. But one leading researcher he invited out to see his scans hasn't followed through, and no one else has ever asked to see them.

They say, to quote Harvard's George Bush, that "he's unethically subjecting people, including children, to potentially dangerous ionizing medication in a diagnostic test of no proven benefit." He cites Michael Devous, a leading nuclear-medicine expert, who writes that "there are no data that have ever demonstrated any harm to humans by radiation exposure at diagnostic imaging levels." The average radiation exposure for one SPECT scan, Amen points out, is similar to that of an abdominal X-ray, which is routinely ordered for common childhood medical conditions, including constipation.

They say, repeatedly and maddeningly in Amen's view, that he claims to diagnose psychiatric illnesses from the scans. He just as repeatedly insists that he never uses SPECT to "diagnose" anything, but looks at the scan within the context of the person's life and after a full psychiatric evaluation to get more information that might shed light on puzzling, difficult, or anomalous symptoms. "I've never said the image is 'the answer.' We use it when we don't know what's going on, when we think it might supply a piece of the puzzle--it's like radar that helps us better target the problem. The alternative to doing scans is blindly putting kids on meds or multiple meds without looking at their brains either before or afterward."

Finally, and most damagingly, they say that what Amen is doing is totally unsupported by the facts--that he hasn't remotely demonstrated the scientific validity or reliability of using scans as he does. They argue that it isn't yet possible to identify subtle distinctions in single subjects that reliably correlate with specific symptoms. "When a radiologist looks at a chest X-ray, he recognizes pneumonia, or an enlarged heart or liquid at the base of the lungs that correlate with disease because he's compared these abnormal scans to thousands of normals and other abnormals," says neuroscientist Bush. "Maybe in 50 years, when someone comes in looking as if he or she has a certain syndrome, we'll be able to refer them to a radiologist who'd be able to interpret that individual scan. But we're not yet, as a field, in a position to distinguish one brain scan from another. Right now, you can look at any individual scan and what you'll find is color blobs across a screen. What separates science from nonscience is the ability to pick out quantitative, statistically reliable, patterns [in those blobs] based on large numbers of scans--set certain criteria for a disorder, show it in 50 cases compared with 50 normals, for example. Amen isn't doing that. Essentially, all he's doing is 'blobology.'"

To this, Amen responds that factoring in the individual variability in each brain, rather than drawing general, statistical inferences from a large base of cases, is a strength of his method, not a weakness. Researchers look for signature features in a scan that will reliably correlate with specific DSM categories, which do not reflect the complexity and heterogeneity of psychiatric disorders as they're experienced by real people, Amen argues. " DSM diagnoses are artificially derived from symptom clusters," he says. "But they don't explain why people are having these symptoms--why one person's depression or anxiety or AD/HD may be entirely different from the same formal diagnosis in somebody else. Only by looking at each person's individual scan can you get some insight into the underlying physiological pattern in the brain, so we can target treatment specifically to what that person needs."

In addition, he says, researchers study "pure" cases--people with one supposed diagnosis without the confounding variables of comorbid conditions (i.e., drug addiction along with their depression, AD/HD symptoms along with their anxiety). This approach simply doesn't reflect the complexity, variability, and individuality of real people and real patients.

Finally, researchers compare people with a DSM diagnosis to presumed "normals," but Amen doubts that there's such an entity as a "normal" brain. Recruiting people for a database of normals, his office screened 1,500 people and found only 72, who met the criteria for "normal"--no signs of head injury, no history of substance abuse, no psychiatric illness, and no first-degree relative with a psychiatric illness. "'Normal' is a myth," he says flatly.

Whatever the specifics of his critics' objections to Amen's work, it's hard not to suspect that underlying the intensity of their response is their objection to Amen himself--his persona, his style, his modus operandi. Most scientists lead comparatively monastic, inconspicuous lives (though not necessarily impecunious--many act as paid consultants to pharmaceutical and medical-device companies). Even those few who achieve eminence do so largely within the circumscribed universe of their peers. How many people can name a recent Nobel laureate in any scientific field? They have their own worldview, and what they consider Amen's heavy-handed promotion of high-tech gimmickry is as far from it as earth is from Pluto.

"The nature of science is agnosticism," says Helen Mayberg in a passionate defense of the way researchers do things. "Our job is to ask questions, measure data, continue doing the research until we find out what's real, what isn't. I've devoted my entire professional life to using imagery to understand depression, and the more progress I make, the more complicated it gets. As a clinical neurologist, I see patients die all the time. I don't have to have anybody tell me how much people suffer. But no matter how much, as a doctor, I want some idea for a promising new treatment to be true, as a scientist, I have to remain an agnostic. We all know the system isn't as good as it should be, but it's the best we've got. We get accused of living in ivory towers, but we do what researchers do--we can't leapfrog over the process."

For researchers like Mayberg, Amen is anathema--a leap-frogger to the nth degree. His disregard for professional politesse can make even his friends and defenders cringe. Jerry Rodos, a psychiatrist in the Chicago area, who regularly refers difficult patients for scans, remembers taking a younger colleague to hear him lecture. "We walked into the conference room, my friend took one look at the Amen concession--tapes and books and CDs, advertisements for his clinics, posters, etc.--and was completely turned off before he even sat down. I think Dan has done a lot of neat work, and what he is saying is very valuable, but he's not a traditionalist and hasn't spent a lot of effort trying to get refereed journals to review his material. If you have something important to say, you submit it to peer-reviewed journals, rather than just run off and start four clinics and write popular books about it. Dan Amen is a big promoter of Dan Amen, and that offends many of his colleagues."

Partly in response to critiques like this, even from allies, Amen has hired a statistician-researcher and is preparing several studies, including one on predicting treatment response in AD/HD patients based on their different scan subtypes. But Amen doesn't believe his opponents will come to like him anytime soon, no matter what kind of studies he publishes. "A friend of mine told me I was like somebody under an old Romanian curse--doomed to know something that's true, but nobody believes him," he says gloomily.

The Client's Experience

Meanwhile, anathema or not, Amen's clinics do 400 to 500 scans a month, and, according to follow-up questionnaires given one month and six months after treatment, 85 percent of this patients think they received "significant benefit" from the process. According to therapy researcher Jay Lebow, however, this isn't unusually high--about 90 percent of psychotherapy users report being satisfied with their treatment, which can simply mean they liked the therapist and felt understood and cared for.

At least some of Amen's patients, however, clearly feel that the experience transformed them, even saved their lives. Whole families get scanned, and then refer their friends and acquaintances and fellow church-members. Some of Amen's most convinced champions are evangelical Christians, who believe that Amen is doing God's work and want to help him do it. Linda and Gaylen Bronson, a California couple who are committed Christians, were so delighted with Amen's treatment of their family that they started the Recovery Assistants Foundation, a tax-exempt, charitable organization that helps people who couldn't otherwise afford it to get and pay for SPECT scans, therapy, and medications.

To get some idea of how the Amen phenomena can build on itself, consider the Woodmansees--Jack, a retired general and businessman, and his wife Patty--who live in a suburb of Dallas. The Woodmansees heard about Amen a decade ago from a friend who felt the SPECT scan and his treatment had dramatically improved her life. Because the Woodmansees had a grandson diagnosed with AD/HD, who was doing very poorly on Ritalin, they sent for an Amen video about AD/HD. Watching it as a family, their adult son (the father of the AD/HD child) came to the conclusion that he probably had AD/HD, too. The senior Woodmansees made appointments for the son and grandson to get scanned, and then decided to take their granddaughter, who had behavioral problems. Eventually, three different branches of the family trooped out to California to be scanned.

Soon they were all talking about the temporal lobes, cingulate gyrus, prefrontal cortex and noting the interesting family resemblances in their brain-perfusion patterns. They also became advocates for Amen, sending along friends, neighbors, and members of their congregation, and even financing scans for people who couldn't afford them. They brought Amen to Dallas to give lectures, and have been trying to convince him to open a clinic there.

Two years ago, Richard and Sarah Mitchell took their 10-year-old daughter, Terry, in for a scan. Always a difficult child, Terry was now throwing herself on the floor in explosive temper tantrums, harassing her siblings, causing classroom disruptions, and failing in school. Diagnosed with AD/HD and oppositional defiant disorder, she'd been prescribed a stimulant, which she vociferously fought taking, and which only made her worse. After the scan, Amen prescribed an antidepressant, a mood stabilizer, and a handful of supplements. He also recommended several therapists. But not one of the three therapists worked out, and the drugs didn't help much, either.

So Amen shifted course. He took Terry off meds, cranked up the supplements, including large doses of over-the-counter omega-3 fatty acids, GABA, and other amino acids (believed to reduce anxiety), recommended a high-protein diet, and helped her parents learn some techniques for handling their daughter better. Now, about two years later, Terry still tends to be bossy and overbearing, has a hard time picking up on social cues, and is emotionally immature. But she's much better than she was--her grades are now high Bs, she likes school, and her mood has generally improved. "She isn't raging anywhere near as much," her mother reports, and she clearly feels more at peace with herself.

Terry's case points to a paradoxical and perhaps misunderstood aspect of Amen's approach. However radical the use of SPECT may seem, his treatment is unconventional only in that it's far more heterogeneous and informed by alternative-healing methods than the Johnny-one-note pharmaceutical orientation of most psychiatrists. While not shy about prescribing medications, often in twos and threes, he also recommends nutritional and herbal supplements, cognitive therapy, EMDR, biofeedback, parenting-skills training, diet, exercise, meditation, and abstinence from alcohol.

How does treatment with Amen compare with what another psychiatrist might recommend? Might not Terry, for example, have done just as well if she'd found a reasonably creative and open-minded therapist willing to try a variety of different approaches and hang in with the family for as long as it took? Of course. Did the SPECT scan speed up the process? Possibly. Does Terry's family believe that scans are magical keys to the kingdom of the inner brain and that Amen is the sorcerer who, essentially, saved their child? Completely. "Without Dr. Amen, she'd probably be in some military school now," says Terry's mother. "I feel blessed to have met him." Among the Amenophiles, this attitude isn't unusual.

For all that people say about what most mattered to them about their experience at one of Amen's clinics, it would be a mistake to underestimate the weight of the old saw that a picture is worth a thousand words. People believe they're seeing an actual picture of something empirically real, fundamentally true, and undeniably revealing about themselves. This apparently incontrovertible glimpse of reality can be unwelcome, even shocking, but it has to be taken seriously. Before the scan, Terry Mitchell had furiously refused to take medications, and felt her parents were disciplining her unfairly. When her scan was shown to her and explained, she looked at it quietly and somberly for a long time, and said, "I guess I really do need medications." It's easy to believe Amen when he talks about the power of these scans to convince even adolescents that the drugs they ingest really are hurting their brains--there's the evidence.

Critics might argue that this troubled child has been conscripted into a possibly false sense of her personal pathology by a misused and misleading test. But, paradoxically, scans that show something amiss can be oddly reassuring. "Do you know what people's biggest worry is about seeing their scan?" Amen asks. "That the scan will show nothing ; that it'll look normal, which means that they're suffering because they're weak or bad." After her scan, Terry felt relieved, her mother said, because the scan explained why she was having so much trouble and removed her sense of self-blame for not acting like a "normal" girl.

Brain and Soul

This peculiar, but almost universal, sleight of thought--"it's not me, it's my brain "--helps explain Amen's appeal and, for that matter, the appeal of all "biological psychiatry." Whether or not we're religious, spiritual seekers, or hard-nosed materialists, we feel intuitively that our real selves, our souls, if you will, aren't the same as the soft "hardware" of the brain. And unlike many drive-thru drug dispensers, as psychiatrists have too often become, Amen actually seems to care about the soul, perhaps even in some way believes he's doing his part to save souls, or at least free them from the malign influence of a sick brain. And clearly, Amen and his staff do everything they can to make the people who come to them feel like real people with basically whole souls, whatever is wrong with their neurophysiology.

Recently, Ted, a nonprofit administrator who'd seen Amen at the Networker Symposium, decided to get his own brain scanned in Amen's clinic in Reston, Virginia, which is directed by psychiatrist Charles Parker. Now in his mid-fifties, Ted says he's been depressed since his late thirties. He describes his emotional state not as sadness so much as apathy, lack of energy, zest, and motivation. "Nothing's wrong in my life. In fact, I think I have a great life. I just don't enjoy it very much," he says. He also has a hard time concentrating and, while he used to read a lot, now just zones out in front of the TV. He was in therapy many years ago, though not since becoming depressed, and has tried a number of medications--Prozac, Wellbutrin, Cymbalta, Paxil--and acupuncture, all to no avail.

Ted loved his whole experience at the Amen clinic. The staff seemed entirely made up of young, attractive, extraordinarily pleasant women with big smiles who, Ted was intrigued to see, all wore very high heels. "It was a little like the Stepford Wives, only they seemed genuinely nice." He filled out a 15-page questionnaire, went through a lengthy interview with the "historian," and then underwent a concentration scan. Two days later, he went in for his resting scan, and a day or two after that, Dr. Parker reviewed the scans with him.

Ted found Dr. Parker to be the nicest person of an amazingly nice staff, scoring about 110 on a 100-point friendliness scale. "The psychiatrist I go to for my meds checks is a nice enough guy, I guess, but he's like an iceberg compared to Dr. Parker, whom I liked much better. He really seemed to want to spend as much time with me as I needed."

As for the scans and what emerged from them, things get a little murky. The report was long, complicated, and somewhat confusing to Ted, who said that, as he listened, "after five minutes or so, I kind of glazed over." The scans showed less than normal perfusion in areas of the prefrontal cortex, temporal lobes, and parietal lobes; increased, or excessive, perfusion in the basal ganglia and limbic system; and "scalloping," or dehydration, on the outer surface. Altogether, all of this signifies . . . well, a lot of possibilities--including, but not limited to, short attention span, low motivation, memory problems, abnormal perception, impulsivity, disorganization, distractibility, anxiety, irritability, depression, and mood cycles.

In this somewhat jumbled mass of findings, what fascinated Ted the most was the pronounced indentation in his left prefrontal cortex, consistent, said Parker, with past brain injury. Amen contends that many psychiatric conditions may result from undiagnosed, and even apparently mild, brain trauma without unconsciousness, and he makes it a practice to ask his patients at least five times if they've ever experienced head injuries. Ted was also interested to learn that several of the patterns picked up on in the scan are often seen in people with AD/HD.

The upshot of all this was that, according to Parker and Amen (who read the scan), Ted had been taking the wrong medication--Cymbalta only exaggerates symptoms of AD/HD and concentration difficulties. He was to begin taking Effexor right away, and Adderall a few weeks down the line. Besides this, he should begin exercising and take various supplements. Ted was given a list of books and referrals to holistically trained MDs specializing in nutrition and brain-injury recovery, neurofeedback experts, and brain-health websites. He was also told to make a follow-up appointment. For a technique that's supposed to provide the focus for well-targeted, specific clinical interventions, Ted's SPECT scan seems to have resulted in something of a hodgepodge of generic recommendations.

But Ted came away from his adventure feeling elated--less like somebody who's had a high-tech medical procedure with no very clear prognosis, and more like somebody who'd won the lottery and been given a new lease on life. "I thoroughly loved the whole thing. I'm very glad I did it. It was uplifting and made me feel so hopeful." And the scans? "They're interesting to look at--very pretty. It's neat to have somebody show you what your brain looks like. And then to be shown this big indentation that's not supposed to be there; well, it's concrete evidence that something really did happen to you. I do think I understand my own brain a little bit better."

Whatever the outcome for Ted's case, or for Amen's crusade overall, it seems inevitable that his work, or some variant of it, represents a glimpse into the future. With the development of revolutionary new technologies permitting a direct look inside the brain, people will be increasingly dissatisfied with the clinical guesswork and serial medication trials that constitute so much of psychiatry today.

Nor will psychotherapists, the workhorses of the mental health industry, be content to wait until the last peer-reviewed, double-blinded study demonstrating SPECT's empirical validity and reliability has been published before making use of these technologies in their own practices. They've never been willing to delay using what seemed useful to their patients until they've gotten the okay from the higher orders of scientific inquiry. EMDR and many forms of body-oriented trauma therapies, as well as a host of other therapeutic methods, are still considered fringe by research psychologists, but that isn't stopping therapists from using them. Whether one considers Amen a devil or a new messiah, his use of SPECT visionary or voodoo, it seems likely that time is on his side.

Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker. Contact: maswylie@midmaine.com.

 

 

The Art of Therapeutic Conversation

by Jay Efran and Mitchell Green

In a memorable scene in Fiddler on the Roof, the main character, Tevye, pretends to have been awakened by a nightmare that he concocts to convince his wife to change her mind about who their daughter should marry. As he describes this "dream," dancers and singers act out the story, accompanied by a small band of strolling musicians. In the original Broadway production, this scene was always a crowd-pleaser. In the revival, however, Zero Mostel (as Tevye) found a way to turn it into a showstopper. In the new version, as he recounts his tale, the audience watches him become increasingly distracted by the deafening cymbal crashes of the nearby percussionist. Suddenly eyeing a solution, Tevye grabs for the nearest bed pillow and hurls it at the musician. It lodges between the cymbals just in time to stifle the next crash. This improvised bit of comedy elicited such howls of laughter from the audience that it was permanently incorporated into the show.

Such consummate pieces of stagecraft are the lifeblood of a theatrical production. However, because they develop organically out of the "conversation" of actor, role, and audience, they're virtually impossible to plan. (Mostel didn't "find" the pillow bit until he'd played Tevye hundreds of times.) For similar reasons, effective psychotherapy interventions can't be fully scripted in advance. Like Mostel's innovation, therapy's most effective moments are improvisations that arise out of the conversational flow between client and therapist. Indeed, every therapeutic journey is unique, involving unexpected twists and turns. These aren't signs of the therapist's lack of skill or treatment failure; they constitute the very heart of the process.

From this perspective, the growing emphasis on treatment manuals and empirically validated methods is a step in the wrong direction. Yes, the public needs to be protected from quacks, and managed care organizations certainly want some assurance that their money is being spent wisely. In the final analysis, however, the effectiveness of a client-therapist pairing is a function of their collaborative dialogue--a process that resists standardization. Undoubtedly, one can specify general principles and guidelines, and therapy can be anchored in a contract that defines roles and sets boundaries. However, therapy also requires a certain creative ambiguity that can't be reduced to stock exercises or "bottled" like an antidepressant.

The past three decades of research on psychotherapy have added little to Lester Luborsky's famous 1975 "dodo bird verdict," that "everybody has won, and all must have prizes." In other words, with only a few circumscribed exceptions, every empirically tested therapy has shown roughly the same level of (some would say mediocre) results. As Mark Hubble, Barry Duncan, and Scott Miller note in The Heart and Soul of Change in 1999, the vaunted list of empirically supported approaches amounts to little more than a recognition that some methods have been tested and others haven't.

 

Even in the case of heavily researched treatments, such as Marsha Linehan's Dialectical Behavior Therapy (DBT), we still know almost nothing about how particular components of the approach operate. All we really know is that the potpourri of methods Linehan assembled--skills training, mindfulness techniques, phone contacts, group sessions, etc.--works somewhat better for certain types of emotional problems than the ragtag assortment of treatments generally available. It's possible, even likely, that the advantages in outcome the DBT studies report are mainly attributable to the skills and enthusiasm of handpicked, crackerjack research teams and the comparative abundance of resources available to them. Thus far, we haven't seen the kinds of dismantling studies that would enable us to understand more about how DBT works.

Unfortunately, manualized treatment protocols, designed to make treatments replicable, create a false impression of objectivity. For instance, we know many who've worked on manual-driven projects and who report, off the record, that they were only able to adhere to the manual for the first few sessions--during the intake phase. After that, the content of their sessions became increasingly variable and idiosyncratic, tailored, as one might have predicted, to the exigencies of the developing client-therapist dialogue. In some of these studies, the therapists dutifully continued to administer the prescribed exercises, but they also felt obliged to slip in side conversations that more directly addressed their client's needs. Unfortunately, such procedural deviations rarely make their way into the published literature. Therefore, readers are left with the false impression that the manualized procedures are easy to implement and reliably produce the desired result. Manuals may not be entirely worthless, but they certainly don't tell the whole story of what transpired between client and therapist.

Several years ago, we watched a manual-driven group treatment from behind a one-way mirror. Time after time, group members were actively discouraged from discussing issues that concerned them because these didn't fit the session's prescribed agenda. The leader kept complaining that the group had to move on because they were "falling behind the schedule." Ironically, it was those forbidden "disgressions" that group members later remembered as the most valuable aspects of the sessions. At a feedback session with an outside evaluator, members were quick to say that they liked being in the group and profited from meeting the other members, but had little use for the leader's heavy-handed attempts to administer "the treatment."

Even the best manuals tend to devolve into a series of vague instructions, such as "continue checking the client's homework," "review the previous week's gains," or "identify other instances of catastrophic thinking." Such directives hardly achieve the goal of insuring standardization. Most such studies emphasize group statistics, ignoring the therapist variability that exists even though each client is supposed to be receiving the same treatment. In fact, much of the field's scientific sweat equity has been invested in studies of therapy's lowest common denominator--group findings from hothouse projects of canned therapies, using inexperienced graduate-student therapists and highly selected populations. The shame is that these studies convey an erroneous message about what works, focusing attention on particular techniques and away from the kind of conversational improvisation that good therapy requires.

 

We can trace the current conundrum we're in--over the difficulty of making real therapy fit into a scientific paradigm--to the "slow-acting poison pill" that former American Psychological Association president George Albee says the mental health profession ingested several decades ago. With this pill, we swallowed the deeply flawed medical/psychiatric assumptions about diagnoses and dosages, culminating in the unrealistic expectation that forms of psychotherapy can be administered with the reliability of, let's say, a surgical protocol. The belief that this level of consistency can be obtained derives from a serious confusion of models--what philosopher Gilbert Ryle called "a category mistake." In other words, psychotherapy has been misclassified; it should never have been considered a treatment in the first place. Rather, it's a specialized form of inquiry--more philosophical journey than medical procedure.

In fact, if Jungian James Hillman had his way, the therapy enterprise would be categorized "as an art form rather than a science or a medicine." At root, therapy is just two people conversing. That would be evident if you peeled back the layers of mystification and simply listened to a therapy tape. "Consciousness," says Hillman, "is really nothing more than maintaining conversation, and unconsciousness is really nothing more than letting things fall out of conversation."

The derivation of the word conversation is worth examining: it comes from vertere (to turn) and con (with). This is a perfect metaphor for the therapeutic process. As Hillman describes it, you "walk back and forth with someone . . . turning and going over the same ground" from a variety of directions until "what we already feel and think [has been converted] into something unexpected." To be effective, therapeutic talk must have an edge: "It opens your eyes to something, quickens your ears, . . . and keeps on talking in your mind later in the day," adds Hillman, and, hopefully, for days to come. Instead of talking of cures, the therapist's job is to "cure our talk."

A week ago, a client came in for her first session. She described the frustrations of having engaged in years of self-improvement efforts--meditation classes, body disciplines, empowerment groups--only to find herself as confused as ever about whether to stay in her marriage and if a career shift might bring greater fulfillment. At that moment, I found myself contradicting Socrates, telling her that sometimes the unexamined life is worth living. That statement struck a chord. She lit up, laughed, relaxed into her chair, and said, "Thanks for saying that."

 

My remark couldn't have been preplanned and wouldn't necessarily have been appropriate for either a different client or even the same client at a different time. Like a thousand other such bits of conversational ingenuity, it worked because of its positioning in the ongoing dialogue--it was exquisitely responsive to the several layers of meaning contained in the client's communication.

It's practically impossible to explain how such comments are generated or exactly what clients make of them, yet the immediate reaction and subsequent discussion in this case made it clear that comments such as these catalyze important shifts in perspective and advance the collaboration inherent in therapy. Like Mostel's bit of chicanery, such spontaneous remarks are not learned from manuals and can't be dispensed on demand, yet they're the essence of the therapist's conversational craft.

Our recent informal survey of real-world practitioners--the folks who actually make their living seeing clients--suggests that most therapists don't use cookbooks, don't place their faith in techniques, and don't pay much attention to what's on the latest list of validated treatments. Moreover, the longer they've been in practice, the less their treatments resemble the rule-bound procedures they learned in school. Experienced clinicians intuitively follow Hillman's advice to avoid fixed positions, realizing that any prejudgments can "stop conversation dead in its tracks"--leading to a sterile monologue rather than a productive dialogue. When that happens, you might just as well send a memo.

Jay Efran, Ph.D., is emeritus professor of psychology at Temple University. He's the coauthor of  Language, Structure and Change: Frameworks of Meaning in Psychotherapy and of The Tao of Sobriety . Contact: jay.efran@verizon.net. Mitchell Greene, Ph.D., is clinical director of Main Line Clinical Associates in Wayne, Pennsylvania. Letters to the Editor about the article may be e-mailed to letters@psychnetworker.org.

 

 

 

The Art and Science of Love

Can the Gottmans Bring Empirical Rigor to the Intuitive World of Couples Therapy?

By Katy Butler

Throughout the 1980s and 1990s, in a specially outfitted studio apartment in Seattle that reporters nicknamed the "love lab," mathematician-turned-psychologist John Gottman videotaped ordinary couples in their most ordinary moments--playing solitaire, chatting, kissing, disagreeing, watching TV, cooking dinner.

Sometimes Gottman, then a professor at the University of Washington, asked them to discuss an area of conflict while monitors strapped to their chests recorded their heart rates. Sometimes he sat them on spring-loaded platforms to record how much they fidgeted. He looked at how they brought up painful subjects, how they responded to each other's bids for attention, how they fought and joked, and how they expressed emotion.

Funded by the National Institute of Mental Health, he and his colleagues studied newlyweds, men who battered their wives, couples who shouted a lot, and others who beat around the bush and never raised their voices. He used an elaborate coding system to track not only their verbal exchanges, but less obvious indicators of emotion: flickering facial expressions, sighs, clammy hands, rolling eyes, and galloping heartbeats. He followed some of the couples for more than two decades, recording who got divorced, who established parallel lives, and who stayed together--more or less happily.

He then took his data and translated them into numbers, quantifying an area of human life usually relegated to the psychotherapist and the novelist. Using complex computer models, he found that he could predict divorce with 91-percent accuracy, simply by analyzing seven variables in a couple's behavior during a five-minute disagreement. What he discovered made him famous. He appeared on network television and was immortalized by Malcolm Gladwell in Blink. Most of what we reliably know about marriage and divorce in its natural state comes from his work.

In the course of studying more than 3,000 couples, Gottman discovered that most of them fought, and that even the most happily married couples never resolved 69 percent of their conflicts. When they returned to his lab at four-year intervals, the issues and even the phrases were essentially the same. Only their clothing and hairstyles changed.

 

What was crucial, Gottman learned, wasn't whether a couple fought, but how. Among those couples whose marriages survived well, whom Gottman and his colleagues came to call the "masters of marriage," wives raised issues gently, and brought them up sooner rather than later. Neither husbands nor wives regularly became so upset with each other that their heart rates rose above 95 beats a minute. They broke rising tension with jokes, reassurance, and distractions. They didn't escalate their arguments.

Faced with a request or complaint from their wives (and 80 percent of the complaints did come from wives), the successful husbands didn't play king or cross their arms like rebellious teenagers. Instead they changed their behavior--doing more dishes, working fewer hours, giving more than lip service to their wives' dreams, or taking an older child to the park to give an exhausted new mother a break. When news of these findings hit the newspapers in the late 1990s, my boyfriend at the time called it the "yes, dear" path to marital harmony.

Perhaps most notable, the master couples made at least 5 positive remarks or gestures toward each other for every zinger during a fight ; in calmer times, their positive-to-negative ratio was an astounding 20 to 1.

The "masters of disaster" in Gottman's study group--those who eventually divorced--fought differently. Wives raised issues harshly--especially when their husbands ignored them or put them down. (He named the wives' openers "harsh start-ups.") The husbands got upset more easily during arguments like these and had a harder time calming themselves down. And 94 percent of the time, conflicts that opened harshly didn't get any better as they went along.

Rather than complaining about specifics, the wives frequently globalized their criticisms, using phrases like "you never" and rhetorical questions like "What's wrong with you?" The husbands, for their part, frequently shut down, playing emotional possum or becoming as blank as a cement wall. The reverberation between them was so toxic that Gottman named criticism and stonewalling as two of his Four Horsemen of Marital Apocalypse. (The other two are defensiveness and contempt.) The presence of the Four Horsemen alone, he found, combined with pulse rates that rose above 95 beats per minute during a disagreement, were highly reliable predictors of divorce.

The background music of the less successful relationships, not surprisingly, was halting. In both happy and unhappy couples, partners made plenty of subtle bids for attention, closeness, or reassurance. But the partners headed for divorce responded to each other's bids only 33 percent of the time, while the happy couples' response rate was 86 percent.

 

Finally, Gottman's research showed him that it wasn't only how the couple fought that mattered, but how they made up afterward--what he called a "repair," echoing the language of engineering. In a longitudinal study of 130 newlywed couples published in 1998, Gottman found that 83 percent of marriages initially exhibiting the Four Horsemen became stable over time, as long as the couple learned to reconcile successfully after a fight.

Then in 1994, John Gottman went canoeing in Puget Sound off Orcas Island with his wife, Julie Schwartz Gottman, an experienced clinical psychologist in her own right. Mindful of the dismal showing of most existing couples therapies in outcome studies, he suggested that they combine his research and her therapeutic wisdom to fashion a science-based couples therapy.

They began writing a manual that night. Later they organized weekend workshops and started a Seattle clinic eventually staffed by 16 clinicians. In 1998, they began leading advanced trainings for therapists. By 2004, 4,000 couples had gone through their workshops or their clinic. By 2006, more than 3,000 therapists had taken a basic training workshop with them, 65 therapists had been certified in their approach, and 600 more were well on their way to certification.

The Gottmans call their new approach Gottman Method Couples Therapy. It braids together classic therapeutic skills with two new elements: scientific dispassion and scientific authority. The dispassion comes from their extensive use of assessment and feedback, a legacy of John's research training. More than 30 pen-and-paper questionnaires are methodically administered to each partner before therapy begins; videotaping and heart-monitoring are part of therapy itself. The authority comes from the research showing that therapists using this approach can decisively stop their clients from exercising the Four Horsemen of contempt, criticism, defensiveness, and stonewalling. They can teach their clients the behavioral skills used by Gottman's "masters of marriage," including little kindnesses that build a strong marital friendship, and tools to regulate conflict. Perhaps most important, the dispassion, structure, and authority of the approach act as counterweights to the discouragement and chaos often generated by couples in trouble--emotional storms that blow many a therapist into taking sides or losing control altogether.

Last April, Brian, my almost husband, and I flew from San Francisco to Seattle to attend a two-day weekend couples workshop with the Gottmans called "The Art and Science of Love."

 

Starting Out

An old joke says that women marry expecting men to change, and men marry expecting women not to. Even though we aren't yet married--we're both long divorced from other people--Brian and I fill that bill. I want him to dress better, set limits with his adult sons, and change his job. He wants me to lighten up. After seven years together, he still leaves me notes saying how much he loves me, and I still bring coffee and the newspaper up to our bedroom on Saturday mornings. But much as I hate to admit it, if John Gottman installed a video camera in our home, he'd sometimes catch us cohabiting with the Four Horsemen. I'm a master at the harsh start-up. I've ambushed Brian with pressing concerns when he's still half-asleep, rolled my eyes contemptuously during arguments, and couched my complaints as variants of "What's wrong with you?"

Brian, for his part, has often promised to consult me before inviting his sons to stay with us--and hasn't. I moved into his house six years ago, and I still sometimes feel perched there, overwhelmed by free-floating testosterone. He doesn't always keep agreements, and when I want a straight answer, he can fend me off with stonewalling and an evasive Irish-American jokiness that drives me up the wall. By the time we flew to Seattle, we'd begun avoiding some of our most tender differences rather than risk a fight.

That, in a nutshell, is our shared emotional climate at 9:40 a.m. on a windy Saturday last spring. We sit together in the front row of a huge conference room, packed with couples in similar straits, not far from the old Seattle World's Fair Space Needle. John and Julie Gottman are standing in front of us, warning us about the Four Horsemen, and suggesting that instead of tackling our most upsetting issues head-on, we start obliquely, building a "culture of appreciation" for each other. In sum, they want us to improve our background music.

"If you make a very small correction," John Gottman says, "doing stuff that seems natural and small, over time, it'll make a big difference." The idea is to fiddle with thousands of tiny daily interactions--things so seemingly trivial that it's hard to imagine they'd make any difference at all--as if we're fine-tuning a complex carburetor.

 

"You build romance and passion and great sex through little moments," he goes on, citing tidbits of his research showing that unhappy couples often respond positively to each other--just not often enough. He's 64 and slight, with a white beard and luminous eyes. He's wearing a bright-red tie and a yarmulke, but there's something about the way he sometimes throws out terms like "vasoconstriction" and "chance levels of prediction" that makes it easy to imagine him in a white lab coat.

I wonder if Brian is getting bored.

John's wife Julie, who's the copresenter of the workshop, is 55, zaftig, humorous, and easy, with long, curling, black-gray hair and the full, low, soothing voice of a practiced psychotherapist. She wears sensible shoes and a therapist-as-priestess black and white kimono, banded with images drawn from Haida Indian totem poles.

Joining Brian and me in the audience are about 200 other couples from many states in the union, in varying states of wedded bliss and distress. Most have paid $600 to be here. Some women lean forward, their expressions hopeful, rapt, or desperate. Some men sit back with their arms crossed, like attendees at a weekend traffic school.

Sometimes I poke an elbow into Brian to underline a point. Every now and again he whispers to me, "Let's acknowledge the men!" amazed that so many have agreed to be here on the opening weekend of the NBA basketball playoffs.

On our laps are melon-colored, three-ring binders entitled "The Art and Science of Love." What differentiates this workshop from others on the market, the binder says, is that it's grounded not in idealistic notions of what marriage ought to be, but on "solid research on what actually works in relationships that are happy and stable."

Embedded in this sentence is a clinical hypothesis: that unhappy couples can be taught to do what happy couples do. This assumption underlies not only this workshop and Gottman Method Couples Therapy, but also aspects of cognitive-behavioral therapy, the Positive Psychology movement, and Marsha Linehan's Dialectical Behavior Therapy.

 

The hypothesis assumes that unhappy couples have the maturity and the emotional wherewithal at least to try to treat each other differently. I wonder if that's true for me.

There's another difference between this and other couples approaches that the binder doesn't mention: the Gottmans' work is men-friendly. Some of the language that their therapy uses--"relationship repair," "overrides," and "harsh start-ups," for instance--could have come from a car-repair manual. It's a dirty little secret that men are often dragged to couples therapy, and feel emotionally illiterate or ganged-up-on once they get there. The exercises in our binders, however, look doable, practical, and circumscribed, rather than like an endless dive into the amorphous emotional depths.

The workshop's goal is to help us learn to imitate Gottman's long-married master couples. The bedrock of their successful relationships, it's explained, is marital friendship, built granule upon granule, through tiny rituals of courtesy, kindness, humor, and appreciation. Successful couples, have large "cognitive maps" of each other's worlds. They're curious about each other's inner lives, and they don't stint on expressing their appreciation for each other. When one of them makes a subtle bid for attention--something as simple as "look at the pretty boats"--the other one usually responds positively.

This system of mutual stroking, according to the Gottmans' model, produces "positive sentiment override"--an emotional tipping point that allows spouses to think, in tense moments, "My sweetie must be having a hard day" rather than "What a jerk!" or "He doesn't love me." And that makes it easier to disagree without being disagreeable.

It all seems eminently doable, but I'm not convinced. For me, the complex weather of human relationships conforms more closely to the dynamics of chaos theory than to Newtonian physics. The Gottmans' structure seems too linear and mechanistic. But maybe, I think with a glance at Brian, who's paying close attention, it's an image that works for men.

In unhappy couples, the presenters continue, the relative dearth of positive feedback engenders a destructive cognitive shift over time to "negative sentiment override"--essentially, assuming the worst about one's partner. This leads to what John Gottman calls the "fundamental attribution error"--a default setting of blame, in which all the problems in the relationship are the partner's fault. Fights escalate and become a contest of wills, replete with the Four Horsemen. Both partners get painfully flooded with emotion and sometimes withdraw. Over time, this can result in a cascade of isolation, distance, loneliness, parallel lives, and eventual divorce.

 

When I hear this, I think of the morning 15 years ago, not long before my marriage ended, when my former husband sat opposite me at our kitchen table and gently stroked my head with the tip of a three-foot dowel, like a lobster using his antenna to groom a mate he dared not touch.

But that was a long time ago. Today, in a series of unthreatening exercises, I have a chance to do things differently. During the weekend, the Gottmans explain, Brian and I will be taught how to put deposits in our joint "emotional bank account" and engender "positive sentiment override." We'll learn to soothe each other and ourselves. And finally we'll develop ways to manage the conflicts we can't resolve, honor each other's dreams, and create a life of shared meaning.

No longer drifting in a river of emotion, I find myself looking at our relationship dispassionately, with the mind of a scientist. I realize how often Brian pays me compliments, and how seldom I compliment him. I ask myself: Why not be nicer? Where's the risk? "I don't give as many small things," I write in my notebook. "I need to criticize less. I need to learn softened start-up. I need to listen when he's overwhelmed. I need to learn when I'm overwhelmed."

And when John Gottman says how important it is for men to make cognitive room for their wives' dreams and accept their wives' influence, I think of times I've felt run over or ignored, and I give Brian an elbow-poke.

A few minutes later, the introductory lecture concludes and the Gottmans send us out to adjoining breakout rooms for the "Love Map," our first partner exercise. We find two chairs facing each other and begin. One by one, Brian and I turn over cards we've taken from a plastic pocket in our binder and guess the answers to questions like, "Who is your partner's best friend? What are his or her dreams and aspirations? Who is his or her favorite poet?"

I miss his favorite magazine-- Mother Jones --but get both of his second choices right-- Rolling Stone and Time. He gets all of my magazines right except The New Yorker. I name his best friend and he names mine, but I realize there are two women whom I talk to daily whose names he doesn't even know. These women are aware that I dream of selling my house in Mill Valley and building a straw-bale house from scratch in the dairy country near Tomales Bay, and going there to write. I've never told Brian about this dream. Mired in our day-to-day struggles, I realize, we seldom talk about our larger hopes and aspirations.

 

I miss his favorite poet--John O'Donohue--but get the next two right--Uriah Mountain Dreamer and Mary Oliver. He misses my favorite poet--Mary Oliver--but gets the next one right: Jane Hirshfield.

We feel close and happy. This is fun. Brian loves the exercise. He says he wants us to do this once a month when we get home.

So the day goes. Every hour or so, after a minilecture and a role-play from the two Gottmans, we stream out of the auditorium with our binders into adjoining breakout rooms to do little exercises with our partners. Along the walls stand roving therapists certified (or close to being certified) in Gottman Method Couples Therapy. Every now and again, a distressed or confused husband or wife holds up a small red card--like the penalty card in soccer--and a clinician quietly moves in like a therapeutic AAA truck to coach them.

Now we pick from a deck of "opportunity cards" that suggest ways we can turn toward each other. Brian nixes the notion of spending an evening discussing what I'd like to change about the interior of the house, but promises to plan a weeklong getaway when we get home. He turns down my offer to bring flowers home, but asks me to surprise him with tickets to a concert. We look down a list in the binder and circle things like "doing a favorite activity together," "playing together," "taking vacations together," and "time to make love." It's shocking to realize how hard we work, how long it's been since we went biking together in the country, and how much we'd like to do it again some time.

We're working behaviorally, moving up stair-steps like the itsy-bitsy spider, building the foundation of what the Gottmans call our "sound relationship house." The structure resembles Abraham Maslow's hierarchy of needs--starting with a solid friendship, proceeding to negotiating conflicts, and then to higher-level relationship needs. The Gottmans' goal isn't for couples to achieve a relationship rivaling Antony and Cleopatra's, but rather to learn how to have a good-enough marriage. A marriage is good enough, John Gottman once wrote, "If the two spouses choose to have coffee and pastries together on a Saturday afternoon and really enjoy the conversation, even if they don't heal one another's childhood wounds or don't always have wall-socket, mind-blowing, skyrocket sex."

 

The day proceeds. Between exercises, we take breaks for tea and pile little paper plates with grapes and slices of cut pineapple. The Gottmans don't drag any of us onstage to open our hearts in front of strangers. They don't deliver any aren't-I-smart paradoxical interventions, tell us that men are from Mars, or teach us how to exchange quid-pro-quos, like "I'll do the dishes and stroke your back if you'll have more sex with me." They don't suggest that marriage is a sexual crucible, as David Schnarch holds, or that it's a God-given opportunity for deep emotional healing, as Imago's Helen Hunt and Harville Hendrix contend. They just want us to create small, gentle changes in the trajectory of our relationships--ones that might create big payoffs if practiced over time.

A good Gottman marriage, I start to think, is a bit like a 16-foot scale model of an ocean liner made from 194,000 toothpicks and seven gallons of glue. They don't want to us to remake ourselves from scratch. They're handing us toothpicks, some glue, and a blueprint.

Struggling to Open Up

The next exercise, after lunch, is a step more intimate. We turn to a checklist in our binders, choose three positive qualities we see in our partners, and tell each other about them.

Brian checks that I'm "thrifty," "creative," and "a great friend," and writes comments like "you know your limits . . . smart bright writer and teacher . . . I trust you."

I'm touched.

I decide he is "virile," "committed," "protective," and "playful," remembering how he took care of both of our airline boarding passes and insisted we squeeze in a ferry ride on Puget Sound before the workshop began.

He smiles.

Like many couples, we come back to the big room hand in hand.

Next, after Brian takes a break, hovering around the tables laid out with tea and cut fruit, comes practicing a "stress reducing conversation." Learning to buffer our relationship from the stresses of the world, the Gottmans say, is critical to maintaining closeness over time. This means being Brian's ally, his sympathetic ear, his cheerleader, and not his educator, coach, critic, or mentor--a big shift for me.

For once, I simply listen and accept when he tells me he's so stressed by his job that he doesn't have the energy to change it. Instead of giving him a checklist of things to do, I take in his exhaustion and fragility.

When it's my turn, and I talk about wanting to drop a work responsibility, he says, "What stops you from doing something about it?" I feel reprimanded. I ask him to just listen. Then I speak not only of my own driven work habits, but of my difficulty saying no and of the day long ago when my beloved father beat me badly when I was caught after running away.

Brian takes my hand, looks in my eyes, and tells me he's never before really "gotten" what my childhood was like. He has tears in his eyes.

What we've just done together sounds so innocuous--a standard-issue exercise in reflective listening. I've done things like it before, although never with someone I'm so close to. And we've gone deeper than I expected. This isn't territory the Gottmans warned us about. I wonder if there are hidden reasons why Brian and I don't treat each other better, and marvel at how easily intimate partnerships can reawaken the hurts of our first deep connections. For a long time--perhaps since the end of my marriage, perhaps since childhood--I've been Miss Hard-Boiled, making sure I didn't risk too much closeness. Now that I've been more open with Brian (and vice versa) my heart hurts.

As it turns out, I'm not alone. Others in the rooms here seem to have emotional reasons--far deeper than mere ignorance or lack of skill--for not being able to "act as if" and do what happy couples do. A man to my left spends big chunks of time either reading the New York Times sports section or sitting with his eyes half-closed. To my right, before another exercise, one woman stays behind in the auditorium, hanging onto her husband and sobbing inconsolably. I wonder about her story: what long-ago childhood betrayal or recent affair fuels her tears? Another man and woman stand outside smoking in the courtyard, not talking, not touching, just staring into space. Are they too far down the "distance and isolation cascade" to turn back? Around the breakout rooms, red cards fly up. Two sets of chairs away from us, a man points to his wife accusingly. "I saw it!" he says. "You rolled your eyes! That's contempt!"

 

That night, Brian and I have a lovely dinner at an Italian restaurant across from our hotel. We bemoan the fact that we didn't set aside a few extra days just for fun, and swear we're going to come back to Seattle again sometime without work obligations. As we look over the bill and recap the day, Brian casually says, "I don't know about the love maps. What difference does it make if I know who your favorite poet is?"

This strikes one of my enduring vulnerabilities: my fear of never being known or understood. Quicker than thought, I say harshly, "You're missing the point." In his eyes, I see reflected the altar boy he once was, being reprimanded by a nun. For a moment, the good feelings of the day are scattered like toothpicks.

We've been here before: what the Gottmans would call my "harsh start-up" has hurt what I'd call the little boy inside my man. Brian starts a slow, sustained, invisible burn. It's little comfort to me that Gottman found many couples like us when he did his research: sensitive couples who easily got hurt; men incurious about their partner's life; women who felt ignored and therefore hit their men over the head with a rhetorical two-by-four to make a point. Those were the couples who often ended up getting divorced.

Later that night, we lie side by side on a huge king-sized bed. We aren't touching. It's a smoking room: the little hotel is full of couples from the workshop, and by the time we signed up, this was the only room left. The smell of smoke is in the air, especially now that we've closed the windows against the evening cold. Brian is on his side, turned away from me, angry.

"Nothing's ever good enough for you," he says.

I think of the toxic effects of the Four Horsemen, and that gives me the wherewithal to tell Brian that's a criticism rather than a complaint. Then, borne on the stream of the workshop, I reach out my hand and stroke his back. I hear two sets of footsteps, and a door open and close down the hall.

 

I stroke Brian's back and shoulder for a long time, as the light in the room fades. I wonder whether his heart rate is over 95 beats a minute, remembering John Gottman's remarks not long before the workshop day ended about the physical flooding or "diffuse physiological arousal" that often occurs when couples fight: cortisol is secreted, the heart races and the blood pumps, perceptions narrow, and the processing of new information virtually ceases. Men respond more intensely than women to a stressor, like a gunshot; they're more likely to sustain angry thoughts after a fight; and their hearts take much more time to slow down again. Through the years, this recurrent neurological cascade can damage men's immune and cardiovascular systems. This gender difference may help explain why women often are more wiling to engage in emotionally upsetting conversations than are men.

As I lie there, I also remember Julie Gottman telling us, in her soothing, therapeutic voice, that it isn't the fight that matters so much as how the couple repairs things afterward. So I murmur, doing my best to own my part in things, and to nudge Brian gently to forgive me. I'm not in a rush, happy simply stroking him, simply feeling his skin. Finally he makes a joke--the kind of thing Gottman says that his master couples do to break tension. He turns to face me, and when he's naked like this, his bright eyes and grey beard somehow remind me of the battle-scarred Ulysses returning, almost unrecognizable after 20 years, to his faithful Penelope.

Finally, after hours of closeness, we sleep.

Learning How to Fight

On the morning of day two of the workshop, the Gottmans show us that they, too, fight, and not always gracefully. They've been married for 20 years. Both were married before, they've told me, and both came from painful, though decidedly different, family backgrounds.

John was born in the Dominican Republic to poor Jewish refugees from Vienna who had lost 24 members of their extended families to the Holocaust. Julie was raised in Portland, Oregon, where her father was a successful doctor and her mother a depressed incest survivor. Her early family life was so painful that she often slept in the woods.

 

John found a refuge at MIT, in the precision of mathematics and science. He admits he was "clueless" about male-female relationships as a teenager, and later decided that since he wasn't succeeding at relationships, he might as well study them. Over the years, he slowly learned to imitate what his master couples did. Julie, by contrast, had visions in the woods calling her to become a healer. She became a clinical psychologist, working with trauma survivors and Vietnam veterans, and she served long apprenticeships with two American Indian medicine women. I sometimes I wonder how they ever learned to respect, much less integrate, their different ways of being.

The fact that it's not always easy is laid bare on Sunday morning, when they reprise an old fight and role-play "repair." Julie begins by describing how she'd woken up one morning having dreamt that John had been flirting with other women. Already anxious about an upcoming speech, she'd wandered into the bathroom, where John was brushing his teeth. She'd told him her dream. He'd murmured reassuringly and hugged her for what seemed to her like a few seconds and what seemed to him like a long, long time.

He'd turned away--abruptly, Julie thought--and she'd gotten into the shower, feeling even more alone.

Now John takes up the thread, describing how he'd thought to himself, Wait a second! He'd apologized to Julie for things he'd done in a dream --things he hadn't actually done and wasn't thinking of doing. Hadn't he been cleaning up around the house lately, the way she asked him to, without much acknowledgement? Hadn't he been cooking her lots of great fish dinners? She has some nerve, having this dream about me being a louse, he said to himself. Don't we have enough problems during the day without her making up new ones at night?!

Then before he knew it, John said, he was snapping at Julie, and she was standing in the shower in tears.

I glance down at the page in my binder entitled "Aftermath of a Fight or Disagreement" and its subheads: Share Your Subjective Reality, Find Something in Your Partner's Story that You Can Understand, Are You Flooded? Admitting Your Own Role, and Making It Better in the Future.

 

I think of times, in my marriage and in long-gone relationships, when I, like Julie, wanted reassurance and had gotten none. At such times, I'd usually decided that I'd picked the wrong man to be with. The Gottmans don't go there. I feel almost naughty listening in on their argument, as if they've raised a black curtain and I'm watching them pole-dance or violate some other cultural taboo. In this culture, very little gets said about the years after the honeymoon, the years that fairytales call "Happily Ever After" and Joseph Campbell called the "spiritual ordeal" of ordinary marriage. If Brian and I had an interchange this painful--and we did just last night, and haven't fully recovered yet--I'd be tempted to tell nobody for fear of hearing, "What a jerk! Why do you put up with him?" or "Why does he put up with you?"

Modeling imperfection for us, the Gottmans show the normality of relationship angst--even recurrent angst. On the surface, they're teaching us behavioral skills and evidence-based techniques--how to understand your partner's equally valid reality, and how to reconcile. But on the metalevel, what they're teaching doesn't come from John's research. It's wordless and embodied--a normalizing of the fact that little things can set off surprising ambushes of hurt in intimate relationships. After watching the Gottmans in action, Brian and I don't look so odd to me.

"My subjective reality is that I come from a background where I was beaten up," Julie goes on as they model the process of repair. "I don't have a lot of self-confidence, especially when I have to give speeches to powerful people."

"I dream symbolically," she continues. "The person in the dream becomes the symbol of someone who's hurting me."

"So I become . . . .?" interjects John.

"You're not supposed to talk now," Julie says quickly. "As a good little psychologist ( Do I detect contempt, humor, or just anxiety here? I wonder fleetingly), I thought you'd understand that my dream is sym-bol-ic. I needed you to be by my side, and you couldn't be, and I felt very alone."

Then Julie softens, moving to find something in her partner's story that she can understand. "You try so hard to be a good husband--and you are a good husband." She starts to sniffle.

 

"Are you flooded?" John asks gently.

"Yes I am," she says. She turns away and takes a few deep breaths.

"I'm a little flooded, too," says John. "Let's take a minute to calm down."

"I have been taking you for granted," Julie goes on after a pause. "Perhaps I haven't made time for good things between us because we're both so darn busy. And you have been making some fabulous fish dinners"

Now it's John's turn to share his subjective reality. "Things haven't been going the way I wanted them to at work," he says, referring to a major federal grant that hadn't come through. He adds, "I haven't had time to play music, and when I don't, I'm mad at the world."

A little while later, as they move toward making it better in the future, John asks, "Next time, would you tell me that your dream is symbolic, so I'm not expected to be a psychologist all the time?"

"What if I say, ´I'm so raw, so vulnerable, I really need a good long hug?'" asks Julie.

John hesitates, pauses, and agrees, without enthusiasm.

"Okay," says Julie. "We're done."

"No we're not," says John. "What's one thing you could do differently?

Julie cocks her head.

"I could start by saying, ´This dream isn't really about you,'" she says.

 

"That's great!" says John, with apparently genuine enthusiasm and surprise. "Okay! Are we buddies?"

If only it were that simple, I think.

A Fight That Deepens Connection

Now it's our turn. We stream out to the breakout room again. Brian takes an inordinately long time getting slices of pineapple and tea.

Our assignment is to take a minor, resolvable conflict and process it the way the Gottmans did. The binder tells us "there is no absolute 'reality' in a disagreement but rather two ´subjective realities.' "We are to practice "softened start-up" and making I-statements.

I glance over the cheat sheet in the binder's back pocket called the Repair Checklist. It contains suggested lines: "I feel defensive. Can you rephrase that? How can I make things better? Let's compromise here." I'm game.

I fetch Brian from the refreshment table. It dawns on me that he looks pale, and that he's not quite as enthusiastic as I am to go on. In the middle of the night last night--after hours of touching--he'd jumped out of bed, having dreamt that I was part of a conspiracy to assassinate him.

I open my binder to the appropriate page and ask him to look over my shoulder at the Chinese-menu list of relationship differences for us to choose from. Yesterday we'd added "television" and "whether or not to get married" to the list, on top of "handling finances" (I'm more frugal), "how to raise and discipline children" (I have none and he has two), and "alcohol" (he likes it and I don't).

"Can we just cool the jets?" he says. It's too much, he goes on. He wants us to sit this one out.

I don't want to say yes.

 

We raise our red card. A therapist comes over and suggests we try "television." That seems too trivial to me, while everything else seems impossibly sticky. As we wander desultorily toward the breakout room, Brian hangs a few steps back.

I want to do the exercise. I'm afraid that if we don't, I'll miss out, we won't learn how to reconcile after a fight, and my article won't pan out well. I'm thinking, Okay, I get it, Brian, you're overwhelmed. Now can we just please go ahead and do the exercise, please?

But now I'm stuck in an Escher-like paradox. In order to do the exercise, I'd have to violate the spirit of the exercise, which is to honor my partner's reality and be willing to compromise. In the Gottmans' lingo, I need to maintain an up-to-date cognitive map of Brian's inner world. At this moment, his inner world is flooded by a neurohormonal cascade of cortisol and adrenaline spawned by last night's fight and his subsequent nightmare. I ponder the strange fragility of men, especially this one particular man. This bearded guy, six feet two inches tall, who loaded all my luggage into the car in Mill Valley, is now blanching at the notion of having a 15-minute argument? This guy who bicycles and jogs and took protective care of my airline boarding pass--he can't stand to look at a cheat sheet and try out expressions like "This is important to me. Please listen?"

Could it be that when it comes to emotional discussions, men are the ones who strain to lift the bags, and women are the triathletes? Could it be that men who tell us in so many words to back off are expressing their vulnerability, not their callousness?

These, of course, are afterthoughts. At the time, I wanted just to forge ahead, like the obedient subject in the Stanley Milgram experiment who continued to administer "shocks" to an allegedly helpless fellow subject who appeared to be in pain.

Not knowing what else to do, we recruit two more therapists, a man and a woman, from the back wall. Brian runs through his story of feeling overwhelmed again as if it belonged to us both. My stomach tightens, and I interrupt: I'm not overwhelmed. He is. I want to go ahead.

 

I wonder if we're too weird for this workshop.

The four of us sit down together, Brian and I facing each other with a therapist on either side, our chairs forming a rough square. The woman therapist turns to me and suggests we two take a break. The male therapist, who's "shadowing" the woman, as part of his certification process, says nothing.

I lean forward, my hands on my knees. I don't want listen to her. I open the binder. I decide to make this current disagreement--over whether or not to do the exercise --the subject of the exercise. At the top of a page I see, "Find something in your partner's story that you can understand." I ask Brian, a bit mechanically, to tell me how he feels. I say back that I hear that he feels overwhelmed, that he needs a break. Merely repeating back what he's saying makes me realize that it's true: he really is overwhelmed. The odd thing is, I'm trying to do that old therapeutic stand-by, reflective listening--this is something that John Gottman says successful couples don't do during fights.

Now I take a turn to share my subjective reality: how important it is for me to follow the rules, to move forward, to be obedient, to get things done. Saying this in the presence the two therapists, who essentially are just tracking what we're doing without commenting, somehow loosens my hold on having to get my own way. And this, in turn, makes it easier for me to do what John Gottman calls "accepting influence from one's partner"--realizing dimly that it's not only men who refuse influence from their partners, not only men who sometimes bullheadedly play the king and cross their arms like adolescents.

I feel heard by the two of therapists, whose names I barely know. And I've heard Brian. Although the exercise isn't officially over yet, I'm ready to stop even though it means not following the rules. Brian and I walk outside to the courtyard and breathe the fresh air until a bell sounds to bring us all back.

During the next minilecture--on how to handle "gridlocked" perpetual conflicts--Brian whispers to me that he's decided to leave after lunch, instead of taking a plane at 3 p.m. as he'd originally planned. I'm sorry, but for once I feel no need to push him or lay out all the good, logical reasons why he should stay with me.

 

It's a paradox: I feel far more connected to Brian, and yet my hands aren't clenched. Before the workshop, I'd assumed that I was a failure--and our relationship was a failure--if we didn't solve our conflicts, once and for all, the way I had in mind. I don't think that way anymore.

Flying home the next day, taking care of my own boarding pass and my own luggage, I remember the cautionary words of Wendell Berry in an essay on marriage that capture some of what I learned in the workshop. "Some wishes cannot succeed. . . . Because the condition of marriage is worldly and it's meaning communal, no one party to it can be solely in charge. What you alone think it ought to be, it is not going to be. Where you alone think you want it to go, it is not going to go. . . . When you unite yourself with another, you unite yourselves with the unknown."

I return to the chaos of the quotidian. Tulips touched with orange fire droop in a vase on our kitchen table and the weekend's newspapers are piled around it. In the living room, my 25-year-old stepson Zack is checking his email with his best friend, Ned, standing by, and both of them, to my surprise, are planning to spend the night. If I ever needed proof of one of the Gottmans' most basic propositions--that 69 percent of what couples argue about doesn't change--this is it.

In the months since the workshop ended, I've found such Gottmanesque statistics oddly comforting--and surprisingly therapeutic. When I raise something with Brian and feel awkward, I remind myself that women raise 80 percent of the issues in relationships, and I feel normal again. When I can't get a straight answer, I cite Gottman's research on the importance of men's taking influence from their wives. And when I'm irritated, I remember that 96 percent of the time, people who use a "harsh start-up" find the conversation doesn't go the way they'd hoped.

As I write these words, it's been four months since the night Brian and I lay on that impossibly wide bed in Seattle. For a month or so after we got back, we consciously had "stress reducing conversations" in the evenings, but lately we've slacked off. I haven't yet, as I promised, surprised Brian with music tickets. (He surprised me.) Brian didn't find us a place this summer for a getaway as he'd promised. (I did.) But he and I did go kayaking last weekend on Tomales Bay, much to our joint delight.

 

Things between us seem different--gentler, warmer, closer, more fun--and not so different, since we have the same old conflicts. But we discuss more and argue less. Brian never invites his sons over anymore without checking in with me (if I weren't typing this right now, my fingers would be crossed). If John Gottman had a hidden camera running in our house today, he'd see a lot less of the Four Horsemen. I wouldn't yet classify us as being among the masters of marriage, but I've become much better at the softened start-up. When I'm grateful or admiring of something Brian has done, I'm far likelier to say it out loud.

Describing things this way seems too pat, though. Not even the most complex computer model could disentangle the variables of our lives together, or even of our weekend in Seattle. When I look back, I don't remember statistics. Instead I remember leaning into Brian's arms and looking out at the dark blue of the bay on our ferry ride; I remember stroking his back in bed at the Hotel Marqueen; I remember the two therapists who sat and witnessed us.

In the realm of numbers and words, the world of the intuitive human community will always be at a disadvantage. Yet quantification always leaves something out. Our weekend was a union of science and intuition, and it's far easier to write about the science. But a mysterious alchemy takes place when a person lets go of old moorings and casts off into the unknown--as I did, when Brian showed me his vulnerable face and I didn't turn away. If he and I hadn't happened upon those two therapists that morning, I might not have dared do that. They held me while I moved into a new experience of accepting Brian as he is. John Gottman's research and all the weekend's little exercises may have prepared the ground for that experience, but they didn't take me there.

I look over my notes at Gottman's percentages and I still find them oddly comforting and reassuring. But it isn't the same comfort that I get from remembering how, in a smoky hotel room one Saturday night in Seattle, I reached across a huge king-sized bed and Brian turned to meet me.

Networker Features Editor Katy Butler was a finalist for a National Magazine Award in 2004. She's written for the New Yorker and The New York Times . She's teaching creative writing at the Networker's Symposium West in San Francisco in October and memoir writing at the Esalen Institute in December. Contact: katybutler9@earthlink.net or www.katybutler.com

 

 

 

The Precarious Present

Why is it So Hard to Stay in the Moment?

By Robert Scaer

"I just can't seem to stop my mind," Linda told me. "I try to relax, but after a few moments, my brain starts to buzz again with a jumble of thoughts and feelings. I can't seem to turn them off." As she spoke to me during our second visit, she was visibly distressed. She had the pinched face and hunched shoulders of someone who felt at once threatened and helpless.

"Lots of times, it's the same old thing, just the same old negative thoughts and worries and blaming myself," Linda went on. "Sometimes I try to head them off by going out for a run, but they come back later. When they really get ahold of me, I get kind of shaky, dizzy, and sick to my stomach. If they go on long enough, I actually get a stiff neck, and eventually a headache."

A client's negative, intrusive thoughts are a therapist's stock and trade. Ditto the accompanying roster of bodily complaints, from stomach pains and neck tightness to headaches and back problems. In my 20 years as medical director of a multidisciplinary chronic-pain program, I've found these body-mind intrusions to be a sort of generic marker for significant emotional disorders, including depression, anxiety, post-traumatic stress disorder (PTSD), and adjustment disorder.

But if Linda's distress seems familiar, it isn't just because we see this kind of client so frequently in our offices. It's also because her complaint rings true for "healthy" people like ourselves. All of us ruminate, bringing up the cud of old memories and unresolved problems, in the process experiencing a sinking feeling in the stomach or perhaps a tightening in the throat. As we well know, these experiences usually arise unbidden and often at inopportune times, such as when we're reading a book, eating a meal, or even, God forbid, making love! And when we're interrupted in this way, we basically lose it: we forget why we went into the bedroom, we lose track of our place in the book, and, if the intrusion is upsetting enough, we may even lose the wherewithal to continue with what's going on right now. We've experienced that most insidious of insults to our mind--the corruption of the present moment by emotion-linked memory.

When we catch ourselves in this state of nonpresence, we're likely to chalk it up to "mind chatter." When a client reports these repetitive intrusions, we may wonder about a tendency toward obsessiveness or the possibility of depression and/or anxiety. While all of these interpretations may have some validity, I believe that much more is at stake. I propose that in many of these moments of body-mind intrusion, our brain is trying to protect us from mortal danger arising from memories of old, unresolved threats. In short, we're in survival mode.

"Ordinary" Trauma

To understand the meaning of these everyday emergency responses, and to transform them into opportunities for healing, we first need to rethink our fundamental assumptions about trauma. I propose that the sources of trauma are far more complex than the standard Diagnostic and Statistical Manual (DSM) definitions. Under Criterion A, the DSM-IV defines trauma as the result of having "experienced, witnessed or been confronted with . . . actual or threatened death or serious injury . . . to self or others" and responding to that event with "intense fear, helplessness or horror."

This definition isn't wrong, but it's woefully incomplete. In fact, any negative life event occurring in a state of relative helplessness--a car accident, the sudden death of a loved one, a frightening medical procedure, a significant experience of rejection--can produce the same neurophysiological changes in the brain as do combat, rape, or abuse. What makes a negative life event traumatizing isn't the life-threatening nature of the event, but rather the degree of helplessness it engenders and one's history of prior trauma.

Let's look at the first criterion--the person's relative state of helplessness in the face of a threat. We can often avoid being traumatized by an actual life threat if we remain in control of the situation, either by effectively fighting back or escaping the situation. If we've adequately defended ourselves, our survival brain doesn't need to store the body-mind messages of a trauma as an ongoing warning signal. But if we haven't prevailed--if we couldn't avoid the oncoming car or fend off the mugger--the brain remembers that experience as mortally threatening.

The second precondition for the development of trauma is one's storehouse of prior trauma. If you endure a relatively minor negative life event that somehow reminds you of a prior event in which you were helpless, trauma can result. Let's say you're facing surgery of a fairly safe and common sort--say, a cataract removal. For many people, the procedure would be relegated to the category of "unpleasant but bearable." But for you, this situation brings back memories of having your tonsils out when you were 6. Your parents weren't allowed in the operating room with you, and you briefly saw a scary, sharp instrument, and, all in all, you felt helpless and terrified. (You may be conscious of these memories, or you may simply be aware of a tightening in your throat or the desire to scream when you think of the upcoming cataract procedure.) Because your survival brain still thinks it's in danger from that tonsillectomy, it'll store this new, similar experience as dangerous by association. Not only will you experience the cataract operation as traumatic, but you'll also be even more vulnerable to trauma during the next medical procedure you undergo.

All of us, clients and professionals alike, will continue to set ourselves up to be retraumatized until we recognize that many of our negative intrusive thoughts and sensations are, in fact, symptoms of trauma. They may not be identified as such in the DSM-IV, but these more commonplace body-mind invasions assume the same meaning, if not the intensity, as the trauma-related thoughts and flashbacks of full-fledged PTSD. In both PTSD and what we might call "ordinary" trauma, conscious and unconscious memories brutally intrude upon and corrupt the present moment. Not everyone suffers from PTSD, but each of us has sustained many of these smaller traumas, setting us up for being continually shoved out of the present moment into a frightening, helpless past.

Who Cares about the Present?

In psychiatrist Daniel Stern's model, the "present moment" is a brief period--lasting perhaps 1 to 10 seconds--that represents our conscious experience of the here and now. Only in the present moment can we fully live. If our "nows" are perpetually interrupted by intrusive memories, we're essentially stuck in a time warp formed by those stored perceptions. We can't problem-solve, we can't experience a daffodil or a sunset, we can't relate to other people, resolve old conflicts, or form new attachments. Only in the here and now can we directly experience, and move ahead with, our lives. The present is indeed a precious commodity.

Yet we repeatedly squander it. Therapists most readily witness this dissipation of the present moment with certain clients, the ones who focus obsessively on ancient complaints and worries to the exclusion of creative or productive ideas that might help them move forward. Many of these clients also complain of various aches and pains, most commonly gut symptoms, such as acid reflux or irritable bowel, or chronic pain in the head, neck, or back.

But if we're honest, we also recognize this corruption of the present in our own lives. How often do we find ourselves ruminating about this or that familiar resentment or well-worn worry? How often do we truly notice where we are, whom we're with, or what's actually happening--that is, experience our own precious moments? It's as though some dark, implacable entity invades our minds and bodies and fills them to the brim, leaving little space for pleasure in our aliveness, much less for growth or healing. That entity, I believe, is the total body-mind experience of a past trauma.

Remembered Horrors

Let's take a moment to look at the two primary types of memory that contribute to trauma. One type is emotion-linked conscious memory, which gives rise to the intrusive, troubling thoughts we keep experiencing. These thoughts arise from some little cue in the environment that reminds us of an unresolved conflict. For example, you may be balancing your checkbook when your mind suddenly jumps to the letter you received years ago from your ex-wife's lawyer demanding an accounting of your income and threatening to haul you into court if you didn't comply.

At other times, intrusive thoughts may pop up from a purely internal cue. You may be thinking about vacation plans for a trip to Hawaii when you flip to the memory of losing your luggage, includi­ng all of your money, in the Honolulu airport on a prior trip. Since you often don't consciously notice these cues--they can flit through the mind in a millisecond--you often find yourself bewildered by a sudden change in mood. You'd been feeling perfectly fine; why, now, do you feel so scared or so oddly dispirited?

And why, for that matter, are you clenching your teeth so hard your jaw hurts? Another kind of memory is at work here: the hardwired recollection of what the body experienced in trauma. Acquired in a flash and stored for a lifetime, these unconscious, procedural memories serve as survival mechanisms, ready to be unleashed instantly in the face of present, perceived danger. The clenched teeth that kept you from crying when you lost all your luggage now sets in whenever you plan a vacation; the spasm in your neck that started after a long-ago car accident now occurs whenever you're stuck in traffic; the cramping you felt in your gut whenever your father harshly scolded you now hits whenever your boss gives you feedback about your work performance. All of these bodily reactions serve as warnings from your survival brain that an old danger has resurfaced. It signals: Watch out! You're in big trouble! Right now! In these everyday circumstances, we experience a terrifying past exactly as though it were the present.

The Trauma Capsule

It's vital to recognize that our memories of a traumatic event reflect that event precisely. So what we've got is a sharply defined and bounded state, or capsule, containing all of the pertinent stored memories for each traumatic experience we've endured. My patient, Linda, for example, can't stop the loop of negative memories of the gender discrimination she experienced on the job last year. Although she came to the job with management experience, she was assigned menial tasks, such as running errands to the office supply store. Worse, she was repeatedly the target of sexual innuendos from her older male boss. When she complained, the harassment ceased. Briefly, she felt empowered, but not for long: Linda was passed over for her next promotion, one she'd worked hard for and knew she deserved. Because she was paying back a college loan and had minimal savings, she couldn't quit--at least not right away. She felt trapped and helpless.

Now, memories of the experience intrude on her consciousness in a host of situations--whenever she's short of money, whenever she gets into an argument with her boyfriend, whenever she has to deal with any male authority figure. She experiences intrusion on the present moment by a kind of internal "capsule" reflecting all of the conscious and unconscious memories of her job experience--cognitive, emotional, and bodily. Simultaneously, she's assaulted by thoughts of her mistreatment, feelings of shame and anger, and a host of unpleasant physical sensations--the same tight neck and gut cramps she experienced at the time of the original trauma.

When these kinds of memories arise, they corrupt the present moment by inserting past events into present perception. If the original trauma was severe enough, such as assault, it can feel as though one's actually reliving a horrifying past event, as in a flashback. For "ordinary" trauma, such as repeated job discrimination, it can ignite the volatile compound of distressing thoughts, emotions, and autonomic states that Linda experienced. Because I view dissociation as the perception of past as present, I call this phenomenon the dissociative capsule.

The Body under Siege

We often misunderstand the physical symptoms of the dissociative capsule as somatization disorder, which is defined as the intrusion of persistent somatic symptoms that don't reflect an actual physical disorder. But the symptoms I've been describing are genuine physiological disorders. The more clearly we understand this reality, the better able we'll be to help our clients in distress. Let's look at how these physical symptoms are produced.

In the traumatized person, the muscle spasm that causes the neck pain and the abnormal motility of the gut that causes the cramps are actual physical phenomena triggered by the somatosensory and autonomic procedural memories of the original traumatic experience. Somatosensory memories include all of the sensations and the exact pattern of muscle activity that accompanied the trauma, such as the tightening of neck and jaw muscles. Autonomic memories, both sympathetic and parasympathetic, are often experienced as visceral sensations--a pounding heartbeat, cold sweaty hands, and pressure in the chest. Initially transient, these bodily changes can eventually lead to chronic disease. Numerous studies suggest links between early trauma and the development of fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, chronic back pain, and a variety of autoimmune diseases. The body remembers, and keeps on remembering.

Dissociation by Degrees

Each of us has our own, distinctive cache of dissociative capsules. The number of life traumas one has sustained will determine the number of capsules stored in procedural memory: there may be a few or there may be dozens. Many factors determine the size and intensity of each. A large, complex capsule created by severe and repetitive childhood trauma may intrude on the present moment repeatedly. In such cases, the present moment may be obliterated most of the time, causing maturational arrest at the age of the most severe trauma. This situation may explain the remarkable maturational suspension seen in such syndromes as borderline personality disorder and other severe attachment disorders in which the "self" may be stuck in the first decade of life. But it's important to remember that these dissociative states may form even in cases of "ordinary" trauma. Recall Linda's experience of gender-based job discrimination: because she suffered not merely shame, but shame in the context of helplessness due to her low rank in the corporate pecking order, her experience was genuinely traumatic.

Viewed from this perspective, one can see how many of the "little" conflicts associated with cultural and institutional bias can assume the dimensions of traumatic stress. In my own medical practice, many female patients who've struggled with persistent job discrimination have developed chronic fatigue syndrome, physical collapse, and even PTSD. Other patients have developed PTSD following their experience with an adversarial justice system during a plaintiff lawsuit following an auto accident.

For those who bear an existing burden of childhood trauma, even more "trivial" incidents can cause new trauma. I've treated hundreds of patients with full-blown PTSD following auto accidents occurring at speeds under five miles per hour. For these highly sensitized individuals, it isn't the accident per se that caused trauma, but the triggering of a dissociative capsule of earlier, unresolved trauma that transformed an unpleasant hassle into a genuine catastrophe.

Treatment: Mere Words Aren't Enough

Trauma healing, in essence, is the recovery of the purity of the present moment. This concept has vital implications for trauma therapy (which, from here on in, should encompass treatment for "ordinary" as well as extraordinary trauma). The bottom line: therapy must adequately address the body-based procedural memories that form a large part of the trauma structure.

Unless we can expunge the somatic contents of the dissociative capsule, they'll continue to emerge with every triggering event, contaminating the present moment and promoting further sensitization to trauma. But if we can find a way to extinguish these somatic cues, the accompanying emotions and autonomic feelings will also be neutralized, rendering the capsule inoperative. Emotions and autonomic states are inevitably associated with "feelings"--the body sensations directly linked to those states. Without the "feelings," the emotions and autonomic state have lost their threatening meaning for survival. The declarative memories of the event will remain, but in the absence of sensations and emotions, they'll be experienced as past events--period. The present moment will be liberated.

So, how do we get from here to there? The royal road to the present moment, I believe, is through the emotional brain. We know that the limbic nucleus, the right amygdala, evaluates the emotional content of incoming sensory stimuli. If stimuli imply threat, the amygdala triggers arousal, unless, somehow, it can be persuaded to go off duty. In his book The Feeling of What Happens, noted neurologist Antonio Damasio describes a woman with bilateral injury to the amygdala. Via personality and psychometric tests, Damasio discovered that while she remained functionally normal, she'd lost the capacity to experience fear or rage. Is it possible, then, that someone without a functioning amygdala would be incapable of being traumatized?

This hypothesis seems well worth exploring. If we can find a way to shut down the right amygdala while a client is exposed to the contents of the dissociative capsule, we should be able to extinguish its contents. With the amygdala "off-line," the traumatic memory would no longer be associated with the somatic cues of arousal--the tight chest, the pounding heart, the constricted throat. These symptoms would no longer intrude on the present moment. Procedural memories of the trauma--both bodily sensations and emotionally linked memories--would no longer convey threat in the here and now, because they'd accurately be perceived as old memories. We'd find ourselves restored to the present moment, in all of its richness and possibility.

Retraining the Brain

What therapeutic processes might convince the amygdala to "down-regulate?" I'm not touting any specific approach. But what we know about the neurophysiology of trauma suggests that some of the so-called somatic and energy therapies, such as Somatic Experiencing, EMDR, Emotionally Focused Therapy (EFT), and Thought Field Therapy (TFT), may be particularly well equipped to escort a traumatized person from the past back to the present. Let's look at how these approaches might fulfill some fundamental needs of trauma healing.

Integration of the cerebral hemispheres. The functioning of the left cerebral hemisphere is a brain state that's normally inhibited during arousal. Theoretically, bringing the left brain back "online" and integrating the left and right hemispheres would interfere with, and inhibit, the independent function of the right amygdala. Alternating visual, tactile and auditory stimulation might well integrate the two sides of the brain and down-regulate the right amygdala while the patient imagines the traumatic event, thereby removing the arousal charge.

Brain integration may explain why some of the seemingly bizarre repetitive behaviors of energy therapies seem to produce dramatic results for some patients. The alternating sensory stimulation of EMDR, as well as the eye-rolling, counting (left hemisphere) and singing (right hemisphere) employed by EFT, may help to integrate the brain hemispheres and thereby relegate traumatic memories to the past. The EFT practice of repetitively tapping acupuncture meridian points, which promotes autonomic homeostasis, may also put the brakes on brain arousal.

Ritual. This is often part of the healing process in non-Western and especially indigenous societies, where it's often practiced by tribal healers or shamans. Rituals often involve repetitive behaviors, such as drumming, dancing, or singing, and frequently induce hypnotic trance states. The use of hypnosis in healing trauma may have its roots in this process. In addition, social rituals may activate the anterior cingulate, the part of the cortex that's known to inhibit the amygdala. We know that the anterior cingulate plays an important role in mother-infant and social bonding, a state that may be replicated by social ritual. The potency of ritual also may explain the impact of the eye movements of EMDR, the tapping procedures of EFT and TFT, and the repetitive affirmative statements of the latter two approaches.

Empowerment. This is the ultimate goal of all trauma therapy. To heal, an individual must recover from the state of helplessness that defines the trauma experience. During a traumatic event, a person experiences physical helplessness and effectively freezes into that state, leading to all manner of pain and illness. To recover, one needs a way to thaw out the body.

This "melting" process is at the heart of Somatic Experiencing, a body-based therapy in which one accesses the felt sense of the trauma and allows the failed motor defense to emerge in the form of a "freeze discharge," wherein the individual moves out of immobility into an effective fight or flight response. This ability to achieve discharge can be facilitated via a number of other somatic approaches, including dance, balance, equestrian therapy, and art therapies. What these approaches have in common is their capacity to access the freeze discharge and extinguish somatic procedural memories through completion of the bodily act of defense or escape. This completion at once permits and celebrates reempowerment.

Making meaning. Talk does play an important role in trauma therapy, but not as the first order of business. Once the contents of the dissociative capsule are extinguished, client-therapist conversations can help to provide the client with conscious, cognitive meaning and perspective. Talk can empower a client with the knowledge that the occasional recurrence of residual somatic symptoms--a sudden bout of nausea, a strangled feeling in the throat--actually represent an event from the past, and not an imminent threat that wipes out the here and now.

All in all, perhaps this is the most important lesson of trauma recovery: we never do quite fully recover. After all, our trauma memory capsules are nothing less than survival mechanisms, working in tandem with the amygdala to try to keep us alive. As one would expect from a primitive survival mechanism, it can never be totally extinguished. (Recall that after many years, Pavlov's dogs were reconditioned to the bell with just one trial.) Our stored memories of personal danger are fierce, focused, and highly motivational.

Of course, we can make enormous strides in discharging the contents of our trauma capsules, especially via approaches that address our body-based memories. But as we make our vital journeys back to the present, we'd do well to cultivate an attitude of gentle acceptance. For it's quite possible that all the body-based therapy in the world, plus regular infusions of meditation, running, yoga, and other mindfulness practices, won't be enough to keep us permanently anchored in the here and now. It seems we just aren't wired to live there fulltime. But we can make extended visits. And when we do, we can explore the lush landscape of the present moment with more wonder, wisdom, and pleasure than ever before.

Robert Scaer, M.D., was formerly associate clinical professor of neurology at the University of Colorado Health Sciences Center in Denver, Colorado. He's published numerous articles and two books addressing the neurophysiology of trauma, diseases of trauma, and concepts of healing: The Trauma Spectrum and The Body Bears the Burden . Contact: scaermdpc@msn.com

 

 

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.

 

 

Altered States

Why Insight by Itself Isn't Enough For Lasting Change

by Brent Atkinson

In the 15 years that I've been following developments in neuroscience, the most compelling clinical lesson I've learned is likely to rub you the wrong way. An overwhelming body of research now suggests that we clinicians rely too much on insight and understanding--and too little on repetitive practice--in promoting lasting change.

This wasn't welcome news to me. I'm a couples therapist, and I got into this business because I loved transformative moments when intimate partners' defenses crumbled and their deep emotions emerged. That was what juiced me--not, getting couples to do the same things over and over again.

Yet, year after year, I watched couples let go of judgment and blame for an instant, only to show up for the next session as miserable, critical, or withdrawn as ever. They didn't even remember the profound insights they'd had that I felt sure were going to rock their worlds.

Then I encountered a series of studies published by neuroscientist Jaak Panksepp, from Bowling Green State University, and came to understand that when they were upset, my clients were in the grip of one of seven major body-brain mood states, which he calls "executive operating systems."

Our Brains' Executive Systems

Panksepp uses the terms rage, fear, seeking, lust, care, panic , and play to describe the signature emotion of each system. But they're more than passing moods. They're complex neurochemical cascades, in which hormones race through the body and brain and electrical impulses fly over familiar neural synapses, shaping what we feel, do, and think. When one of these systems becomes active, emotions, motivation, and thoughts take over in the service of the goals it's programmed to achieve. It's as though we've gotten on a plane to Paris, and no amount of fiddling with the seatbelt is going to change the plane's direction before the wheels touch down at Orly.

Four of the systems are wired for love: they draw us together. One of these is old-fashioned lust. Another promotes spontaneity and play. A third, the instinct to nurture others, which Panksepp calls care , is activated by the release of the hormone oxytocin into the bloodstream and brain. Another mood system Panksepp calls "panic" is experienced as yearning or even abandonment, when an intimate partner leaves on an unexpected business trip or storms out of the house during a fight.

Most of these mood states can help promote emotional bonding during couples therapy. But the states that therapists find the most frustrating in the consulting room--and often the most common--are two other body-brain mood states that used to be called fight or flight. Activated by the amygdala, they produce self-protective thinking and action. Fight, which Panksepp calls rage, quickens the breathing, sends blood to the muscles in preparation for striking out, and releases adrenaline and noradrenaline into the bloodstream and brain. It sharpens some mental functions and leads a person to think in decisive, impulsive, blaming, oversimplified ways. It's accompanied by the attitude "You're wrong, and I'm right."

This hormonal cascade can be lifesaving in the appropriate situation--in the face of a dangerous driver, say, or a possible mugger or rapist. But in intimate relationships, it's often toxic. In its grip, men (and some women) can become physically abusive; others yell, nag, blame, and complain. And as almost everyone knows, it's much easier to get on this particular tiger than to get off.

The second self-protective cascade, which Panksepp calls fear, produces feelings ranging from anxiety to intense fright, along with worried thoughts and the impulse to freeze, flee, withdraw, or hide. It, too, is accompanied by critical thoughts about the intimate partner. A man in the grip of this neurochemical cascade may exhibit sullen, disgusted, or spacey withdrawal in the face of a barrage of angry complaints from his wife.

Hence my frustration. I couldn't understand why couples continued in these patterns when they'd learned--in those magical moments of insight--that blaming or withdrawing didn't help them get what they wanted. It seemed so irrational. But when people are in the grip of these emotional takeovers, certain parts of the prefrontal cortex (the folded outer layer of the brain behind the forehead) are less active than when they're calm. The prefrontal cortex is the seat of free will and self-awareness. It allows us to plan, strategize, imagine the results of our actions, and choose to do one thing rather than another. When portions of it are inactive, as they appear to be when we're in the grip of one of our executive operating systems, our inner switchmaster is asleep: we simply can't shift from one state or course of action to another. So the wife keeps blaming, like a hamster on its treadmill, and the husband, in an equally mechanical state, keeps staring out the window.

Learning to Shift Mood States

When I first encountered this information in the early '90s, I worked at getting clients to shift out of these powerful mood states. When I got frustrated, I reminded myself that they were caught in neurochemical reactions beyond their control. I'd usually have one partner wait in the waiting room for a few minutes while I worked with the other, finding that a few minutes of concentrated empathy, validation, and acceptance would often calm someone down. Under these conditions, they could hear me say--in a soothing tone--that blaming would only stimulate the other's defensiveness and not get them what they wanted. We could then brainstorm more pragmatic, emotionally open, skillful ways of communicating. I was training them to reactivate the neocortex--the inner switchmaster--in the face of strong emotion.

I assumed the lessons would stick, but I was disappointed. I'd underestimated the hardwired nature of my clients' automatically activated, neural- response programs, ingrained through years of relating to each other. They needed far more practice than a weekly therapy session could provide.

It wasn't enough for my clients to rehearse new thoughts in calm moments. They needed to practice new ways of thinking under "game conditions"--when they were actually upset and least able to think clearly. And they'd have to do this over and over: most neuroscience researchers agree that the brain acquires new habits through repetition. One of the most enduring concepts in neuroscience is Hebb's Law, named after the pioneering McGill University neuroscientist Donald Hebb, who stated that brain processes that occur together over and over again become grafted together, and are more likely to occur in conjunction in the future. According to Hebb's Law, if my clients engaged in new thinking processes while they were upset, and did this enough times, the new thinking processes would begin happening spontaneously each time they became upset.

Audio-Facilitated Change

Then one of my clients, a registered nurse named Judy, who kept struggling to tame her tendency to get enraged with her husband, said to me, "If only I could take you home with me!" When she was furious, she was in the grip of the delusion that her anger was her empowering friend, only to find that her outbursts actually disempowered her. She asked me to make an audiotape for her to listen to precisely at the moments when she became upset with her husband. In this audiotape, I offered encouraging words and reminded her repeatedly that she was far more influential and powerful when she stood up for herself in ways that didn't put her husband down.

She loved the tape and listened to it not only when she was upset, but also when she was driving in her car and on a Walkman, while she was doing the laundry and cleaning house. Within three weeks, she experienced a dramatic shift in a lifelong destructive pattern.

I made more elaborate tapes for Maria and Tony, who trudged into my office one crisp October evening for their fourth session. Maria was so upset that she refused to speak to Tony. She'd had elective surgery the previous week, and had gone into rage mode when Tony left her alone in the hospital one night to go home and get some sleep. I asked Tony to stay in the waiting room while Maria told me how incredibly selfish he was for thinking of himself when she was in so much distress. In the grip of her amygdala-driven cascade, she couldn't see that her attack was sending Tony into disgusted withdrawal as usual. I sympathized with her feelings, and then simply suggested that although her attitude was perfectly understandable, she'd need to drop the idea that he'd done something wrong, and simply tell him how she felt. She struggled inside for a moment and then relaxed. Her eyes moistened and she said softly, "Okay, I think I can do it." When Tony joined us, Maria spoke from a different place inside, and Tony responded instantly with an apology.

I then made an audiotape that essentially repeated the words that had helped Maria shift during this session, and asked her to listen to it each time she became upset with Tony during the following week. The next day, she got off work early, pulled into the driveway, and saw her children playing at the neighbor's house, even though Tony had agreed that he wouldn't let the kids go out to play after school until they'd finished their homework. She felt a surge of anger, but as she reached for the car door, she remembered the audiotape in her purse. She paused for a split second, torn between the urge to vent and the desire to avoid going down the same old path.

Reluctantly, she plugged in the tape and listened in the car. After 10 minutes, she realized that she was in no frame of mind to talk to Tony, and decided to take a walk around the block. After 20 minutes, she felt calmer, and by the time she saw Tony, she was able to keep an open mind and simply ask him why the kids were playing, rather than accuse him of breaking their agreement.

What happened during Maria's walk around the block? Frankly, I don't know. In Maria's audiotape, I didn't tell her what to do or how to shift her attitude, I simply reminded her of a few reasons why she might want to try. The decision was hers. Clients often have difficulty describing how they get shifts to happen. Most report a willingness to let go of control and a momentary surrender to the fact that you can't make life go exactly according to your plans. The shift is usually accompanied by physical relaxation and a release from obsessive thinking. The client returns to the present moment, and is able to respond to what's actually happening, rather than what they fear is going to happen. The most important ingredient in getting an attitude shift to happen is desire. When clients decide they truly want to shift, they do.

Ancient Wisdom

What clients report helps them shift brain states has something in common with many repetitive religious practices--from praying "Thy will be done" to practicing mindfulness, kissing a St. Christopher medal before going up to bat, or making a list each night of things one is grateful for. All of these approaches help people create enough of a pause to free them from the grip of intense rage or fear and to generate states of generosity, acceptance, and trust. Like them, my audiotapes allow the body and brain to calm down, and they serve as timely reminders that it's in the client's best interest to try to shift.

Maria, for instance, used her tape as regularly as some people light candles at mass. She told me that she often could feel an attitude change beginning as soon as she heard my calm, confident tone. It reminded me of what attachment researchers speak of when securely attached children evoke images of their caregivers to soothe themselves. In her third week of using the tapes, Maria told me that she began to spontaneously hear my voice inside her head every time she got upset.

Some clients need little more than a verbal reminder. Others require vivid images or metaphors. Tony, for instance, once told me that when he reflexively defended himself, he felt like he was swatting Maria's complaints back at her with a baseball bat. In a minisession without Maria, I helped him imagine turning the bat into a pillow. The image worked, and when Maria returned, he was better able to absorb and digest what she had to say.

I put the pillow image on a tape for Tony. Then we got Maria to record a tape full of her complaints--a litany about how Tony didn't keep his word, didn't fix things around the house, and hadn't kept the kids quiet on Saturday morning after promising he'd let her sleep in. In a solo session, I had Tony listen. As soon as he began feeling defensive, we'd stop the tape and he'd focus on how his body felt; he'd tremble and go into a sort of disgusted shutdown. Then he'd practice trying to shift, seeing the pillows, relaxing physically, reminding himself that there might be some validity to her point of view. Then we'd start the tape up again and repeat the process. Tony used the tape regularly in his truck and became so adept at generating a state of acceptance and compassion that one of his employees remarked that he'd undergone what seemed like a spiritual shift.

I still love the drama of transformative experiences, and my favorite moments are still the tearful ones, when partners drop their defenses and exchange heartfelt expressions of love. But nowadays, I see these moments as just the beginning. They give clients the motivation for the real work of change, which is much less dramatic. I rarely get to see it because it doesn't happen in my office. It happens a little bit at a time, day in, day out, as clients practice letting go of the critical judgments that arise with the brain's self-protective mood states.

My happiest clients make shifting a daily practice, not unlike prayer. The tape recorder, and all my modern knowledge about neuroscience, have ended up supporting the practice of routine and ritual, largely ignored by modern psychotherapists, but intuitively known and practiced by sages since the beginning of time.

Brent Atkinson is the director of the family therapy program at Northern Illinois University, and is in private practice in Geneva, Illinois. Address: School of FCNS, Northern Illinois University, DeKalb, IL 60115. E-mails to the author may be sent to: Brent@thecouplesclinic.com.

 

 

Why is This Man Smiling?

A Self-Described Grouch is Trying to Turn Happiness into a Science

by Mary Sykes Wylie

Martin Seligman reports spending much of his life as a "walking nimbus cloud enduring mostly wet weather in my soul." Former president of the American Psychological Association and about as famous as any research psychologist is likely to get, he admits he never much liked doing therapy. He usually felt relieved when sessions ended ("I was always itching to leave the room," he says) and thought he wasn't much good at therapy, anyway. So how did this admittedly depressive man of science--someone who'd rather conjure up research projects than meet real, live clients face to face--come to be known as the "father" of something called positive psychology, a movement that could change the face of psychotherapy as we know it?

For those who haven't looked at a psychology journal or even a newspaper for several years (Seligman's work has been featured on the front pages of The New York Times, Time, Newsweek, U.S. News and World Report , and USA Today ), positive psychology--the hottest new trend in the field right now--is basically the scientific study of what makes people happy and good. Its proponents believe that positive psychology not only has the potential to shake clinical research to its roots, but may directly challenge some of the most basic attitudes that psychotherapists bring to the practice of their work.

Accenting the Negative

To understand just how novel this perspective is, positive psychologists ask you to consider the field's history. For 50 years, they say, professional psychology ought better to have been called victimology, so obsessed has it been with the study of what's wrong with people--what's wrong with their emotional lives, their relationships, their physical brains, why they fail and feel bad and do terrible things to each other. The entire so-called mental health establishment has become a giant public edifice dedicated to mental illness --from the National Institute of Mental Health (which only funds studies geared to treating mental diseases) to the Diagnostic and Statistical Manual of Mental Disorders ( DSM ), an 800-page, quasi-scientific classification of human unhappiness, to virtually every textbook a student therapist reads in training.

In the meantime, what makes for good, healthy, and happy human functioning has not only been ignored, but considered an unscientific and virtually disreputable academic pursuit, like researching astrology or psychic phenomena. "We know a great deal about the psychology of conformity, cowardice, and prejudice," says Laura King, associate professor of psychological science at the University of Michigan, "but we don't have a good take at all on generosity or heroism--why, for example, ordinary people on flight 93 on 9-11 could become heroes in rising up against the hijackers."

 

However promising the new science of positive psychology, it probably wouldn't have achieved its current high level of visibility and apparent success without the formidable Seligman persona behind it. "Marty is a big, big person, with a big personality, a powerful, booming speaking voice, and an authoritative style," says King. A can-do kind of guy, he has established something of an empire devoted to positive psychology. Among other accomplishments, he has set up a scientific foundation, three distinct research centers and a training institute to promulgate the faith, launched a book series, led numerous conferences featuring various academic stars, gotten the American Psychological Association behind his efforts, fired up platoons of young research psychologists around the country, and generated enough grant money to fund a host of studies in universities around the country of what, empirically, constitutes the good, the true, the wise, the spiritual, and even the merely pleasurable in human affairs. To cap it off, he has gone beyond the academic world to attract national attention for positive psychology with his just-published book, Authentic Happiness , a neat counterpart to Learned Helplessness , the book that helped make his reputation more than 25 years ago. Not too shabby for a movement that's only about four years old.

A few tiny shadows dog this expansive and, well, optimistic enterprise, however. First, some humanistic psychologists grumble that there's nothing remotely new about positive psychology--they've been ploughing the same field for 40 years, ever since pioneers like Carl Rogers, Abraham Maslow, Rollo May, and others broke with psychoanalytic tradition to emphasize their clients' potential for growth, wisdom, love, pleasure, and creativity. Then there are the critics from within academic psychology, who say that positive psychology isn't and never can be real science. These skeptics argue that the terms of positive psychology are too vague and susceptible to individual interpretation ever to be defined, let alone measured, by the methodologies of empirical science.

Learning to Feel Good

Seligman, now Fox Leadership professor of psychology at the University of Pennsylvania, was catapulted to prominence in the field as a graduate student in the mid-1960s, when he and several colleagues discovered the phenomenon of learned helplessness in dogs. They found that dogs given shocks while restrained and unable to escape soon "learned" that trying to escape pain was futile. Even when the restraints were removed, the dogs refused to run away from the shock, or go on to learn any other tasks, but simply remained where they were, whimpering and passively enduring whatever happened to them. This and other experiments confounded standard assumptions of behavioral psychology--that animals (including humans), when conditioned, respond noncognitively, reflexively and involuntarily to pain and pleasure, trying to avoid the first and get at the second. Seligman's work showed that even dogs could actually learn a generalized state of expectancy that went beyond a response to any particular stimulus and paralyzed their capacity for any action.

 

If dogs can learn to feel too helpless and hopeless to make any effort to change their plight, Seligman wondered, why not people? The theory of learned helplessness--the acquired attitude that "nothing I do matters, or ever will"--along with systematic techniques for treating depression developed by psychologist Aaron Beck, gave a tremendous boost to the nascent movement of cognitive psychology, emphasizing the vital role thinking played on subsequent feeling. What we learn to expect from ourselves and others can determine our emotional experience of the world and how we deal with life. Over the past 25 years, cognitive behavioral methods for treating a range of clinical problems, grounded in this perspective, have come to constitute the core of empirically-supported therapy practice.

For Seligman, the next step after developing the concept of learned helplessness was obvious: if people can be taught to feel bad , perhaps they can also be taught to feel good . He began work on what would be his real vocation: not just studying optimism and well-being, but devising successful methods for teaching the skills of optimistic thinking to potentially depressed adults and children. "Seligman showed that you can literally change the minds of pessimistic people in a relatively short time, thus getting really good outcomes for preventive therapy," says psychiatrist and resilience researcher Steve Wolin. "It was elegant work."

In 1995, Seligman acted as consultant on a huge national survey done by Consumer Reports , which showed that most of the respondents felt they benefitted very substantially from therapy, and those whose therapy lasted the longest felt they had benefitted the most. Although academicians roundly denounced the survey for its lack of scientific rigor, psychotherapists loved Seligman for it. In 1996, thousands of clinical psychologists helped elect him president of the American Psychological Association by the largest margin in the organization's history.

As APA president, Seligman brought positive psychology front and center to the attention of field. The spotlight, however, also provoked criticism. In response to the special 2000 issue of the American Psychologist on positive psychology, a group of irate humanist psychologists charged that positive psychologists had "hijacked" the humanist movement, "stolen its premises," ignored its predecessors, "derided its history," denied its legitimacy and "cancelled" its right to be considered a ­serious player at the mainstream psychology table. Solution-focused and resilience-oriented therapists also protested that they, too, have long underplayed pathology and focused instead on helping clients bootstrap themselves up on their own strengths and abilities.

 

The Science of Happiness

What sets Seligman apart is his determination to ground positive psychology in tough-minded, grown-up science. Unlike the humanists, who wanted to jettison standard research techniques as too mechanistic and reductionistic to measure experiences like happiness, creativity, spirituality, and the like, Seligman and company want to subject these soft concepts to the hard science of empirical tests and statistical analysis, take them out of the woozy realm of pop psych and inspirational platitudes and give them intellectual backbone. They've produced reams of reports that, on paper, reduce inchoate ideas about happiness into orderly categories and subcategories. So far, they define three major branches of the positive-psychology tree: subjective happiness (positive emotions and mood), human excellence (positive personal strengths and virtues, like optimism, wisdom, and knowledge, courage, spirituality, love and humanity, justice and temperance) and positive institutions (democracy, family, a free press). At universities around the United States, researchers are beavering away, trying to ground amorphous concepts in valid research designs to determine what they mean operationally and how they objectively affect the way people behave.

Compared to studies of psychopathology, these sun-drenched efforts can sound quixotically cheerful--Academic Psychology Meets Mary Poppins. Different "pods," as they are called, of positive psychology researchers are studying, for example, the factors associated with a happy, satisfying Christmas, the emotional consequences of overconsumption and greed (one major focus of the movement is "finding alternatives to materialism"), and the impact of feelings of awe and transcendence on cardiovascular physiology. Other projects seem more mainstream: how positive traits and life events promote immunity and health; how positive emotions and social interactions protect students from loneliness and depression (a prospective study of Stanford University's entering class of 2000); what sorts of school-based interventions can promote ­optimism, hope, perseverance/resilience, courage and duty/citizenship in students.

This blossoming of research projects doesn't cut any ice with academic critics, who maintain that much of positive psychology still remains on the squishy side of scientific legitimacy. In an upcoming issue of Psychological Inquiry , psychologist Richard Lazarus and several colleagues take positive psychology to task for shallow and overly casual research methods, oversimplifying the meaning of basic concepts, ignoring individual differences and changes over time in individuals, and failing to show real causal relationships among emotions, health, and well-being. Positive psychologists respond that every one of the critiques leveled at them could just as well be made of virtually all psychology research (the behavioral sciences aren't physics, after all) and that, if anything, positive psychology has gone overboard to make its studies as unimpeachable as any research in the field has ever done.

Critics are particularly unconvinced by Seligman's classification schemes, his assumption that foggy, philosophical terms can someday bear the weight of empirical science. How can inescapably qualitative concepts like "wisdom," "joy," "judgment," "courage," and the like be rigorously defined, much less objectively analyzed and quantified? Even more to the point for therapists, how can such vague entities become relevant to any practical, down-to-earth interventions with real clients? Steve Wolin remembers being astonished when he first saw the list of qualities--wisdom, courage, humanity, justice, temperance, transcendence--Seligman intended to turn into universally valid scientific constructs. "This is all well and good," he wrote in an e-mail message to Seligman. "But this is not what my patients are interested in. My patients are interested in sex, shopping, drugs and rock 'n' roll."

 

Wolin thinks Seligman is so focused on the definitions of universal strengths and virtues--untainted by relativistic, culture-bound, everyday human context--that these terms risk languishing in the realm of meaningless abstraction. "People use their human strengths like creativity, humor, relationship in specific contexts, to overcome particular adversities, hardships, and struggles--but Marty doesn't seem to be interested in that--he's interested in their pure, Aristotelian essence. I want to see his work make sense to those of us in the trenches. How can I use what he is doing?" In response, Seligman and his colleagues concede that positive psychology is still baby science, but point to such achievements as devising eight-week training workshops that, when given in controlled studies to school children and college students at risk for serious depression and anxiety, reduced the development of symptoms as shown in follow-up studies three years later. With hundreds of young adults and schoolchildren at risk for depression, their research has shown that learned optimism programs used preventively halve the rate of depression and anxiety disorders over long-term follow-up.

Good Character

Positive psychology may remind people of "positive thinking," the feel-good/get-happy movement most often associated with uplift gurus like Norman Vincent Peale in the 1950s. But positive psychology has a paradoxical side, which could only emerge from the mind of a born pessimist, someone deeply familiar with the dark side of life. Seligman not only knows firsthand about human unhappiness, he has come to accept and respect it. "Evolution stamped dysphoria pretty indelibly into the psyche of the human species," he said in a Slate online debate with evolutionary psychologist Stephen Pinker last October. "It was the dysphoric hominids that survived the bad weather of the Pleistocene, not the blithe ones." Sadness, anger, and anxiety are built into the human frame--some frames more than others--and no amount of therapeutic tinkering or positive affirmations is going to turn a natural-born Grinch into Goldie Hawn.

If negative emotions are a necessary part of human nature, so too are the positive ones--with one big difference: it's probably far more feasible, not to mention more pleasant, to expand and build up our capacity for good feelings than it is to eliminate the bad ones. The underlying message of positive psychology is that we can to some extent make ourselves happier, even when we can't entirely rid ourselves of our miseries.

But this happiness-building project is not a walk in the park (though a walk in the park may be a very good happiness-building project). Feelings of joy, contentment, love, awe, even physical pleasure don't consistently "just happen," particularly to those of us who, like Seligman, are more naturally inclined to emotional twilight or even foggy drizzle than brilliant sunshine. These good feelings evolved as emotional rewards humans got for the kinds of activities that make decent civilization possible--hard work, cooperation, self sacrifice, child care, learning, teaching, seeking transcendent meaning in ordinary life. In other words, pleasure and satisfaction most often don't come without previous expenditures of will power, courage, applied intelligence, and damn good attitude. Not normally found in psychology textbooks or therapeutic interventions, nor reducible to popular self-help bromides, these qualities used to be encapsulated by the term good character .

 

Indeed, Seligman writes in Authentic Happiness , "the notion of good character is a core assumption of positive psychology." Which brings us to a surprising feature about Seligman the scientific psychologist--his deep commitment to a very old philosophical quest: understanding the nature of goodness and virtue. He asks questions that would have been familiar to thinkers in Athens 2500 years ago: what constitutes the good life? how do we define happiness and pleasure? what role do virtue, morality, and ethics play in finding happiness?

For individuals pondering these imponderables, wondering how to make them relevant to their personal lives, Seligman offers both a question and a route to the answer: what personal abilities, strengths, and potentials within our own natures can we draw on to create the good life? Seligman has devoted himself to giving this age-old project the full treatment of modern science. In the end, he believes that happiness is a pursuit, as Thomas Jefferson suggested, not an automatic benediction; it doesn't come easily or without struggle for most people. Seligman has been known to say at the end of his talks, "All my work can be boiled down to the one-word answer to a single question. The question is: 'What is the word in your heart?' Is it yes? or is it no? "

In the following interview with Networker editor Richard Simon, Seligman explores the implications of positive psychology for the psychotherapy field.

Mary Sykes Wylie

Psychotherapy Networker: As a therapist and researcher who has spent three decades trying to build a bridge between the world of science and the world of everyday practice, are you impressed with the hard evidence of psychotherapy's effectiveness?

Martin Seligman: Not really. Over the past 20 years, it looks to me like we have hit something I call the 65-percent barrier.

 

PN: Meaning?

MS: If I average all the therapy outcome studies that I've ever read--which by now is probably in the four figures--and I take the percent relief provided by both drugs and psychotherapy across all the disorders, I'd say the average improvement is around 65 percent. That means that, by and large, we produce only mild to moderate relief.

PN: So let me make sure I understand what you're saying. If cure is 100 percent--a touchdown--then 65 percent is a field goal?

MS: Yes. And also that, overall, about 65 percent of the people who come in for therapy see some degree of symptom relief. And 50 percent is what a placebo typically does. And by placebo, I mean either a drug with no known effect on a particular condition or, in the therapy context, an interaction that isn't designed to have specific treatment effects. In other words, both through drugs and psychotherapy, we're dealing with doing 30 percent better than placebo. Of course there are wonderful cases in which there are complete cures, and I'm a collector of those, and you can find those in some of my books. But the average is 15 to 20 percent better than the placebo.

Now that prevents a lot of suffering and you could argue that it's worth the $20 billion investment in drug companies and the psychotherapy industry. But let's look at it in another way. Over the past 25 years, I've been regularly revising a formal textbook about abnormal psychology that has gone through five editions. Over that time, the 65-percent figure hasn't changed. That means to me that we may have reached the limit of progress for our current approaches through psychopharmacology and psychotherapy.

 

PN: Do you see a lot of difference between the results of drug studies and therapy studies? Are the two approaches generally comparable in their effectiveness?

MS: It all depends on what you're treating. For things like obsessive-compulsive disorder, I think psychotherapy's better. For panic disorder, I think psychotherapy's better. For depression, I think they're about equal. For bipolar depression, I think the drugs are better. I can take you through each one of these, but what is important is that I haven't seen a lot of change over our lifetime, and that says to me that some natural limit has been reached by these procedures.

PN: Why do you think that collectively the therapy field has hit this wall?

MS: First of all, I think that negative emotions that are the product of evolutionary constraints are a big part of the reason there are limits to our therapeutic effectiveness. Evolution has been very concerned to give us only limited conscious control over our survival mechanisms. From an evolutionary perspective, negative emotions like fear, anger, and even depression are just too closely tied to survival, and voluntary attempts to gain exert control over them have upper limits.

PN: For example?

MS: Take phobias. I think they are evolutionarily prepared to help us avoid situations that may be dangerous. Some phobias are curable, but if you are agoraphobic, behavior therapy may make you less avoidant and less afraid, but I don't think you're ever going to really love going to a big shopping mall. I think the dirty little secret of biological psychiatry is that it's given up the notion of cure. All the medications being prescribed for depression and anxiety and other negative states are all cosmetic and palliative--when you stop taking them, you're back where you started. Similarly the advances in psychotherapy have been palliative. For example, the most that cognitive therapy can do is help a depressed person dispute the inner critical voices, but there's nothing in cognitive therapy about getting rid of the voices.

 

On the other hand, Freud and the psychodynamic therapists really had a vision of cure. But after 100 years of therapy, it's hard to find much evidence for that sort of cure. Of course, if you believe some of the great clinical anecdotes, when a client gets enough emotional catharsis and insight into the source of a problem, it's gone. That's a cure. And there are enough cases on record to think that that happens some of the time, although no one's ever been able to bottle it. So bottling it up would be the great advance. My guess about the future would be that if we see major advances in therapy, it won't be on the palliative side. I think we've kind of run out of tricks to relieve symptoms.

PN: So where are the advances going to come from?

MS: I think the positive side of life is where the big potential for growth lies. Because positive emotions are much less tied to survival issues, they are much more plastic. When you begin to deal with the human capacity to create things that weren't there before, you are moving out of pre-wired survival mechanisms into a different arena.

PN: So, concretely, what does that mean for the future of psychotherapy?

MS: Working on weaknesses and doing remediation is an uphill battle. After all, words like "intervention" and "therapy" are all appropriate to working out of weaknesses. Let's say we're conducting this interview about my weaknesses. I think it would be an uphill battle and neither of us would have a very good time, and we'd both be waiting for the interview to be over. But when you approach people about what they're good at, they like to talk about it. Time really zips along when the subject is how to use more of what you're good at in your life. What I'm saying is that spending more and more time on strengths is not only a rapport-building technique, it's a natural therapeutic buffer against our troubles.

 

PN: What you mean by a "buffer?"

MS: Okay. Take me. I consider myself a depressive, so I could see that in a different life course, I could wind up a basket case, but, fortunately, there are a few things that I'm really good at--verbal skills, writing, listening to both sides of an argument--that kind of thing. And I've chosen a life course--marriage, a way of parenting, a job--in which I get to maximize my strengths, and therefore I think I'm protected against depression. And I think, in general, our best protections against the kinds of conditions listed in DSM are our strengths.

In the Consulting Room

PN: So how might you then apply that kind of positive psychology approach in a therapist's consulting room?

MS: Let's imagine that a waitress who's got moderately high depression comes to see you and, after she goes through a litany of complaints, you conclude that the core of it is how much she hates her job. You do a very careful assessment to determine her highest strength, which turns out, among other things, to be her social intelligence. At that point, the task becomes helping her to recraft what she's doing at work to better use her strengths. So although she hates being patronized and hates carrying heavy trays, she redefines her job to make her customers' encounter with her the social highlight of their evening. And while she doesn't succeed in that all the time, that keeps her level of challenge and interest up to give her an experience of flow at her work, which now becomes fun, something she's good at.

PN: The concept of flow seems to come up again and again in your work. Say more about it.

MS: Flow, of course, is my friend Mike Csikszentmihayli's signal contribution to psychology. It refers to those activities in which time seems to stop, the moments when you find yourself doing exactly what you want to be doing and never wanting it to end. For most people, perhaps the key to the good life is developing interests and discovering activities that enable you to experience flow regularly in your life. You can probably best understand flow by understanding the reverse. From the first day I took up skiing to the day I gave it up five years later, I was never in flow. Skiers call it "fighting the mountain." So instead of the flow experience, of being comfortable letting yourself ski downhill, I was always worried about falling and trying to figure out what I should be doing. Right now, I think too much of the experience of psychotherapy, for both therapists and clients, involves fighting the mountain.

 

PN: And that's where what you call positive psychology comes in.

MS: Yes. Positive psychology is a lot more like the flow experience of downhill skiing, and it's my hope for getting therapists out of the remedial business. Positive psychology doesn't involve manipulation or much of what we think of as standard therapeutic interventions. You don't need to use clever techniques to get people to change. The focus is on helping people identify what they're really good at, with the premise that doing what they're really good at buffers them against their weaknesses. So when a person finds out that they're really extraordinarily kind and they like being kind, and you suggest to them, "Maybe in your daily life you should take opportunities to display kindness more often." And when they start to do that more, it's self-reinforcing. So, in my case, I don't know how to dress, and if you tried to make me a snappy dresser, I wouldn't have any fun doing it. But even if I don't dress well, I talk well. So it kind of makes of up for the fact that my socks don't match.

PN: Lots of therapists today are turned off to DSM and share your position that therapy should focus on clients' strengths. What's distinctive about positive psychology?

MS: That's a good question. I'm still working on a full answer to it. Basically positive psychology is devoted to giving a solid scientific legitimacy to the interest in strengths. For a weakness-based psychology, we've got a DSM . We've got all kinds of ways of measuring things like depression, and we concentrate on training people in graduate school how to undo the weaknesses people bring to therapy. But up until now, we haven't had a classification of the strengths that make a real difference in people's lives, and we haven't explicitly trained people in interventions that produce well-being. Most therapists decide if a client is depressed by seeing if they have five of nine symptoms, but, from the viewpoint of the science of therapy, it will make a tremendous difference if we had a systematic nosology of strengths that gave them equal weight with DSM diagnoses.

So we've developed a 800-page classification of strengths and virtues that will soon be published by the American Psychological Association that I hope will become psychology's un- DSM . It's what we need to bring us out from under the yoke of medicine, which is about undoing illnesses, not buffering strengths. Now undoing illnesses is fine, but it's just part of what the therapist's job should be.

Along with a classification system, we've developed a panoply of validated assessment tools for measuring the positive side of life. We started with tests for strengths and virtues, but there are also tests for well being, tests for amount of meaning in life, tests for strength of relationships, tests for gratitude, tests for forgiveness, tests for optimism. Those are all free on the web (www.authentichappiness.org). So there are now all kinds of materials to help clinicians measure where a person's weak and to find out where they're strong.

 

PN: What about treatment applications?

MS: What we're doing now is developing a set of positive interventions that we've been testing on normal people and ninth grade-students to see what difference they make. One example involves gratitude. One of the best correlates of life satisfaction is gratitude. So we ask people to take someone in their life that they've never properly thanked and write a testimonial to that person and then visit that person to deliver it. Personally, I'm a pretty ungrateful sort, but I've done that assignment and it had a profound effect on me.

PN: Can you say something about that experience?

MS: I did my own gratitude exercise on the morning of my 60th birthday. My wife and I had invited 50 people to celebrate with us and when I woke up that morning I suddenly had a very clear realization about two different ways of looking at your life--the autobiographical and the biographical. It became so plain to me that my story about myself had been very  autobiographical-- I got this award, I wrote this article, I did this, that, and the other thing. It was all about my fighting one obstacle after another and overcoming it. It was filled with I and about accomplishments as something I did . And, of course, that's so common--our  own will and our own actions are often in the forefront of the drama of our lives, and we put into the background things like the sacrifices of parents, the loyalty of friends, like a wife who reads every word you write and critiques it, children who create a background of happiness, a mentor who, in the beginning of your career, approves everything you do until just the right time comes and then starts to critique it. But as I thought about all the people coming to my birthday party, I found myself filled with gratitude and moving from an autobiography of an I to a biography, in which my life was a part of many more lives that had me possible.

PN: Do you think that therapy can encourage people too far in the direction of the autobiographical consciousness that you're describing?

MS: Our evidence is that gratitude is strongly related to subjective well-being, and so a question for therapists is how they can better promote gratitude. But at the moment, the area of interventions is the least validated in positive psychology. The validation of diagnostic categories is way ahead of evidence-based interventions. That's why I want to encourage your readers to dream in this direction. They're much better at developing interventions than researchers like me, who spend so much time sitting in front of computers.

 

Science and Therapy

PN: It sounds like you're encountering one of the limitations of science. The strengths of science is in measurement and being systematic, but you're saying that there's a big role for the creativity of the clinician in what you're trying to develop.

MS: Absolutely. Before yeoman scientists can go to work and see if things really work, you need the imagination of clinicians to provide something to test.

PN: Do you think that positive psychology will one day do away with psychotherapy as we have known it?

MS: Not at all. Positive psychology is not remotely intended as a replacement for all of therapy. I've been a therapist for 35 years and I'm proud of it. Whatever its limitations, I think therapy has important effects. What I'm describing as positive psychology's contribution is intended as another arrow in the therapist's quiver. I feel the same way about it as I do about drugs--it's another arrow in our quiver. More specifically, teaching our clients optimism, gratitude, forgiveness, identifying their signature strengths, and moving them in the direction of recrafting their lives to use them everyday--these are some of the new arrows for the positive clinician.

PN: But all in all, you sound like a bit of a skeptic when it comes to therapy and the results it has achieved so far.

MS: No, no. I'm tremendously impressed by the 50-percent symptom relief that most therapists are able to bring about using so-called "nonspecific" treatment factors. What they're really talking about are things like listening and taking an interest in people. The secret of therapy as a profession is that it draws in people who are just naturally good at helping other people screw their heads on straight. We could probably put most therapists through four years of learning how to make great coffee and they would still help 50 percent of their clients, whereas if we took the kind of people who I play poker with, I don't think the results would be anything like that.

 

So I think whatever we're doing in selecting and training clinicians, and whatever they do in the consulting room, is 50 percent of the wonderful stuff that helps people. So far science has added another 15 or 20 percent to it. That's good, too. But the biggest thing the psychotherapy field has going for us now is the people who do it, who without using science a lot of the time, bring about change 50 percent of the time, and sometimes do much better.

While the clinician's job is to alleviate troubles, I also think the development of things like character, positive emotions, and strengths are an end in themselves, completely independent of alleviating troubles. But the science isn't there yet. We don't yet have clear empirical demonstrations that if you work hard on developing your strengths, then your troubles fade into the background. When we get that kind of data, it could change the future for psychotherapy.

Richard Simon

Mary Sykes Wylies, Ph.D., is a senior editor of the Psychotherapy Networker HASH(0xc85a294)

Richard Simon, Ph.D., is the editor of the Psychotherapy Networker . Letters to the Editor about this article may be sent to Letters@psychnetworker.org.