It’s always been difficult to evaluate the effectiveness of psychotherapy.
By now, most therapists and patients have figured out that psychoanalysis can neither treat nor cure mental illness. They have moved on to medication and cognitive-behavioral treatments (CBT).
New York City psychiatric institutions, previously a bastion of Freudian psychoanalysis, discarded psychoanalysis a couple of decades ago, and replaced it with psychopharmacology and CBT.
It was not all Aaron Beck and Martin Seligman. There was also Marsha Linehan.
I began hearing about Linehan more than a decade ago. Her variation on CBT was strikingly effective with patients suffering from borderline personality disorder. It was called dialectical-behavioral therapy (DBT).
Young therapists in New York psychiatric hospitals were flying out to Seattle to learn the technique from Linehan herself.
Yesterday, Will Lippincott testified to the therapeutic benefit of DBT in the New York Times.
The Times has begun a column called “Couch” wherein therapists and patients recount their experiences with treatment. Lippincott’s is dramatic and telling.
It offers an indication of where the therapy profession is today.
Lippincott opens his story:
In January 2012, two weeks after my discharge from a psychiatric hospital in Connecticut, I made a plan to die. My week in an acute care unit that had me on a suicide watch had not diminished my pain.
Back in New York, I stormed out of my therapist’s office and declared I wouldn’t return to the treatment I’d dutifully followed for three decades. Nothing was working, so what was the point?
One is tempted to speculate about what kind of treatment Lippincott was following for three decades, but whatever it was, it left him suicidal... even when accompanied by a stay in a psychiatric hospital.
As a young man Lippincott had made a plan for beating his depression. He was doing talk therapy and taking medication. The plan worked… until it did not:
But I had an ambitious plan to beat it. I’d be a performer: work hard, keep my goals in the line of sight at all times, and make as much money as I could. Professional success would be my first line of defense to keep hopelessness at bay. In parallel, I’d find excellent doctors and be a compliant patient, take my meds and show up for talk therapy.
And for a long time, through my 20s and 30s, that plan worked.
Then, in 2008, a business deal fell through, and I couldn’t shake my disappointment.
This episode recalls an observation made by Helen Block Lewis in her excellent books on shame and guilt in neurosis. She noted in her own practice that some of her patients who had completed psychoanalysis later suffered breakdowns because they did not have the tools or the skills to deal with failure and shame.
Instead of committing suicide Lippincott checked in to the Menninger clinic in Houston. Originally founded in Topeka, KS in 1919, the clinic was originally known for offering psychoanalytically oriented treatment.
When he got there, Lippincott was introduced to dialectical behavior therapy:
A few weeks after I arrived, I was enrolled in a dialectical behavior therapy skills group.
D.B.T. is a therapy that was developed in the 1980s by the psychologist Marsha M. Linehan as she worked with suicidal patients suffering from borderline personality disorder. In spite of my 30 years as an avid, often desperate medical consumer, I’d never heard of it.
I, too am surprised that Lippincott never heard of Marsha Linehan.
Linehan’s approach is a variant on cognitive treatment. While cognitive treatment focuses on the mind and the way it interprets emotion, DBT identifies behaviors that patients employ to deal with their symptoms and helps them to replace them with new, more constructive behaviors.
(For a description of the CBT treatment of social anxiety, see my post yesterday.)
The concept will be familiar to readers of this blog. Linehan is adopting Aristotle’s idea that the best way to overcome bad habits is to replace them with good habits. Note well, her approach does not require patients to discover the root causes of their bad habits.
But Dr. Linehan found that C.B.T. didn’t always work for her suicidal patients. Some found its emphasis on changing their own thinking tantamount to the belittling notion that their pain was “all in their head.” Many of them had experienced very real trauma, and many had tried fruitlessly to change many times before. C.B.T.’s implication that their emotion was “wrong” — merely a consequence of inaccurate thoughts — made the therapist seem unsupportive, and reinforced their sense of isolation and hopelessness….
It’s not that we have the “wrong feelings”; it’s that our feelings flood and overwhelm us, in ways they might not overwhelm someone with different genes, and that it takes longer for those feelings to ebb and subside. In response, she began articulating strategies, or “skills,” for people with these vulnerabilities.
It is in the pivotal moment between experiencing a feeling and acting on it, the theory goes, that I have a chance to “act opposite”: to behave differently from how I have historically, and often destructively, managed distress.
Here, the key concept is to “act opposite.”
When people have, for example, been traumatized, they develop certain behaviors and certain ways of conducting themselves. In principle, the behaviors help them to avoid trauma and mitigate their anguish. In fact, they replicate the trauma.
If, for example, people feel depressed and cut off from others they will likely try to construct relationships by being overly dramatic and overly emotional. They will not know that the best way to develop relationships involves being polite and well-mannered, considerate and respectful.
In a DBT approach, patients are coached to develop those and similar skills.
Lippincott described his own experience. Note that he identified behaviors that accompany his depressed states. He did not attempt to find the root cause of the depression:
When I was depressed, the self-possession I presented to the world belied just how out of control I felt inside. In my search for relief from anxiety, anger or sadness, I’d act impulsively — spending money when I couldn’t afford it, isolating myself from friends, lashing out at those people closest to me, even hurting myself physically. Afterward, I was kept low by regret. My urges to act out may have been satisfied, but now I had a set of new problems: debt, broken relationships, a hangover. Unable to forgive myself for my mistakes, the anger returned.
As for managing his anxiety, Lippincott learned to perform specific actions that would mitigate it:
I followed the strategy of distracting myself with highly specific tasks just long enough — usually for two or three minutes — to lower the intensity of the fear before it overwhelmed me. Depending on where I was — at home, at work or on the street or train — I’d reach for a situationally appropriate activity. And because I can’t rely on my memory when anxiety swells, I’d carry lists on an index card or on my phone: pull out a piece of paper and write down all 50 states and their capitals — in my non-dominant hand; grab ice cubes from the fridge and hold them on the back of my neck; snap the rubber band on my wrist. At the office or in a meeting, I learned to make subtle changes to my posture like bunching my toes, half-smiling to activate facial muscles, even slowing my breathing.
Treatment taught him how to direct his focus away from feelings and toward facts. Reasonably so. You cannot solve problems in the real world by getting in touch with your innermost feelings:
Mindfulness challenges me to accept emotions and situations as they are, not as I want them to be. I’ve learned how to “observe and describe”: to state the nature of a problem with facts, not judgments, so I can determine how best to solve it.
As for emotions, DBT taught Lippincott how to step back from them and to try to understand what they are trying to tell him about reality.
Emotion regulation teaches me how to identify and understand the functions of my emotions, and how to decrease my historic vulnerability to extreme moods. If I’m aware of how I feel physically when I’m sad, or how my speech pattern changes when I’m angry, I can recognize where I am and change course before the intensity of the emotion gets too high.