Unifying the Psychotherapy Schools

                                                                  

                                                

                                       Jeff Magnavita                                          

                                                                                            

In my post of December 3, 2024, I discussed the reasons for the fact that there are hundreds of different “schools” of psychotherapy in use today, each with their own theories to account for problematic behavioral, relationships, and thought patterns in individuals. Most of them are variations on the six major schools of thought in the field: psychodynamic, cognitive, behavioral, affect-focused, existential, and family systems. Still, they often have completely different ideas about what is important to focus on in psychotherapy and what techniques to use.

New techniques continue to proliferate at an alarming rate. An increasing number of them are being developed to treat, for example, members of racial and ethnic minority groups. Some have been politicized. This situation is becoming even worse as the quality of psychotherapy is declining, as I described in my post of 4/10/25.

I’ve also discussed the psychotherapy “integration” movement, an attempt to put some of these ideas together, as exemplified by the organization Society for the Exploration of Psychotherapy Integration (SEPI) It has been around since the 1980’s. Unfortunately they seem to  put little emphasis on a completely integrated model for fear it would be just become yet another school. So they content themselves mostly with adding slightly altered versions of techniques from one major school for use in another.

I attempted to form a more unified model which incorporates many of the valuable concepts from the major schools into a single framework way back in the late 1980’s, resulting in publication of my book, Unifying Individual and Family therapies, since re-titled a Family Systems Approach to Individual Psychotherapy. Since then, I've been joined by several people who have also been trying to do that, such as Jeff Magnavita, Andre Marquis, and Gregg Henriques. We each have somewhat different ways of doing so, which may sound like the society’s worries re more schools are well-founded - but these new unified models are very similar and have been a long time in development.

                                                                    Andre Marquis

The more integrative schools look at the fact that there are a huge number of interacting factors which lead to specific behavioral problems – both intrinsic to the brain and external factors such as social ones. And every disorder, and individual with a disorder, is usually subject to different combinations of them. Greg Marquis has divided them up into four groups or quadrants. Example from each are listed here:

Interior-individual: self image, self concept, self efficacy, stability, depression and anxiety

Interior-collective: relationships, cultural norms and meanings, family dynamics

Exterior-individual: medical disorders, brain functioning, medication, diet, sleep patterns

Exterior-collective: Socioeconomic status, neighborhood, environmental stressors, interpersonal and dynamics and history, racism, sexism.

IMO, a clinical evaluation examining factors in each of these areas is an absolute prerequisite for planning strategies for change in any given individual. This requires a somewhat long  session by therapists with a sense of leaving no stone unturned.

Magnavita and others also look at processes occurring at various levels such as in the brain, within the individual's psychology, between individual and family, and families and the larger social context. Unifiers often notice what is referred to as parallel process, where there are similar problems and processes between levels, say, in the family and in the family's ethnic group. I write about shared intrapsychic conflict, in which several members of the same family are all conflicted about personal behavioral standards because of changes in the ambient culture which require different ones than had been required before.

Therapists try to make a determination about at which levels they might have the most leverage for helping clients make changes and have useful therapeutic strategies for possible interventions – such as medications for the brain, or family systems models for problems at the border of the individual and the family. As the reader can tell, therapists familiar with the widest range of models for change and individual strategies to affect various aspects of the patient’s problems will have the most options to choose from.

My unified model is a system of interventions designed for those with personality disorders to change a client’s interactions with attachment figures that trigger and reinforce repetitive self-destructive behavior. (This would obviously be inappropriate for use with other types of disorders in the DSM such as bipolar disorder, which is primarily treated with medication. Some other disorders like panic disorder can be a byproduct of dysfunctional family interactions and be treated both medially and psychotherapy using my model).

My model addresses several important processes that were first described by the other major therapy models, in new, integrative ways. To greatly oversimplify, within a family, family behavior (family systems) leads to behavior in individuals which is reinforced on a variable intermittent reinforcement schedule by parents (behaviorism) which then creates a false self in individuals who are trying to stabilize unstable parents (psychodynamic). Patients keep the false self in line using defense mechanisms (psychodynamic) and irrational thoughts (cognitive). If they do not do this and try to “self-actualize” or follow their own muse (emotion-focused) they become subject to existential terror (existential therapy). Therapy aims to help patients understand family behavior through extensive family history (genograms) so that they can use empathy and a variety of strategies to get past parental defenses to discuss the whole process with them and put a stop to it.

Now, if only we all could just get the rest of the psychotherapy field to pay attention to this stuff.

Factors in the Decline in the Quality of Psychotherapy

Jonathan Shedler

Jonathan Shedler, Ph.D. is a critic of many aspects of today's practices in psychotherapy, and many of his views are similar to my own. He recently listed what in his view are the main factors in the dramatic decline of quality psychotherapy (I thank Dr. Steven Reidbord for calling this to my attention):

Deep intrusion of health insurance agendas into psychotherapy and its training

Dramatic decline in reimbursement. Psychologists in managed care paid 70% less than 1980s. “Best and brightest” now choose other careers

Out-of-control proliferation of for-profit graduate training programs that admit and graduate anyone who can pay

Influx into psychotherapy professions of vast numbers of practitioners who lack adequate training and aptitude

Pharmaceutical marketing/PR campaigns changed public perceptions, normalized meds and seeking MH care from primary care doctors as solution for problems in living

Therapy researchers operate in academic silos with little knowledge of psychotherapy and no contact with real-world psychotherapists. Most “therapy” research irrelevant and useless to clinical practitioners

Conflation of psychological problems with DSM diagnoses (by health insurers and academics researchers both)

Conflation of psychotherapy “outcome” with DSM symptom lists (driven by health insurers and academics researchers both)

Rise of social media therapy influencers and their self-promotion (“the death of expertise”)

Intense politicization of therapy professions; emergence of a training culture that incentivizes “right” politics & ideology over professional competence

Impact of tech companies/private equity. E.g., lowest tier therapists recruited, marketed, paid like Uber drivers. Advertising deliberately erases distinctions between levels of training and experience

Low or no barriers to entry; MH field is low hanging fruit for all manner of self-promoters and opportunists

“Clinical supervision” no longer a clinical training relationship with skilled clinical teacher/mentor, but often reduced to an administrative function by clinics/agencies

Runaway bureaucratization—inordinate time spent on forms/paperwork/documentation/ever-expanding bureaucratic requirements that neither benefit patients nor develop clinical skills in therapists

Extreme gender imbalance in training programs (classes often >90% female) with resulting loss of balance and perspective. Male students routinely report feeling unwelcome/marginalized/silenced

Increased emphasis in training programs on paint-by-numbers “manualized” therapies in place of fundamental psychological principles and core psychotherapy skills

Endless proliferation of “new” therapy brands/models/acronyms instead of emphasis on fundamentals skills. Virtually all are repackaging of well-established principles, endlessly reinvented/rediscovered by people lacking profound knowledge

Rampant denial of the role of unconscious mental life

–and neglect of personality & personality pathology. 

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To those I would add seeing people's problems as "all in their heads" while ignoring family systems and sociocultural issues.

Book Review: The Origins of You by Vienna Pharaon

 

My “Unified Therapy” psychotherapy model, which I’ve been writing about since the publication of my first book in 1988, is meant to treat people who engage in repetitive self-destructive and self-defeating behavior, particularly in relationship contexts. You know, like people who marry one alcoholic or narcissist after another. While looking at their past is essential – in fact I look back three generations to find out why my patients, and their parents and grandparents, act the way they do – what’s even more important is what goes on in the present.

I found that people were acting out roles in their families to stabilize their parents, not for selfish reasons, and were suppressing who they really would want to be if left to their own devices. We all have a tendency to do this due to the effects of an evolutionary process called kin selection. We can choose to do otherwise, but if we do we become subject to terror when our families invalidate us.

Family roles are something modern day therapists pay almost no attention to, so when a book comes out that addresses dysfunctional behavior that dates back to family processes in childhood, I’m keen to read it. The Origins of You by therapist Vienna Pharaon is such a book. She looks at her clients' repetitive dysfunctional behavior in their relationships  as a way for them to feel safe because of earlier interactions with parents. She looks for ways that people do things like act like doormats in relationships – or go to opposite extremes and constantly try to dominate other people.

She addresses five needs from which these behaviors arise, which she says derive from what she calls “origin wounds.” She notes that her clients who had previous therapists often had not mentioned them. The needs which lead to these origin wounds are:

1.       I want to fell worthy.

2.     I want to belong

3.     I want to be prioritized.

4.     I want to trust

5.     I want to feel safe.

After review their childhood history, she uses a lot of popular techniques which are basically supposed to lead to behavior changes after insight into these wounds is achieved, and then has her clients monitor their behaviors for those which lead to conflicts, communication problems, and lack of boundaries. Then they talk about what changes need to be made.

The author claims a fair amount of success doing this, which I don’t doubt. She talks about emotionally abusive parents and a little about physically abusive ones, and domestic violence in the family. But not very much about severe physical abuse and neglect or child sexual abuse which families have refused to acknowledge. In my experience, clients like those who follow the recommendations here would be subject to massive invalidation by their families, which I found eventually and (almost always) undid any positive changes they had made from the type of therapy described in the book.

To her credit, the author does say that these problematic patterns are learned in the family and passed down to subsequent generations. And that the parents also have their own origin wounds, with which I totally agree.

But there are two issues that I (but almost no other therapists) have with her ideas. First, aren’t these people really aware at some level of what they are doing, even when they won’t admit it - even to themselves? Second, are they really protecting themselves, or are they altruistically sacrificing themselves for their parents?

On the first issue, the author does seem to come closer to my point of view in the text and with a couple of her clients. She mentions that a dysfunctional path “is easily recognizable, but sometimes hides in plain sight.” A client named Amir could clearly describe what he was doing but claimed to have no idea why. A long time ago I came to the conclusion that people are not stupid or blind about this, but acted as it they were. To understand what’s going on in my view, check out these posts on a groupthink process called willful blindness.

On the second issue, it’s hard to believe that clients are acting this way because they are protecting themselves, when the patterns are obviously bring them much pain. (There is one selfish motive mentioned above: the phenomenon of existential groundlessness). But as I have said, they are sacrificing their own needs to help maintain family stability.

Which also means that the process going on with the parents continues well into adulthood. The author seems to know this on some level but does not talk a lot about the response of their parents to new changes in the client’s behavior, so it’s hard to judge if she thinks this happens very often. Near the end of the book she does mention only briefly the risk that her clients maybe be “judged, shamed, rejected, or even disowned.”

In general, the author describes these patterns and how to conceptualize them very well, along with techniques which may lead to significant behavioral changes in some families where massive invalidation is far less likely that in those producing offspring with severe personality disorders. 

Why Are There so Many Different "Schools" of Psychotherapy

 

Head honchos of all the differing schools of thought in psychotherapy met together in 1985.

There are currently hundreds of  different “schools” of psychotherapy, each with their own theories to account for problematic behavioral, relationships, and thought patterns in individuals. Most of them are variations on the six major schools of thought in the field: psychodynamic, cognitive, behavioral, affect-focused, existential, and family systems. Still, they often have completely different ideas about what is important to focus on in psychotherapy, as well as the reasons for their clients' problems.

In 1985, the Milton Erikson Foundation put on the first of several "Evolution of Psychotherapy" Conferences, in which they were somehow able to get all the current head honchos of the various schools (pictured above). I was there and it was impressive to hear them present their ideas and argue with one another. Before I even became an academic and while in private practice, I had done extensive reading and noticed that each of these differing, very complex schools of thought had  valuable things to say about human nature, but that each was riddled with some logical fallacies as well as outright distortions.  I decided to attempt to write a book on what I called a "unified theory," which I somehow managed to get published in 1988.

So why so many schools of thought? In a way, this plethora of theories and methodology is not at all surprising in light of the fact that  psychology is still a relatively young science, and having several theories is typical of new scientific endeavors. In the case of psychology, coming together is particularly difficult because of the sheer number and magnitude of natural processes involved, coupled with the fact that we cannot read minds. When it comes to important phenomena such as domestic violence and child abuse, people lie all the time – not only to others but to themselves as well. They do so out of shame or a desire to protect other family members.

 So-called “empirical” studies in the field are, in a sense, collections of anecdotes: the impression of the researcher coupled with the self report of the individuals being studied. To really know with any certainty what is going on with, say, family interactions , experimenters would have to be able to watch them, over a significant period of time when people were not aware they are being watched. This cannot be done to the extent necessary.

The problems in the field are further made difficult to sort out due to the complex structure of the human brain as well as the sheer number of environmental factors which impinge on it.  The brain has billions of neurons, each with up to about 1000 constantly changing synaptic connections caused by a process called neural plasticity. These connections are further impacted by scores of different genes, which do not determine human behaviors but each making certain behavioral tendencies a little stronger or a little weaker.

Relevant environmental influences probably number in the hundreds and come and go in various and constantly changing combinations and intensities. Then there is the so-called “butterfly effect” in which even small differences in initial conditions lead to major differences later on.

Finally, the complexity of the problems that bring clients to therapy varies widely depending on their specific issues. Some problems are rather straightforward like simple phobias or lack of assertiveness with strangers. Others involved horrendous issues such as a family violence or substance abuse and their ongoing effects. One-size-fits-all interventions such as cataloguing irrational cognitions do not really seem adequate for comprehensive treatment.

Treatment outcome studies have been little help. Generally, all the major treatments come out about the same in terms of efficacy. People in SEPI, a professional group  that looked at these issues, used to jokingly refer to this as the “Dodo Bird” (from Alice in Wonderland) verdict: All have won and all must have prizes. Even then, a significant percentage of subjects do not respond that well, and those that do improve often the improvement does not last for more than a year. When one paradigm is directly compared with another in a study for a given condition, 85% of the time the treatment favored by the person designing the experiment "wins" and outperforms the other treatment. This is most likely to something called the “allegiance effect.” Another issue: sometimes acceptance of an idea in the field is due to the eminence of the experimenter and not due to the actual evidence.

It seems to me that many of these schools of thought assume without real evidence that all the problems of people who are repeatedly self-defeating or self destructive, or who make choices in life that make them unhappy, do so because they are mentally deficient in some way. I have categorized these alleged deficiencies as their being either “mad, bad, or stupid.” That is, insane, evil, or unintelligent.  Non-psychotic clients are usually are none of these things.

Furthermore, as described in a previous post, psychological problems are often seen by practitioners and theoreticians alike as existing only in people’s heads, as if the client’s current social and relationship environment is almost irrelevant.  For example, in studies of the alleged over-reactiveness of people diagnosed with so-called borderline personality disorder, subjects keep diaries of when they have strong emotional reactions – “ecological momentary assessment” – but are not asked to also write down what it is they are reacting to.

In the 1980’s and 1990’s, family systems schools began to address this deficiencies – but then they went to the opposite extreme by viewing clients entirely as pawns of their kin groups with no capacity for critical thinking and independent decision making.

Psychiatry, in the meantime, has swung back and forth between, as L. Eisenberg put it back in 1986, brainlessness (Freudian psychoanalysis, for example) and mindlessness (eugenics in the 1930’s and the over-estimation of biological psychiatry in the present).

There are a few of use who are still trying to put all these various ideas together in some sort of valid and coherent form. Gaining acceptance by the field for these efforts is an uphill battle.

New Podcast, Part II. Family Dysfunction Effects Not "All in Your Head"

New podcast, Part II, discusses my family dysfunction model in more detail. Your problems with it are not "all in your head."

https://www.youtube.com/watch?v=pjG5LbV26ps

The Canceling of the American Psychotherapist

 

In my review of the book, The Coddling of the American Mind by Haidt and Lukianoff, I focused on a cultural shift on college campuses that has often led to an environment characterized by political correctness rather than free and open debate between opposing viewpoints. Groups have even turned on their own members for deviating ever so slightly from a “party line.” I discussed how this is one way that groupthink can manifest itself.

A  new book by Lukianoff and Schlot talks about how this situation has apparently gotten much worse, and has spread to other educational institutions and vocational venues such as journalism.

One of the most problematic ideas of groupthink on campuses has to do with the so-called Diversity, Equity and Inclusion (DEI) philosophy. Of course, diversity, equality (of opportunity, not of outcome), and inclusiveness are virtuous and wonderful things when applied to individuals with all of their family and historical influences and experiences. Unfortunately, this has now morphed into defining people entirely by their ethnic group. Members of groups are either ALL victims (ALL black people) or ALL oppressors because they may have benefitted in some  way from their “advantages” (ALL white people). 

Apparently except for Jews, who have been just about the most oppressed group for the longest time over history but also somehow counted some of the world's most successful people among their numbers. This obvious rebuttal to “Critical Theory” has been solved by some people by seeing Jews as White colonialists, while by others seeing them as Colored. Whichever is convenient. These people are still trying to figure out how to classify Asian Americans who aren’t white but who are who also more successful on average than other American groups.

This is in fact exactly the opposite of what Martin Luthor King preached! He spoke of judging people by the content of their character and not by the color of their skin.

But no matter. The primary reason that I am reviewing this book is because this type of thinking has now spread to psychotherapy teaching programs! Your problems all now seem to originate, not from your family or personality or genetics, but from the fact that you are either an oppressor or a victim, according to your group identity, and you need to admit it! As the authors say, “It’s not about your problems. You are the problem.”  

Everything wrong with people is seen through this lens. Therapists are now lecturing patients who have “incorrect” political views. “Multicultural and social justice counseling competencies” has even been endorsed by the American Counseling Association. The American Psychological Association is beginning to follow suit. They endorse, for instance, the idea that the repression of feelings of males typically seen in many cultures (who, say, won’t cry), often modeled by parents, is an example of traditional masculinity invariably being “toxic.”

The authors of the Cancelling book believe that these approaches are counterproductive. They can cause patients to see themselves only as helpless victims, and discourage people who are automatically assumed to be perpetrators from seeking help. How do these therapists reconcile themselves to the fact that, in 2020, 70% of completed suicides were “privileged” white males (according to the American Suicide Foundation).

When I first read the chapter about psychology programs I was a little unsure how common this was, since I hadn't heard about it. But then I saw an advertisement for a book for therapists in the Psychotherapy Networker magazine. It was called Decolonizing Therapy by a PsyD named Jennifer Mullan. I quote from the ad: "Ignoring collective global trauma makes delivering effective therapy impossible; not knowing how to interrogate privilege (as a therapist, client, or both), and shying away from understanding how we may be participating in oppression is irresponsible." 

Well, I do believe a therapist has to understand what each family may have experienced in this regard to understand certain shared intrapsychic conflicts that are seen within a given family - but each family is unique. And hopefully the therapist is not acting out blatantly racist attitudes. To assume all white therapists are doing this is what is irresponsible.

Anyone who disagrees in some graduate programs is in high danger of being “cancelled” by fellow students. One student said the environment was so mean that a student who lost a family member to COVID was afraid to tell anyone lest they be told that they were crying “white tears” and lectured about how people of color were the real victims of the pandemic!

Now of course it is true that many people have been severely traumatized  by racial or group experiences and that such trauma can lead to psychopathology, but that is not the same as saying that other factors might not be equally or even more important.

This is a perfect example of one key feature of Groupthink: either/or or black and white thinking. No context, no subtlety. I recently had a negative personal experience with that type of thinking with psychology interns I used to lecture to. This one didn’t involve oppressors vs. victims, but there was a certain similarity in its misclassification scheme. And it’s something brand new.

I used to lecture them about borderline personality disorder (BPD). The interns came from the University of Tennessee Health Science center and another group of interns from the Memphis VA. Now admittedly I did discuss some of my own, outside-the-mainstream ideas, but I also discussed other current psychotherapy paradigms and theories about the disorder. 

After I retired, I was still invited back every year to give the talk. Then suddenly the person in charge who called me to do this stopped calling. It took me two or three years to find out why, but I finally was able to corner her. First the VA, and then the UT interns said they no longer wanted lectures about doctor’s individual practice experiences (mine was over 35 years), but only from people who did literature reviews or active researchers! 

This same type of thing was happening on my Psychology Today blog. One post I wrote was rejected because, they said, it was an opinion piece not based on research - when most of their posts are NOT research based. They just, for the first time in years, didn't like my opinion. So I stopped posting.

As readers of my blogs know, the literature in both psychotherapy and BPD is weak - and that's being generous. It is characterized by false assumptions, the fact that whole schools of therapy are evaluated but not the individual interventions which comprise them, the ignoring of many obvious impacting factors, and clinically-useless correlations between certain symptoms within one diagnoses or between two of them. People with a lot of clinical experiences in this area are a hell of a lot more knowledgeable than researchers. 

The interns even wanted solely literature-based reviews a about the treatment of transgendered patients, which has barely begun as a subject for any studies at all!

If a therapist is more interested in politics and your ethnic group than in you, drop them ASAP and find another therapist.

I am Interviewed on Two New Podcasts

 I'm interviewed on two new podcasts. 

The first describes my background and how I got interested in the family dynamics of self-destructive behavior (particularly borderline personality disorder) and its psychotherapy:

https://www.youtube.com/watch?v=XPQdl664QgM

In the second one, I talk about my self-help book, Coping with Critical, Demanding, and Dysfunctional Parents: Powerful Strategies to Help Adult Children Maintain Boundaries and Stay Sane:

https://www.youtube.com/watch?v=MLM6tvLe_Oo&list=PLOSSy_bIynJqUnE3ilzI9UR7J92aYeCI2&index=42

Behavioral Disorders are not "All in Your Head"

The serenity prayer: 

God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

 

When I read psychotherapy journals and posts on psychotherapy list-serves, it often sounds to me like the field has lost its collective mind. Some authors seem to think that every behavioral syndrome results entirely from some deficiency within a person, rather than being mostly a reaction to their social environment (the fundamental attribution error). If their patients are upset or anxious, they ask them things such as what is wrong with your thoughts or why they don’t know how to calm yourself down (cognitive behaviorists). Or what might be their deep-seated desires that they won’t face (psychodynamic therapists). 

(To be clear I’m not talking about major psychiatric disorders that are most likely real brain diseases such as schizophrenia).  

While these types of questions can be helpful for people who are not very disturbed about their lives and relationships, sometimes their use has been comical. As a psychiatrist named Jim Dillon put it:

“As a psychiatrist, I cringe upon hearing recommendations for psychotherapeutic methods employed to resolve ongoing social conflicts. It is like suggesting labor unions obtain group counseling when the threat of a strike is the only strategy that will improve their economic circumstances.”

Or teaching clients “mindfulness” when they are being invalidated, criticized or abused by their family and spouses - instead of helping them learn how to put a stop to the dysfunctional interactions.

 

As I described in a previous post, more systemic or social types of therapy that involve family members (family systems therapy), while still out there and being employed by masters’ level therapists, have fallen out of favor with psychologists. And they were never taught to psychiatry trainees at all (except in a residency program that I ran). This has occurred because of a number of social issues. Examples: Feminists thought systems people were blaming just women, who are still the primary caretakers for children;  some folks believed that there were people using the “abuse excuse” for criminal behavior and to avoid taking any personal responsibility for their problems; unscrupulous therapists were uncovering “false memories” of abuse through suggestions to the highly suggestible, as well as through hypnosis.

 

That last one also points to another issue that shows the field’s current state is more political than scientific. Just because some of the ideas therapists' used for problematic behavior were being misused in some contexts does not automatically make them invalid. Furthermore, if some of aspects of complex theories are wrong, that hardly means that all of them are wrong.

 

These phony arguments are also used to further the financial interests of  pharmaceutical companies, who want to sell more pills. If everything is a disease, drugs should be all you need. They are also used by the medical insurance companies. These insurers refuse to pay for any longer-term psychotherapy treatments in order to better cash in. They only cover symptomatic treatment. Bogus “medical necessity” criteria are used to drastically cut down the number of sessions therapists can administer. In other words, the current models help the greedy. The federal parity law that says psychiatric disorders must be paid for by insurers just like physical disorders has been a complete joke.

 

Science has clearly shown beyond a reasonable doubt that the structure of the “plastic” human brain is in part shaped by interpersonal interactions. Most of what we do in social situations is learned (or intuited as I believe some are),  and is then done automatically in response to environmental clues. The brain has about 6 Billion neurons with up to a thousand connections each, and the circuits change in response to what is learned. And learning also includes how to best react to literally thousands of environmental factors operating at different times, strengths and combinations.

 

An article published by Harvard University Center for the Developing Child says that 700 new connections per second are made in the brains of newborns within the context of care-giving relationships  Another recent study showed that small differences in a mom's behavior early on in interactions with infants may possibly show up in child's epigenome (epigenetics is the study of how genes are turned off and on in response to such things as social interactions).

 

It is time for therapists to learn, not how to change their clients’ “internal” family system (another recent therapy fad), but how to help them react better to their external one.

Book Review: Building a Life Worth Living: A Memoir by Marsha Linehan

The predominant and most widely-used school of thought in use for the psychotherapy of borderline personality disorder (BPD) is called dialectical behavior therapy (DBT). Marsha Linehan, a psychologist at the University of Washington, was the person who came up with the theory and treatment ideas. The treatment paradigm has been shown in studies to be somewhat effective in reducing some symptoms of the disorder, but mostly ineffective in helping patients solve their problems with love and work.

She believes that a combination of a genetic propensity to be over-reactive combines with a so-called “invalidating environment” to produce the disorder. Studies  that attempt  to identify genetic propensities tend to have a major flaws in distinguishing normal neural plasticity in response to the environment from purely genetic effects, although the combination of a baby that tends towards being reactive and a parent with attachment issues would be problematic – an example of gene-environment interaction rather than just genetics.

The invalidating environment is clearly that in the patient’s family of origin, although this is seldom spelled out in the DBT literature.

Interestingly, in 2011. Linehan, in a story in the New York Times, “…admits that when she was younger, she "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." She added, “I felt totally empty, like the Tin Man."  Self injurious behavior and feeling empty are two of the hallmark symptoms of BPD.  Did she have the disorder?  According to the article at least, BPD is a diagnosis "that she would have given her young self."

So I was intrigued when she recently published her memoir. I was particularly interested in hearing about her family of origin and hints of any shared psychodynamic conflicts they may have had, a phenomenon that she appears to be clueless about with her patients. I had wondered why, if she came from such a family, she rarely wrote about how to address invalidating family members, as opposed to merely teaching patients “radical acceptance” of their parents’ ongoing behavior so they react much less.

So if she herself had BPD, and if an invalidating environment is one of two main causes of the disorder as she theorizes, I've long wondered how come she does not address this very much in her treatment plan. She says she sometimes does family therapy, but mentions it only briefly and without any details both in her memoir and her primary book about DBT.

While I cannot be certain of anything about her family based just on what she chooses to reveal in her memoir, the family’s conflicts over gender roles – particularly career aspirations for women – and religion just seem to jump off the page of her memoir. So the following forms the basis for my speculations.

She herself draws the parallel between her mother’s experiences growing up and her own conflicts with her mother. The mother’s parents were described as having lost their fortune and died young. The mother then took a job to support her two younger brothers but later moved in with a maternal aunt, who drilled into her head that she was to be a social butterfly and attract a successful businessman for a mate. Which she did. Yet she never seemed particularly enamored with her husband.

In particular, her aunt told her she had to lose weight to be more attractive. She did that. She never again had a paying job, but was extremely active doing charity work and also painting. Her art was admired and was hung up prominently in their house, but Marsha only found out that she was the artist much later. I guess traditional women could work as long as they didn’t get paid and thereby threaten their husband’s traditional image. Mom did all this work despite having six young children.

The author writes that marriage and children were most important for mother as they generally were for her generation where she grew up. But were they really, or was she just following her family’s rules?

When Marsha was a teen Mom tried compulsively to get Marsha to do the same thing her aunt made her do - unsuccessfully. Marsh was compared negatively with her younger sister who followed the supposed family philosophy re marriage and work. In particular, Mom constantly nagged Marsha about losing weight. Marsha was the only child in the family with a weight problem, so perhaps that wasn’t “genetic.” Marsha writes that the thing she wanted to do more than anything was to gain her Mom’s approval, but somehow she couldn’t manage to do this one simple thing - that her Mother had been able to do - in order to get it.

Marsha writes clearly that she knew that Mom’s relationship with her great aunt was the reason her Mom was so critical of her, but she seems to not understand exactly what made her family act out this issue in the first place nor exactly how it might be transmitted from a previous generation to her. Again, her solution in DBT seems to be “radical acceptance” – you just use mindfulness to accept this reality without trying to change anything, and to stay calm.

If she were my patient, I would start to explore the possibility that she actually was doing what her mother seemed to need her to do - in effect acting out her mother’s repressed ambition, so clear in her non-family activities – so mother could experience her success vicariously. And then trying without success to put up with her Mom constantly invalidating it. Meanwhile, sister Aline was acting out the other side of conflict and appeared to be Mom’s favorite. Mom even told Aline to stay away from Marsha. Aline late apologized to Marsha for this but only after Mom had passed away.

When it comes to religion, Marsha’s description of her behavior seems even more conflicted. She was a practicing Roman Catholic throughout her life, and says that her mother “gave” that to her. However, in the book she frequently criticizes the church for such things as its rampant sexism and for the belief of the Pope’s infallibility. She disputes the circular argument heard by many fellow parishioners that God is real because it says so in the Bible. She later started to mix Catholic ideas about God with Zen Buddhist ideas about the ultimate oneness of everything in the universe in ways which are basically incomprehensible.

Further evidence of conflicts over beliefs and how they may have played into her issues regarding marriage: she couldn’t marry the guy who she most loved because he wanted to enter the priesthood. Even though he didn’t and eventually married. She wouldn’t marry her next boyfriend because he was an atheist. Going from one extreme to another and ending up in the same place - single - is a hallmark of an intrapsychic conflict.

Mixed messages from parents conflicted over the role of being parents is in my theory the hallmark of families with BPD members, and this one seems to qualify. Her mother having six children and no apparent career might be evidence for such a conflict. Dr. Linehan was hospitalized with self cutting and suicide threats for over two years just weeks before finishing high school. 

Family Roles: A Form of Method Acting

 

When I was teaching psychotherapy techniques to psychiatry residents and psychology interns, one piece of advice I gave them ran counter to the advice most frequently given by other supervisors. I told them, when doing therapy with patients with personality disorders, to pay more attention to the words that the patient/client verbalizes than to their non-verbal expressions and body language. 

In general, body language is in fact usually more important than what a person says in determining how they really feel or what they really believe. This is true because, biologically, non-verbal communication evolved in our species long before language did, and became a more primal representation of what is going on inside of us.

 

So why do I give trainees the opposite advice? The fact that non-verbal behavior conveys more and more accurate information to another person than verbal behavior is precisely the point. People who have personality disorders are playing roles in their family. In a sense, they are acting! These people have developed a false self or persona that is one of the various roles I have described in prior posts – savior, avenger, go-between, spoiler, defective, loser, monster, covert caretaker, etc. In order to do this most effectively, one has to be a good actor, and therefore hide one’s true self – one’s actual beliefs and feelings which are not part of the act! Because role players have to be convincing, they are purposely giving off the wrong impression with their body language. How do they know to do that? Probably through trial and error.

 

Why do they become such good method actors? The simple explanation is that for them, playing the role as well as possible seems to be nearly a matter of life or death. Not playing the role leads to a form of existential terror called groundlessness. A person nonetheless does have the power to go ahead and exhibit their true selves in spite of this, but in dysfunctional families, doing so is terrifying. One of the things I learned in dealing with spoilers (borderline personality disorder) is that, whenever they feel that what they are doing is not working, that is when they start to self injure (cutting and burning themselves).

So what about their verbal behavior? Shouldn’t that also be misleading for the same reasons? Well yes it is. But there is a peculiarity of language that leads to my second piece of advice to beginning therapists: whenever patients say something that is a little ambiguous – when there is more than one way to interpret it – I tell them to at least think about the less obvious one. This is also the secret to solving the New York Times Sunday crossword puzzle, in which a lot of the clues can be interpreted in a bunch of different ways to throw solvers off.

For example, the mother of a nurse yelled at her, “I can’t believe you talk to doctors that way!” The nurse was far more outspoken than most people in her situation and often surprisingly got away with it. Of course, the nurse interpreted the mother’s remark as a criticism because of her tone of voice. But the words themselves contain no value judgment at all! I think the mother actually admired her daughter for being outspoken because she couldn’t be herself, but could not admit it. 

I also think the nurse knew that because she was in fact acting out successfully in that regard, and the mother was vicariously living through her. The reason the nurse got upset when Mom yelled at her was because the mother was now seemingly upset with her for doing the very thing that the mother seemed to want her to do in the first place. The ambiguity in the words Mom chose can give clues as to what Mom's real feelings are.

Psychotherapists Ignore Powerful Groupthink Forces

 

One thing that is a major theme in this blog is that many if not most therapists seem to think that most people’s problems are “all in their heads” and have nothing to do with the ongoing reinforcement of problematic behaviors through interaction with kin and ethnic group members. Groupthink is clearly one of the most powerful, if not the most powerful psychological force in everyday life. 

 

To see this clearly, think about what is going on in the USA today that is a constant focus in the press, talk shows, podcasts, and other media venues: the polarization of political life. Just look at the almost cult-like behavior on both sides, from the QAnon conspiracy theories on the right to the habitually offended community of social justice warriors on the left. Free speech, supposedly a cornerstone of the United States ethos, is attacked relentlessly by both sides without any irony or sense of awareness of the inherent contradictory nature of some of their viewpoints.

 

Yet so many therapists just ignore groupthink. The only exception is those who believe in family systems therapy, which was big in the 80's and 90's but has since fallen out of favor, particularly with psychologists. The problem with many family systems therapists, however, is the opposite: they seemed to have lost the individual. Although many people do not do it, they  are perfectly capable of employing critical thinking and coming up with their own thoughts, and behaving according to their idiosyncratic desires, if they are brave enough to do so. 

The current state of affairs would be amazing if it weren’t so sad. 

 

When I first started looking for clues about what was really going on in the lives of my patients when they were free associating in the psychoanalytic sense (back then, most psychiatrists still did psychotherapy and were analysts), I began to focus in on such things as logical fallacies. I, like most people, just thought those were common, somewhat accidental errors of thinking. I would start to express confusion about what the patient was actually meaning to say, and eventually happened upon information patients had not before volunteered. This lead me to start asking questions that my psychoanalytic supervisors never taught me to ask, like “what does your mother think about this?” – and I meant in the present, not when the patient was a kid.

 

What I didn’t know then was that the use of logical fallacies is one of the hallmarks of groupthink, so when I questioned them I was really finding a way to get at what they really thought, not what they were supposed to think. As my colleague Gregg Henriques points out, logic evolved not to get to the truth, but to justify group norms.

 

The more I got into it, the more I realized there were a whole lot of other “markers” that told me when I was hearing family groupthink and not the patients’ true thoughts and feelings. The following is a list of them, and there may certainly be other ones:

 

·       Logical fallacies

·       Defense mechanisms (as listed by psychoanalysts)

·       Irrational, self-scaring thoughts (as listed by cognitive therapists)>

·       Willful blindness (the refusal to even look at data which may challenge the group’s “wisdom”).

·       Plot holes (like when you are seeing  a movie and you get the feeling that such characters would never have said something like they did in the script, or that one of characters seems to know something they should have no way of knowing).

·       Ambiguous language (in which a sentence can mean two completely different or even opposite meanings, or a word has several different definitions and I couldn’t be certain which one the patient was using). This phenomenon is very familiar to people who work crossword puzzles.

·       Going off on tangents without returning to a main point or issue.

·       Circular reasoning

·       Spouting proverbs or maxims to justify behavior, such as “the grass is always greener…”  Often a marker for a family myth.

·       Mixed messages such as those exhibited by the infamous, so-called “help-rejecting complainer.”

It is interesting that when I bring up the ideas about group processes at professional meetings or in my books, no one actually disagrees or even argues with me. Instead, they just change the subject - or ignore the issue entirely.