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If Lily had a hard time figuring out what was behind such dark emotions, she was in good company. When a psychoanalyst named Adolph Stern coined the term borderline in the 1930s, borderline patients were said to be those between Freud's two big clusters: psychosis and neurosis. Borderlines, Stern wrote rather poetically, exhibit "psychic bleeding — paralysis in the face of crises." Later, in the 1940s, Dr. Helene Deutsch said borderlines experience "inner emptiness, which the patient seeks to remedy by attaching himself or herself to one after another social or religious group." By 1968, when Basic Books published the groundbreaking monograph The Borderline Syndrome, the No. 1 characteristic of borderline patients was said to be, simply, anger.
Eventually, borderlines became pretty much anything a therapist said they were. Says Dr. Kenneth Duckworth, medical director of the National Alliance on Mental Illness: "If you hated the patient — if the patient was pissing you off — you would bandy this term about: 'Oh, you're just a borderline.' It was a diagnosis that was a wastebasket of hostility."
It was Linehan who changed all that. In the early 1990s, she became the first researcher to conduct a randomized study on the treatment of borderline personality disorder. The trial — which showed that a treatment she created called "dialectical behavior therapy" significantly reduced borderlines' tendency to hurt themselves as well as the number of days they spent as inpatients — astonished a field that had come to see borderlines as hopeless.
Dialectical behavior therapy is so named because at its heart lies the requirement that both patients and therapists find synthesis in various contradictions, or dialectics. For instance, therapists must accept patients just as they are (angry, confrontational, hurting) within the context of trying to teach them how to change. Patients must end the borderline propensity for black-and-white thinking, while realizing that some behaviors are right and some are simply wrong. "The patient's first dilemma," Linehan wrote in her 558-page masterwork, 1993's Cognitive-Behavioral Treatment of Borderline Personality Disorder, "has to do with whom to blame for her predicament. Is she evil, the cause of her own troubles? Or, are other people in the environment or fate to blame? ... Is the patient really vulnerable and unable to control her own behavior ...? Or is she bad, able to control her reactions but unwilling to do so ...? What the borderline individual seems unable to do is to hold both of these contradictory positions in mind."
Linehan's achievement was to realize that borderlines are, in fact, on the border between various dualities — dualities that they have to learn to accept and reconcile in order to change their lives. That's easy to say but seems impossible to do — until you see it work.
A Life Redeemed
After she cut herself, Lily was horrified. In a panic, she called her father, who took her to the hospital. When she was released, she and her parents redoubled their efforts to find her good psychiatric treatment. Through a friend at the University of Washington, they heard about Linehan and contacted her Behavioral Research & Therapy Clinics, which are housed in a homey little annex on the UW campus, where you might find little foil-wrapped chocolates next to the coffee and tea.