Marsha Linehan, PhD

Last month, Marsha Linehan, PhD, spoke at Baylor College of Medicine, where she was honored for her significant contributions to the mental health field. Her lecture, “Dialectical Behavior Therapy: Where it started. Where it went. Where it may be now. Where we are going,” could have also been the title of her personal narrative. The lecture took place nearly a year after Linehan came out about her own mental illness.

Linehan is well-known for her development of dialectical behavior therapy (DBT) as a modality for chronically suicidal individuals. Treaters soon discovered that the therapy could be expanded to treat other severe and complex disorders, including borderline personality disorder.

In 2011, Linehan spoke about her own struggle with mental illness at the very facility where she was first treated as a teenager. At the Institute of Living, a Hartford, CT-based clinic, Linehan entered treatment for her suicidality, self-harm and a diagnosis of schizophrenia. Linehan underwent electroshock treatment, a list of psychiatric medications and psychoanalysis, but nothing seemed to help. She spent a lot of time in one of the clinic’s seclusion rooms. By the time she was released three years later, her prognosis was grim.

None of this was known publicly until last year. Since then, a flurry of media attention has been bestowed on the famous founder of one of the mental health community’s most commonly used treatment modalities. In her April lecture, she spoke about her journey to founding DBT and where it might be headed. There were steps and missteps to manualizing the therapy, but through willing participants and government funding, Linehan found a way of reaching those who could not be reached, those whose prognoses were grim.

Wounded healer

Knowing more of her personal history gives the long process of fine-tuning DBT more of a basis. Yes, Linehan is persistent. She’s committed to helping others. But since coming out about her mental illness, she has also earned the badge of a wounded healer. The concept of a wounded healer hinges on the therapist’s use of self — many mental health clinicians have silently grappled with their own diagnoses and resolved to help others on their journeys.

It is said that the very concept of the wounded healer is derived from Carl Jung, who had a patient struggling with alcoholism. Jung reportedly told the patient that analysis could not help him with his primary concern of substance abuse, and said the patient’s best bet was a religious or spiritual conversion. That patient became one of the founding members of Alcoholics Anonymous, a program designed so that recovered individuals could help others. Years later, Jung acknowledged, “Only the wounded physician heals.”

Challenging the myth

In fact, Linehan said in her Hartford lecture,while she could not be reached in her seclusion room those many decades ago, she “made a vow: When I get out, I’m going to come back and get others out of here.” She joins the ranks of other popular therapists who have come out as wounded healers, including Kay Redfield Jamison, MD, who wrote An Unquiet Mind about her experience with severe bipolar disorder.

Linehan, Jamison and others have attempted to “say no to stigma” by breaking down the myth that mental health clinicians do not suffer from diagnoses, some just as daunting as the ones they deliver to their patients. Each of them had to consider the fact that their level of self-disclosure could affect how they are viewed by colleagues and patients, and yet they each determined it would be relevant and important to show their true selves.

As she finished her recent presentation, Linehan spoke of the significance of being honored for her achievements in the field. She said, “I’m a person who lived with stigma all my life.” From being the wounded to being the healer, Linehan serves as a model for resilience, perseverance and bravery. What would it look like if we all followed her lead?

Occupy Wall Street protests grow.

It has been more than a month since the demonstrations in New York began, and protests have spread to cities across the country. Occupy Wall Street started as a movement about economic inequality in the country, with the demonstrators’ common refrain, “We are the 99 percent,” referring to the gap between the top one percent, who control about 40 percent of the United States’ wealth, and the rest of the population. The movement speaks of themes of unemployment, inadequate health insurance and the quest for a living wage.

The Occupy Wall Street group has seemed to tap into a common frustration and despair among Americans. According to Mental Health America, nearly half of Americans are stressed by finances, and 32 percent of Americans also report employment issues as a source of stress. And as anxiety levels increase, other mental health indicators are impacted, including depression and sleep disturbances.

Lessons to be learned

So what can the movement teach us?

First, it’s important to underscore what the National Alliance on Mental Illness makes clear:

“Mental illnesses can affect persons of any age, race, religion, or income. Mental illnesses are not the result of personal weakness, lack of character or poor upbringing.”

However, according to The Equality Trust (an independent, evidence-based campaign located in the United Kingdom), the bigger the gap between a nation’s rich and poor populations, the greater is the dysfunction in that nation’s society. Utilizing mental health studies culled from the World Health Organization, it appears that different societies have very different levels of mental illness. In some countries only five or 10 percent of the adult population have suffered from any mental illness in the past year, but in the U.S., more than 25 percent have. Mental illness is much more common in more unequal countries, not to mention in richer countries as well.

What the Occupy Wall Street movement serves to teach us, regardless of our stance on the intentions of the group, is that there is power in being part of a group process, and there is power in learning how to speak about our experiences.

Strength in numbers

In a sense, the therapeutic value in announcing something which has been stigmatized, such as your mental illness or lack of wealth, is akin to exposure therapy. As a society not accustomed to sharing privileged information such as our bank account or personal narratives, being a part of a movement which asks you to do just that can be a way to face and control fears that are not often addressed.

Being a part of a group with a shared goal can be a powerful experience. The commonality of the members of the Occupy Wall Street contingent can be seen through the sea of signs announcing their discontent or shared experiences of poverty and disenfranchisement. Similarly, being a part of a group in a mental health setting can bring up feelings of peer support and a greater sense of normalcy. Many people feel as though they are struggling with solitary experience, and it can be cathartic to realize that you are not the only one grappling with a particular issue. Group psychotherapy serves to create a container for people, as they begin to shed their feelings of isolation. The same could be said for political rallies and movements.

Perhaps one of the reasons why the Occupy Wall Street movement has continued is that people no longer feel so alone. Members of the movement have seen a unity that bonds them together. Might the same be said for people fighting the stigma of mental health?

More and more, people are clamoring to speak up about their struggles with poverty and the inextricable links to depression and anxiety. The shame of sharing continues to be alleviated, as evidenced by the growing movement. Even if you are not marching in the streets yourself, it’s hard to deny the importance of bearing witness to people finding freedom in speaking their truth.

October 11 is National Coming Out Day

October 11 is National Coming Out Day for people who identify as lesbian, gay, bisexual or transgender (LGBT).

This day is set aside to acknowledge the triumph and bravery of those who have come out as LGBT to themselves and their loved ones. Coming out is a never-ending process, not limited to a singular event or moment in a person’s life. Coming out can be an exhilarating and transformative process in the lives of LGBT individuals, but it can also be a source of frustration and loneliness as they attempt to explain their identity to the rest of the world.

The LGBT community frequently confronts prejudice and discrimination based on their sexual orientation or gender identity. This can lead to negative mental health outcomes, such as depression, anxiety and substance use. In some cases, it can lead to death, as evidenced by the startling number of youth who have suicided after facing anti-gay bullying from their peers. LGBT people are more vulnerable to feeling alone, unheard and ridiculed due to the societal stigma unfairly placed upon them.

Likewise, people who have mental health issues often encounter similar feelings of isolation and hopelessness. So for members of the LGBT community who also grapple with mental illness, a double stigma occurs.

According to the National Alliance on Mental Illness (NAMI),

“Some people report having to hide their sexual orientation from those in the mental health system for fear of being ridiculed, rejected or in extreme cases, subjected to physical violence.”

The Family Acceptance Project reports that LGBT people are less likely to seek timely treatment in healthcare settings for fear of provider bias and discrimination.

Unfortunately, this chronic stress within the LGBT population is not uncommon.

A 2003 study on the prevalence of mental disorders among LGBT adults found that they are likely to be at higher risk for depression, anxiety and substance use disorders. The likelihood that LGBT individuals have a mental health disorder doubles when compared to heterosexual men and women.

Yet another study found that lesbian and bisexual women were more than three times likely to have experienced generalized anxiety disorder within the previous year. Gay and bisexual men were more likely to report major depression and panic disorder.

The mental health profession has come a long way, but we have a long way to go.

Up until 1973, the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the DSM, listed homosexuality as a pathological psychiatric condition. But then, in the 1973 manual, the American Psychiatric Association changed the definition of sexual deviance and further rejected the notion that homosexuality was a mental disorder. A fascinating insider’s look at how this took place can be heard on NPR’s This American Life.

Since then, the DSM has gradually shifted its thinking on homosexuality. When homosexuality was removed from the manual, a new diagnosis, sexual orientation disturbance, was added to describe persons attracted to members of the same sex “who are either disturbed by, in conflict with or wish to change their sexual orientation.” In the fourth and most recent edition of the DSM, there is no reference to homosexuality as a mental disorder.

In the transgender community, the diagnosis of gender identity disorder is often needed in order to get medical services to transition from one gender to another. There is a growing movement that contests the classification of transgendered individuals as “disordered,” and a proposed change to the DSM-V, which will be published in 2013, would create a new category of gender dysphoria instead. While it’s still a contentious issue, many people in the transgender movement acknowledge that retaining a diagnosis in the DSM will make it easier to have mental health services covered by insurance.

So what can mental health professionals do to decrease the double stigma?

In order to provide competent care, it is crucial for healthcare professionals to ensure that the LGBT population can feel comfortable disclosing their sexual orientation or gender identity. Mental health agencies can establish cultural competency models that underscore the acceptance of and respect for the LGBT population. Acknowledge where changes can be made and work within the system to address those issues.

Mental health professionals can educate themselves on proper terminology and common concerns of their LGBT patients; families and friends can do the same. Don’t assume that an individual is a particular gender or sexual orientation because of how they dress or what types of previous romantic relationships they’ve been in. Recognize that being part of the LGBT community comes with its own stressors and be sure to empathize and validate those experiences – use your mentalizing skills! Honor their triumphs and joys. Sit with their sadness, as you would with any other patient.

Just as we make it a priority to establish a therapeutic alliance with patients, we should strive to provide an open and affirming place from the moment a potential patient enters our care. LGBT patients should feel safe to disclose their feelings about their sexuality and gender identity. If they don’t feel supported, they may not be able to fully engage in the treatment process. If an LGBT individual feels comfortable disclosing with mental health professionals, they’re more likely to share their experiences with their peers.

Cultural competency is a learnable skill. Let’s take it upon ourselves to make sure that all patients are welcomed and affirmed!