For this article I’ve interviewed Lewis Mehl-Madrona, a psychiatrist from Maine with 40 years’ experience in psychiatric hospital and outpatient psychotherapy settings. Lewis is a practicing psychiatrist and healer with his own website, his own personal blog, and his own online articles.
Lewis and I did a phone interview which I have transcribed below. Here are some highlights of Lewis’ thinking:
On BPD as an identity: “What the label BPD is is a story or identity that people are encouraged to take on. And it’s not necessarily a story that’s conducive to feeling well or being well…”
On DBT and its founder: “Marsha Linehan would say people get better, hope, you can feel better, you can do these things and you will feel better.”
On BPD as a lifelong illness: “I think it’s really insane to say that the label (BPD) is lifelong… I mean how do you know that?… It’s not even logical. It’s a pretty cruel world we live in where we make people incurable – is it so we don’t have to work hard to understand them?”
On Recovery: “(In response to my question about can people labeled BPD truly get well)… Oh absolutely, absolutely. And you know I think that it’s the same work whatever your label is.”
On the role of medication: “I think the role for medication in our society has become a replacement for community… The medications don’t produce lasting change… no real solutions take place.”
On writing your own story: “The science behind BPD is not good at all… I always remind people that the DSM is mostly created by white males over 50 years old sitting in hotel rooms around the beltway of Washington DC. These may not be the people you want to write your story… The story you create might be a lot more interesting.”
For more context, read on to the full transcript. Please note that Lewis’ views are his own, and his interview appearing on my site does not imply that he agrees with or endorses my positions. With that said, here’s the interview:
Edward: Lewis, thank you so much for making time to speak to me. I found you through the International Society for Psychological and Social Approaches to Psychosis (www.isps.org), and you know that I run a website dedicated to challenging the medical model of Borderline Personality Disorder and promoting a recovery model. I’m going to ask you some questions I’ve put together about the label BPD, and I’d like you to answer however you feel is best, which may or may not mean directly answering the question. First, so that readers can get a sense of where you are coming from, let me start with asking you to describe your professional background, your training, and what you do now:
Lewis: Ok well, I went to med school at Stanford, then did a couple of years of training at the University of Wisconcin, then went off and did a PHD in psychology and a postdoc in neuropsychology, and then I came back and finished my residency training in family medicine in psychiatry at the University of Vermont. Then I did some extra time to be certified in geriatric medicine as well.
Currently I’m teaching family medicine at the University of New England in Maine, so I’m one of their faculty, and I also do the psychiatry consulting service at Eastern Maine medical center [Lewis has worked on psychiatric wards]. And then I have my evening and weekend life as a person who dabbles in the healing arts. What that means is doing healing work with people – because I’m native American, it’s kind of a native American flavor, I try to help people using that background. I grew up with my grandparents who were part of the Indian culture.
For many years I’ve also had a psychotherapy practice, more so earlier in my career; I don’t do much outside therapy at this point. I’ve always done a combination of different medicines, psychiatry, psychotherapy, other healing arts.
I’ve worked in medicine for 40 years, starting in 1975. Actually earlier, 1973. I started doing psychotherapy in training in 1973.
Edward: Ok thank you; I can see you’ve had a lot of experience in the psychiatric system. Do you have an idea of how many clients you’ve worked with who were considered “borderline” or who would approximate the DSM label for “Borderline Personality Disorder”?
Lewis: You have to clarify the term “borderline”. When it was first created, borderline was meant to refer to people who were not psychotic, but had severe emotional issues – I can’t remember if it was Otto Kernberg or someone else who coined the term – but it was supposed to mean people who under high stress crossed the border into psychosis but could then cross back. It was people who oscillated between those states.
I don’t remember when it happened, but somehow borderline came to mean people who are incredibly good at getting what they need from systems, like hospital systems. That’s how people are using it now, to refer to manipulative people that we don’t like in the system. I think that’s how the term is commonly used now.
Over the years I’ve seen a lot of people who fall into that category, as labeled by others. And yes I’ve certainly done psychotherapy with quite a few people who were given that label at one time or another.
Edward: Ok, interesting. I guess what I had in mind was more the first description; people who have serious emotional issues, can become psychotic under stress, are prone to splitting, can’t regulate their emotions, and so on. Can you say something more about how you understand the word borderline – how does it describe the functioning, feeling, defenses present in these people?
Lewis: My personal belief is that it’s a fairly useless label. I think people are more individual. Such a label really doesn’t say much about who the person is and what do they need help with. I think by and large all of the DSM labels are like that. For the most part they’re not really based on science of any kind. You can say in general terms things like depressed, anxious, psychotic, etc – maybe give general labels people fit into, with overlaps. But the craziness we have now is just something else.
Personally I don’t find BPD to be a very useful construct. What the label BPD is is a story or identity that people are encouraged to take on. And it’s not necessarily a story that’s conducive to feeling well and being well. So I think that’s the danger of the internet because people can get together and embrace their story about who they are as borderlines. And it makes it harder, if that becomes your identity, to not suffer in that way, or to see that it’s just one way to describe however it is you suffer, and there are other more helpful ways.
Edward: Ok thanks, that’s an interesting idea about how taking on the borderline label becomes a story, a kind of self-fufilling prophecy in a way. I do see that when I read online forums focusing on BPD at Reddit, Psychoforums, Psychcentral. Can you say something now about the causes of “borderline” states – are they mainly psychological, biological, etc? I realize now in asking this that the question may not make sense to you in these terms.
Lewis: I think trauma and isolation are the big things leading to mental health labels – if you’re surrounded by community, you can tolerate a lot more trauma than if you’re alone. And I think that’s been the process of the 20th century; the process was to eliminate community and get everybody alone in little boxes. It’s easier to manipulate people when they’re alone in little boxes; it makes a more malleable work force and prevents unionization and collective bargaining. It prevents people getting supported by each other.
So I think that a lot of what we see now [in terms of mental health and psychiatry] is so different from what we might have seen in the year 1900. People in general are so much more isolated now than in 1900 or 1800, and so it’s harder to build resiliency or regulate your moods when you’re always or mostly by yourself, and I think it’s crazy. For example the two parent child-rearing approach is insane; who ever thought that up was completely crazy. Healthy cultures have cross fostering, cross mothering, multiple mother figures at any given point, the idea of the whole village taking care of the children.
So I think some of this is political. And I relate these processes of isolation to more people getting these mental illness labels. I think more people are getting labeled everything, because there’s less social support and thus less resiliency. And some people of course have been severely traumatized in this isolation. When you’re isolated you don’t have anyone to go to to get nurturing, to help you feel better and regulate your mood…. almost everyone I see has trouble regulating mood, and are isolated, and the really amazing thing in the settings I work in [in psychiatric hospitals] is how little some of them are willing to do about it.
Often people come in and they want a drug to make them regulated and feeling happy, and that drug doesn’t exist; it’s not going to happen. I don’t know when we made that transition, I think it was probably in the 80s, when I was in training we used medication to make unbearable affects bearable so you can work with the feelings.
But as a a profession now we’ve trained people to think you should just take a pill and feel fine, and if it doesn’t work try another one and then everything will be great. And that embarks on the perpetual search for the right pill, which is a never ending story. I don’t meet many people who have found the right pill.
Edward: Ok, thank you and of course I agree with these ideas about medication. Now let me ask you about the way other therapists use the label borderline. Many therapists, including probably some you’ve heard, use the label borderline in a pejorative way to refer to people they consider difficult or unlikely to get better. Did you ever feel that way?
Lewis: Since I didn’t believe in the label borderline I wouldn’t have ever talked that way. It’s interesting because I’ve always given my cell phone to everyone I work with, which therapists who believe in the label BPD would say is insane, but I’ve never had anybody abuse that. The issues they have with clients; it seems it’s a side effect of a certain kind of power relation and not intrinsic to people, so I always give my phone to people and say if you’re in crisis I want to hear from you; it’s our goal to keep you out of hospital so I want to hear from you early. So my approach is probably a different approach than the people who roll their eyes and label people borderline.
Edward: Ok that makes sense. Let me jump in now and ask about therapists or psychiatrists who say that BPD is a lifelong mental illness and something that cannot be cured. Do you agree with that?
Lewis: I’ve definitely heard that more than I’d like to believe, and I think it’s really insane to say that some label is lifelong… I mean how do you know that, you’d have to be at the end of someone’s life to know that, it’s not even logical. It’s a pretty cruel world we live in where we make people incurable – is it so we don’t have to work hard to understand them? At least there’s people like Marsha Linehan who don’t believe that. I think she’s interesting since she began as a service user and did her own healing which is mostly Buddhism.
If you think about DBT it’s almost entirely basic Buddhism. She did her own healing and then she came up with a therapy that matched her own suffering. But really DBT works for everything because it’s basic Buddhism and Buddhism works for everything. But she would says people get better, that’s her whole message, hope, you can feel better, you can do these things and you will feel better. So there are people like her who don’t believe in the inevitability of perpetual life long suffering. Of course I certainly don’t believe that.
Edward: Ok yes I agree with your ideas against the idea of a lifelong BPD illness being bogus; this is a large part of what my website is about. Can you speak now a little bit about what sort of results you’ve had in working with these people – I guess now I’ll call them people who’ve been seriously traumatized and isolated, rather than “borderlines”, since it seems like you don’t think that way. Have you had good results with these people in terms of their feeling better, having satisfying relationships, working in jobs they like, and so on?
Lewis: Oh absolutely, absolutely. And you know I think that it’s the same work whatever your label is, I mean, What do we all need to learn how to do? – we all need to learn how to connect with other people because we all need others, we all need to learn how to regulate our moods and each other’s moods, we all need to learn to manage our suffering, and to a large extent most of us need to learn to eat better, to exercise, to do things that are good for us like yoga, tai chi and chi gong. We all need to live a healthier lifestyle, that involves meaning and purpose, having good relationships with others, and to the extent you can move in that direction, no matter what mental illness label you’ve managed to earn, you’re going to suffer less and feel better.
And so I think the work that I do is more experientially narrative. I’m trying to get at people’s stories about why they are the way they are, and then to look for ways in which that story could be altered so they can live differently. And I use a lot of what of what you could call DBT or a Buddhist approach or some of it is native American ideas. One of the profoundest things that Marsha Linehan pointed out is that life isn’t fair, and you have to live anyway, radical acceptance. Thomas Merton said things are sometimes not ok, and we may not be able to change them, but because it’s the right thing to do we need to try to change them whether it works or not. Part of recovery is also making an effort to be helpful to other people, and/or to change the political environment we’re embedded in.
Edward: Ok. So with the people you work with who get better, what are the most important things that help them to get better? I guess you’ve aleady talked about a lot of them – community, close connections to other people, living a healthy lifestyle, and so on?
Lewis: All the things I mentioned above; by and large that’s what we all have to do regardless of whether or not we’ve managed to achieve labelhood [i.e. been labeled BPD or some other DSM label]. We all need to cultivate community and find each other and build social networks that are nurturing and healing. We need to feel like what we’re doing is meaningful, that we’re creating value with the lives that we’re living. And we need to take good care of ourselves physically, exercise, diet, all those good things. Regardless of the label someone’s given you, it’s pretty much the same, what you need to do to get better.
Although we may have a different story to explain how we got to where we are. That’s the unique thing about doing therapy, no one’s story about how they got to where they are is the same. Each person has a wonderful story that needs to be cultivated and appreciated, and if it’s not satisfying hopefully changed to get to a more well story.
Edward: Ok, I like that description of changing one’s story. It’s so different than the DSM idea of managing symptoms of an illness. Can you discuss psychiatric drugs now – As a psychiatrist, how much do you use them with people, and are they more helpful or harmful, generally speaking?
Lewis: I use them as little as possible, and I think the role for medication in our society has become a replacement for community. If you have enough people around you, you have incredible support and you don’t need so much medication. If you’re isolated and by yourself, then medication stabilizes you whereas otherwise community would. So I tend to use the least possible medication to keep people out of hospital. Because I know if they get into hospital that they’re typically going to be given much more medication than they need. I think medication does allow some people to stay out of hospital; I don’t think it’s a good long-term solution.
The biology is clear that the brain receptors, over the course of a year or so on medication, tend to move back to where they were when they started the medication. The medications don’t produce lasting change, they just make it harder to get off the medication; you have to keep increasing or changing the medication to get an effect. The external world is a much more powerful shaper of the brain than any pill that you can take. If you haven’t changed your external world, and you come off medications, then you’re going to fall back to the same neurophysiological state you were in when you started the medication. This can become a vicious circle. The meds have to be increased, and switched, and so on; no real solutions take place.
Edward: Ok, thanks and I totally agree with this view on medication. I would add that taking medication strengthens the false narrative and identification that a person “has” a certain mental illness label that needs to be treated by taking that medication. Can you say something now about how working with more difficult people – people who might more often be labeled borderline – how is it different than working with less traumatized people? Does working with very traumatized people help you to work more effectively less difficult people?
Lewis: I think so… I don’t know that the level of trouble has much to do with the difficulty of the work. I think that sometimes people who are deeply suffering can be easier to work with than people who are suffering a little. Because if they [the deeply traumatized people] just do anything different they feel so much better and it can be incredibly motivating for them. I just personally enjoy getting to hear people’s stories. And figuring out how they might have a little less friction in their self-to-world interface. Some of the worlds that people visit are incredible, and to some degree we have to be grateful to people who are visibly suffering because they’re the canaries in the social mine shaft; they’re showing us we’re all unhealthy but for some reason they’ve visibly taken it on for us. Because of that I think we have an obligation, those of us who are feeling more well, whatever that means, to help people who are feeling less well, to suffer less.
To me the label BPD and other similar labels is sort of like a cultural story that’s been created for people to put on. It’s kind of like clothing that you wear and everybody’s encouraged to put on this same kind of clothing and behave in this kind of way. It’s almost like a prescription for the label BPD, like here, “Be this way, be a borderline”. I think it’s really unfortunate because people think BPD means something inevitable or they think that it’s true because some authorities say that it’s true.
But the science behind BPD is not good at all. Even the director of the NIMH Thomas Insel, who’s as hardcore a biological psychiatrist as they come, he said the DSM 5 is not acceptable as a diagnostic tool just because it’s so divorced from science. I always remind people that the DSM is mostly created by white males over 50 years old sitting in hotel rooms around the beltway of Washington DC. They may not be the people you want to write your story. You may want to find your own story about your suffering and your strengths. Their stories aren’t very strength based. The story you create might be a lot more interesting.
Edward: Ok, thank you. I like the last part there about the old psychiatrists and writing your own story. The idea of clothing people are encouraged to take on is interesting; I hadn’t thought about it in exactly that way. Ok, next questions, what are some books and experts you find useful in the mental health field? I was going to ask this question about BPD specifically, but given your earlier answers I’ll make it more general.
Lewis: Well of course everyone should read Mad In America [by Robert Whitaker], just because it’s so amazing. But in terms of books about therapy I like Marsha Linehan’s work, she comes across as amazingly compassionate and practical.
I also like Narrative CBT of Psychosis by Jakes and Rhodes; they’re very funny – they say “now that you opened the book, you can forget we put CBT on the cover, we only put it on there because the establishment requires us to put it on there.” And the the way they work with people is completely different.
I love everything RD Liang wrote, I suppose that dates me. I like the narrative work of Michael Wyatt. I like the guys in Finland, the Open Dialogue guys, Juuka Altonen, Jaako Seikkula, I can’t pronounce most of their names, but they’re pretty cool.
Those are the people that I try to have trainees read. I have trainees read Whitaker, John Weir Perry, RD Liang, Jakes and Rhodes. I like to share my own books of course.
Edward: Ok. I didn’t know you had written a lot. What have you written about?
I have a book called Coyote Medicine. It’s an autobiographical story of being an Indian in mainstrream medicine and how crazy it can feel at times. Kind of a cross cultural work .Then there’s Coyote Miracles, about people who have miracles, people who work with traditional healers. Then there’s Coyote Healing, also about working with healers. Then there’s Healing the Mind through the Power of Story – The Promise of Narrative Psychiatry which is a newer book.
And my latest book with Barbara Mainguy is Remapping the Mind, The Neuroscience of Self-Transformation. The word borderline is not in that book! We don’t like diagnoses. It’s better to get the experience, to get people to tell you what their experience is, than to use a label. It’s gotten harder to get people to tell you their experience. People come in to a therapy session and say, “I’ve been manic this week”, and I say, “Ok what does that mean? Tell me what happened?” There’s not a lot of use of the labels in any of my books.
Edward: Ok thanks, some good references there. I didn’t know you’d done all this writing. I’ll have to check it out. Now my last question, which you’ve kind of already answered: Is borderline or BPD a useful or accurate word to describe people? Would you replace it with something else?
Lewis: I would get rid of it. I think that it’s great to help people overthrow their label. If I ran the world, I would just say that some people are more well than others. And those who are more well should help those that are less well. And leave it at that.
Edward: Ok thanks again Lewis. I’m really glad you made time for this. Since you’re an ISPS member, I was pretty sure you wouldn’t answer the questions in the diagnosis-based way I asked them. And that’s great. Because I want to show people that many professionals out there don’t think BPD is a useful word and that there are other more hopeful ways of conceptualizing our suffering. And in the way you’ve answered my questions you’ve shown that approach. It’s particularly interesting because you’re a psychiatrist working across mental hospital and outpatient psychotherapy settings, and you still think the way you do. So thanks again for your time.
Lewis: My pleasure. Take care.
For more information about Lewis Mehl-Madrona, please see:
Lewis’ Personal Website
Lewis’ Personal Blog
Lewis’ Articles on Future Health
Lewis’ Books on Amazon
Lewis’ Professional Resume
[Note: Lewis knows me me under my real name, which is not Edward (see the “About” page). He consented to have the interview appear here, understanding that I disguise my identity because I prefer my employer not to know about my history in the mental health system.)