I became aware during college that I was drawn to remoteness amidst gatherings of people, and self-imposed deprivation amidst plenty. So it was not as unusual as it may sound that for nearly a week during one Thanksgiving break I confined myself alone to the depths of the university’s catacomb-like biological laboratories, where almost the only living things were in crates, cages, jars, bowls, and Petri dishes. As if camping, I arrived with food, drink, a sleeping bag, my guitar, my diary, and a book to read if I needed a break from my singular focus, a research project for a biology class. Though I hardly knew it at the time, the motivations to spend my first ever Thanksgiving alone were as much personal as academic. I was studying interdependency, connection, and communication within a biological system, while personally, I was on retreat from other humans, communicating with no one.

I wanted to answer a question. How can all of the two billion separate heart muscle cells of the human heart, each one having the inherent capacity to “beat” at its own pace, beat together, like members of a synchronized swim team swimming together, unerringly, from birth to death? Each cell has its own complex inner world, with its own complete set of DNA and multiple magnificent molecular machines contained within a sophisticated semi-permeable membrane, allowing just the right things to pass through from outside to inside and from inside to outside. How could so many separate cellular beings beat as one, propelling blood throughout the body, sustaining life? How did each one know when to beat? If they didn’t beat together it would be fatal.

A specialized collection of cells at the top of the right atrium, known as the sinus node (SN) or the sino-atrial node (SAN), functions like the coxswain of a crew boat in a race, setting the pace for all muscle cells to beat as one. Delicately reflecting the range of bodily needs coming to it from sympathetic and parasympathetic nervous systems, from hormones and other chemical influences, these nodal cells have the capacity to initiate an “action potential” forty to one hundred times per minute, which spreads like an electrical impulse coursing along electrical wires, across specialized conducting channels in the wall of the atrial chambers. Within a fraction of a second, that action potential arrives at a second specialized cell collection, the atrial-ventricular (AV) node, which serves as a “relay station” sending the impulse along similar conducting channels in the walls of the ventricles. Such is the “electrical” conducting system in the heart.

The mechanism for sending an action impulse from cell to cell along a pathway is not dissimilar from the way action potentials pass from one neuron to the next, and is therefore not that puzzling. An action potential results from an asymmetrical distribution of positive and negative ions (small molecules with either positive or negative charges) across a cell membrane, which creates a very small but measurable electromagnetic charge. In a process known as depolarization, the membrane of that cell suddenly allows ions to pass through. The ions rush in directions, through the membrane, that equalizes the charge between inside and outside the cell. The changes external to the cell membrane immediately impacts the membrane of the next cell, leading to depolarization of that one. Very rapidly, a wave of depolarization takes place from cell to cell along the specialized conducting channels.

Much more puzzling, at least back in 1969 when I was doing the project, was that the impulses not only traveled down these channels, but also spread like a wave across the entire heart muscle. While the vast majority of heart muscle cells were not adjacent to the specialized conducting channels, still they would beat in synch with all other cells, at the pace set by the sinus node. When the membrane of a cell depolarized, the flow of ions would change the internal milieu of the cell, causing the cell to “contract” through changes in the micro-tubular skeleton of the cell. But how could each cell know when to beat? How did the message get communicated across the heart so quickly, allowing so many to act as one? Could I find structures within the cell membranes that would facilitate such a wave? That was my question.

For those six days the only human I saw was a security officer who walked the halls once in the morning and once at night. He was aware of me, and we never spoke. I was alone with some live frog embryos that had been left for me by my professor. My strategic plan, while I knew it would be technically challenging, was clear to me. What I did not expect was the sense of foreboding that gripped me at different times of day and night. I felt as if something bad were about to happen. I tried to ward off the unnamed demons by talking out loud, singing to myself, taking brief walks down the hallways, soothing myself: “Charlie, don’t worry, there is nothing weird going on here, it’s just your imagination.” I couldn’t eliminate the sense that it was spooky to spend days and nights without human contact amidst long dark corridors, watched over by collections of dead and live biological specimens. I began to dissect the frogs that were left for me. When I separated the hearts from the brains, the hearts continued to beat. When I severed connections to the rest of the body, still the beats continued. The hearts had lives of their own, living in life-sustaining soups in Petri dishes, pumping away even though divorced from anything to pump.

With a scalpel, next I cut each heart into small pieces of heart tissue, each piece still beating but not necessarily at the same pace as other pieces. Then I cut each piece into smaller pieces. Still they kept beating, the way that members of an orchestra separated from the whole might reassemble themselves to play in quartets and trios. As I cut the pieces smaller and smaller, inevitably a point would come when the beating would stop; the heart cells would stop. At some moment, impossible to determine exactly when, the music would end, life would stop, as a result of my cutting. My technical challenge was to cut the hearts into clusters of cells that were as small as possible but still beating. When I was spooked, I felt eerily as if I were playing God with frog embryo hearts, that it was wrong to do so, and that there would be consequences.

This went on for about three days, perhaps longer, I can’t tell. Every step forward followed dozens of missteps in a process of trial and error. My patience and tolerance were seriously tested. After innumerable trials, I was able to predict at what point in cutting the tissue into smaller and smaller pieces, the cells would stop beating. I learned to stop cutting just this side of the life-and-death line, and then count the number of cells remaining in the cluster, using a microscope. Finally I isolated several tissue clusters with fewer than 25 cells each, maintaining their beats. I was glad to have arrived at the end of the technical challenge by then, since my irrational mind had again fallen prey to dark and eerie forces. For instance, a few times, after cutting and cutting, I pictured pieces of tissue, clusters of dead cells, all emerging from the carnage, joining together, zombie cell clusters attacking me from all sides. I deliberately interrupted the troubling images, shining the light of reality on them. But I couldn’t deny that paranoia had crept in. It troubled me to think that if the dead cell clusters smothered me to death, no one would ever know what happened.

I bathed the tiniest still-beating clusters in liquid nitrogen, freezing them instantaneously, stopping all cellular activity while preserving cellular structure and membrane integrity to the degree possible. Finally I had several frozen clusters. In the next step, known as freeze fracturing, which would have to wait until school was back in session, I would gently but firmly strike the frozen clusters with a small tool called a microtome, causing the frozen clusters to fracture. Done correctly, the fractures would occur along predictable plane, between cell membranes, so that on one side I would find the outer surfaces of some cell membranes, and on the other side the outer surfaces of cell membranes that had been adjacent to the first ones. As I ended my most bizarre Thanksgiving ever, I emerged from the long dark hallways back into the light, clutching my precious frozen tissue samples. I was glad to leave the dark dream-like world in which tiny heart cells were superior beings capable of extraordinary capacities, that I was a Godzilla playing with their lives, and that in the interest of scientific technique I was destroying their communities.

As school resumed, I took my treasure to the medical school, where with the help of a professor and a technician, I freeze fractured the clusters into smaller clusters. As hoped, the samples fractured along the planes of the cell membranes. We could view the outer surfaces of the membranes under the extraordinary power of the electron microscope, which appeared like the surface of the moon, with bumps and valleys, clumps and tiny structures. We could look at the cell membranes of two adjacent cells, which had been juxtaposed, and we could see where the configurations on one cell membrane matched up with corresponding ones on another membrane. It was amazing, and we recognized that the among the structures on the membranes were a multitude of well-defined tiny holes, large enough to allow small molecules to pass through but small enough to block larger molecules or organelles from leaving or entering the cell. These holes turned out to be gap junctions discovered in research in that era, well constructed channels that linked the inside of one cell to the inside of another, the perfect candidates for structures that could allow small ions (e.g., potassium, calcium, and sodium) to pass through with almost no resistance, depolarizing the cell membranes, which could cause the cell to contract.

Suddenly a new concept took hold in my mind. If the wave of depolarization could happen within the same second across the entire heart, opening up all gap junctions of all heart muscle cell membranes almost simultaneously, allowing the flow of ions all nearly at the same time, all driven by the beat of the sinus node, it was imaginable to have two billion cells act in synch. In fact, the two billion independent cells, by opening the windows between them throughout the heart all at the same time, would functionally convert two billion small independent chambers into one big cooperative one. The contractile potential of all two billion could be activated at (nearly) the same time.

It’s been almost fifty years. The memory of those days remains vivid: the excitement of the investigation; the challenge of isolating a “living” cluster of cells; the thrill of succeeding; and the paranoid halo that came and went. But the most lasting legacy of this project for me is my respect, even love, for the miraculous lives of cells. A cell membrane surrounds, protects, and supports the complex inner world of the cell: a world with dozens of complex structures perfectly adapted to carry out dozens upon dozens of activities; hundreds, perhaps thousands, of different types of molecules, always moving, always transforming, and playing their parts in the intricate cellular world; and processes of energy production, genetic transcription, protein construction, waste removal, nutrient ingestion, and more. To think that something so small could be so complex and so beautifully organized for the ultimate purpose, the heartbeat that sustains us, is incredible. And that cell, each of those cells, lives in a huge neighborhood of cells, crowding each other like apartments in a giant apartment building.
Molecules flow between and among the cells through a variety of specially constructed openings, through both active and passive transport in both directions.

The life of a cell carries lessons. 1) This is a living entity that has a clearly defined purpose, which justifies the multitude of operations going on inside and around it. It all makes sense, far more so than often seems to be the case with our lives. The suggestion, as I see it, is that regardless of the nature of my current purpose, I am functioning at my best when I am attuned to processes around and beyond me, finding my purposes there. 2) The cell is so busy, and conducts it all with such amazing balance. What is taken in must be balanced with what is put out. What is consumed by the constant activity of the cell has to be replaced by nutrients and oxygen. The cell lives with rhythms balancing activity and rest, energy output with recovery and replenishment, attending to the inner life while maintaining awareness and responsiveness to the outer world. 3) As I see it, the cell is a model of willingness to do just what is needed, humility in playing a small part in a large world, and model of sustainability in constantly recycling just the right amounts and types of matter and energy to stay alive and fresh. If I am adrift or preoccupied, I can sometimes think about the life of a cell, which moves me toward purpose, willingness, humility, balance, rhythm, flow, and the kind of sustainability that comes from maintaining my inner self and the world around me with which I am interdependent.

Perhaps the deepest lesson I take from the life of a cell is the capacity to be both independent and interdependent. The cell, as a distinct entity boundaried by a cell membrane, is made up entirely of elements that come from outside itself. Even the central “identity” of the cell, as stored in the DNA in the nucleus, is the same DNA double helix to be found in all other cells. In this respect, the cell has no uniqueness, no true separateness, any more than one wave in the ocean is separate from all other waves. The cell is entirely a recycling operation, carrying out its assigned purpose. Similarly, the concept that there is a boundary around the cell turns out to be an illusion. There is a semi-permeable membrane, made up of elements that are constantly turning over, and that allow things to move in and out so that the heart cells, the two billion of them, can act as one. In one sense there are two billion cells; in another sense, there is one. When I personally allow myself to see that I am made up entirely of circulating stuff from the rest of the universe and that there is no unique Charlie Swenson substance inside, that I represent a constant recycling operation, and that there is no true boundary around me–I am in constant exchange with the world around me to a degree far beyond my usual notions, I try to relax into this level of truth. I feel more relaxed, more joined with what is around me, and energized. It automatically creates in me a greater sense of synchrony and responsibility with and for the rest of the world. I can never accomplish this to the degree that a cell can do it without even trying, but I still find it helpful to have a hero to look up to.

In 1980, when I visited China with a group of twenty-five other Americans, before the modernization of that country, I remember waking up early in my hotel in Beijing. Looking out the window, at about 6:15 a.m., I saw hundreds of people gathered in a large open space. They were practicing the ancient art of Tai Chi, and they were silently moving in complete synchrony with one another. Hundreds became thousands as individuals and families from every generation arrived, joining in the same movements and with the same rhythm. Each person was like a heart muscle cell, separate and complicated. Without missing a beat and without hesitation they synchronized with each other, creating something much larger and more powerful than any one of them. At 7:00 a.m., a horn sounded in the city, and within seconds they all were on their way, most on bicycles, others on foot.

It can be reassuring to realize that each of us is breathing in, breathing out; opening up, closing down; eating, fasting; sleeping, then being awake; acting in harmony, acting in conflict; joining, then separating; and that this rhythm is what life is. And that to the degree that we can synchronize our rhythms, and the opening and closing of our personal “gap junctions,” we can join with each other to do amazing things that we cannot do alone.

His Holiness the Dalai Lama gave a public lecture in our little town, Northampton, Massachusetts. When he invited questions from the audience, he was asked if he had any advice for raising children.

“Raise children? Me? I’m afraid I have no experience.”

He laughed his sweet Dalai Lama laugh at the thought of being considered an expert on raising children, reminding the audience of his celibacy vows.

“Maybe I will go away from here and have children and raise them so that I can answer your question.”

He went on after a pause:

“But I do know something about raising children, because I was a child and I was raised by my parents. And I learned that the most important thing is to love the child no matter what. The child needs to feel loved.”

We might expand on this to say that everyone needs love.

But what do we do if the love in our family, or in the families with which we work as therapists, has for all practical purposes been extinguished, replaced by acrimony, disengagement, mutual disrespect and invalidation? Given how important it is, how do we access or catalyze love among them? We can think of it as the glue that holds things together through thick and thin. Without it things deteriorate, things fly apart, things can become quite ugly. I once worked with a single father and his two sons, ages 13 and 15. During the previous year, the mother had died at the end of a prolonged illness. The father wanted to have family therapy to address the level of tension and conflict among the three of them. Both boys had essentially retreated since their mother died, staying in their rooms, playing videogames, using social media to stay in touch with friends, decisively objecting to any efforts the father made to engage with them or to bring them together with each other. The only way the father got them to family therapy was through blackmail—he threatened to stop giving the rides to their friends’ houses if they refused, not a great way to begin but from his point of view, the only way.

In sessions the boys were silent to the extreme, resisting my efforts to converse with them, attacking the father if he tried to get them to talk. The only words they uttered at the start were in response to something the father said, in which case they would attack his credibility and intentions.

“He acts that way here, but if you saw him at home all you would see is that he yells at us, and goes out to meet girl friends. He doesn’t care about us!”

If one of the boys were to paint himself in a positive light the other one would accuse him of being a liar, or worse than that a goody-goody. Mutual invalidation was the default position, and invalidation flew in every direction including at me. If I validated any one of them, one or both of the others would invalidate my validation. It was bleak.

I met individually with each of them to establish some rapport and to get some history. The picture that emerged was of a family in which there was a good deal of love, affection, activity, laughter, and mutual engagement, all of which died as the mother became terribly sick, until her death. She had been the connector in the center between the three males, and now the connection was gone. The father was searching for a way to rekindle the connections and the love among them. His failures in doing were burning him out, which showed in his frustration toward the boys.

Within my family of origin I had three brothers and a sister. I had personal experiences with the male-male connection, and a lot of pained feeling about it. And my wife and I had two sons and no daughters. In our family, disconnection between the boys, and between the boys and myself, often caused me distress. So the distance, the hurt, and the disappointment among the males in this family in therapy, obscured by acrimony and accusations, was painful to see. Any effort to define and solve a problem was immediately shot down. Any hint of validation, in any direction, was immediately shot down. What was left was tension, heartache, and paralysis. To say that I felt ineffective would be the understatement of the century. In my heart of hearts I was hoping they would quit, as the sessions evoked such hopelessness, helplessness, and eventually irritation in me. In my individual meeting with each of them, I found them to be courteous, interesting, willing to reflect life past, present, and future, and able to accept validation and support. But it all vanished in the group context. It was clear to me that there was hunger for normal exchanges, desires to be understood, but not manifest in the family sessions. Still I could find no way to break through in the sessions by addressing these matters. I couldn’t bring them out.

I shifted my focus away from them, disclosing some of my own pain and disappointment. I explained that when I was 12 years old, and one of my best friends was killed in a freak accident, electrocuted in the presence of his father, I withdrew from life, became bitter, and questioned the point of living. The boys asked detailed questions about him and what happened. It would not have worked if they perceived my personal story as a gimmick to get them to open up. As I recalled the story, I was definitely, emotionally, into it. When I said how much I had missed my friend, day after day, the 13 year old said that he missed his mother every day. The others were silent, as if he had touched a dangerous live wire. Little by little the boys and their father alternated between small but potent doses of talking about her death, and then focusing on conflicts in the house such as curfew, chores, and the use of cell phones after bedtime. Movement was slow but obvious. I wish I could say the outcome was positive. Maybe it was helpful in the long run, but sadly, the therapy ground to halt when the 15 year old suddenly refused to attend any more sessions, and the father insisted that we not continue without his older son. I haven’t heard from them again.

Love in a family takes direct forms: physical and verbal expressions of affection, tuning in to the other’s distress, jumping in to help when help is needed, protecting one another and so on. And it takes indirect forms when things are difficult: biting your tongue when you are dying to scream at someone, taking distance when closeness breeds judgment and contempt, maintaining the mundane details of family life when relationships are fragile, basically holding things together when they are coming apart. Love manifests as concern, more as compassion than passion. Love starts with understanding where the other family member is coming from, and acting accordingly. It is hardest, of course, when other family members are behaving in ways that repel us, alienate or hurt us, and drive us away. Most broadly, love is the life force that motivates us to hang in there, to move toward one another, to work things out, ultimately creating safety and bonds of concern.

When things are coming apart, as was the case with the father and two sons I was treating, so many ordinary strategies don’t work. Identifying a problem, defining it, taking hold of it, and solving it, seems impossible. The trust and willingness isn’t there. Simply listening, reflecting, expressing sympathy and understanding, resonating with distress, seem to go nowhere, and may trigger a downward spiral of invalidation and judgment. As therapists (or as friends to another family), sometimes the best we can do is a holding action, maintaining the status quo for the time being, using trial and error, specifically refraining from doing those things that make things worse. It’s like having arrived deep within a maze, having run into several dead ends, not knowing which way to turn. It is at this point that the DBT therapist turns to the principles and strategies of the dialectical paradigm, the paradigm specializing in patterns of opposition, polarization, isolation and stuckness. It is at this same point, in working with families, that family therapists find ways to contain the conflicts without inflaming them, engage in maneuvers to disrupt the painful family homeostasis without knowing what the outcome will be. The therapist might have people switch places in the room, might use paradox or counterparadox, and might at times come up with off-the-wall interventions. Carl Whitaker, when stuck, used to “fall asleep” in the middle of a session, “wake up with a dream,” share the dream, and move the session in an entirely different direction. It is no accident that DBT’s dialectical paradigm functions in a way similar to these disruptive and creative family therapy strategies, since Linehan admired and studied the work of family therapists when she was working out her ideas about dialectics. Using these ideas with families is different than using them with individuals. We have to center our thinking on the group as a whole rather than as a bunch of disengaged individuals.

More than two decades ago, while attending a course at the Ackerman Family Institute in New York, several of us had the privilege of watching an amazingly skilled family therapist, Olga Silverstein, treat a family from New York’s Orthodox Jewish community. The identified patient was a 15 year-old boy, previously a spirited, ambitious and accomplished student, who had stopped attending school for no obvious reason. He refused to do schoolwork, and at home he was distant and irritated. The parents, having tried every way they could think of to get him to attend school, seemed worn out, defeated by their son’s stubbornness. They brought the son, and his sister, in hopes that Olga could solve the problem and get their son back on track.

From the beginning, she barely even looked at or acknowledged the boy, who looked downward throughout the sessions, or at his rather shy 13 year-old sister. She just spoke with the parents. The tension in the room was high, although Olga’s demeanor was relaxed and open, a stark contrast to their icy stances. As if taking part in a casual conversation, she sympathized with the challenges of parenthood and learned about the parents’ work lives. The father acted as the authority in the family, sitting bolt upright, head up, his arms folded in front of his chest. His wife deferred to him, and he seemed baffled and amazed that he could not get his son back to school, as if his son’s willfulness was a threat to his authority. The mother expressed her worries about her son, but also about her husband since he seemed so distant and angry. Olga wandered her way into an appreciation of each parent, and perhaps of greatest importance, gradually kindled rapport with the father. It seemed that mutual respect grew between them, and even humor at times.

The father’s frustration with the process spilled into the fourth session. Nothing was changing at home, sessions seemed non-productive, the boy was missing school and living mostly in his room. The father insisted that Olga give them advice immediately about how to break the logjam. She caught him by surprise, all of them really, when she responded,

“don’t worry, we’ll get to that, but for now I think we should see what we can do about your depression.”

This was a shock to all of them; they were not accustomed to having someone challenge the father, or even comment on his behavior. The son looked up for the first time, seeming genuinely interested and concerned. The wife looked frightened, anticipating her husband’s response. He seemed insulted:

“what makes you think I’m depressed?”

Olga:

“It’s rather obvious. You never smile, you seem grumpy and irritable, you seem distant and withdrawn from everyone including your wife, and you are filled with pessimism about your highly accomplished son who is taking a little break. You just don’t seem at all happy.”

The father dismissed her comments, saying that to talk about him would be a waste of time.

“I’m fine!”

The session ended on this note.

As the next session began, the mother couldn’t wait to speak. She explained that her husband, for the first time in their marriage, had moved out of the bedroom and into a vacant room in the attic. He was not speaking to her or anyone else. Meanwhile, their son, in a complete reversal, without a word of explanation, had returned to school, was back to doing his homework, and seemed more engaged in his life than he had been in a long time. Olga spoke with the boy, asking him about his studies. His responses were normal and upbeat. She spoke with the shy 13 year-old about her interests. The father sat still, looking down at the floor, emanating tension and disappoval. Olga announced, mid-session, that the kids were no longer needed. She sent them to the waiting room.

Then she inquired into the father’s mood in more detail, and noted that his move to the attic confirmed her impression that he was unhappy with his wife. As his wife quietly wept, he admitted that his love for her had waned many years earlier, maybe beginning around the time the children were born. His wife, as he put it, had abandoned her job as a wife in order to be a mother. He knew that the children needed her, but still he felt he should have come first. He was giving voice to a grudge he had kept to himself since the kids were born. He wondered aloud whether they had had children too soon, indeed whether they should have had children at all. Olga asked them about their relationship with each other before the children were born. The tone became sweeter; it was clear that they both had enjoyed the brief time they had together prior to children. In remembering some of the good times, they seemed more joined. Olga recommended a series of couples sessions to recapture and resume the connection they had in the beginning.

Olga navigated the tensions and the oppositions dialectically—not taking sides but finding wisdom on all sides, letting the process unfold without knowing where it would go, finding balance and freedom by moving in unexpected directions, and keeping things moving even when they seemed to be stuck. It seemed that the locked door between the two parents was unlocked, and for the first time since sessions began they seemed and acted like a couple. There was some kidding and the father smiled now and then.

Per the Dalai Lama, love is at the center; everyone needs it. Per the case examples, love can be extinguished or buried in response to accumulated hurts and disappointment, almost impossible to access. By working with principles and interventions of the dialectical paradigm of DBT to create disequilibrium and movement, new configurations and new elements come into view that open new possibilities. Once the system shifts, the therapist can work with principles and interventions from the more “ordinary” paradigms of acceptance, including mindfulness and validation, and of change, including problem solving. Family members whose lives have been inexplicably interrupted can, if they can get “unhooked” from some paralyzing dynamics, move on with more freedom. Ultimately the family can function as a safe, trustworthy platform for each member, so that he or she can thrive at chosen life goals.