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Marsha Linehan has seen her share of despondent patients. As a psychotherapist
and researcher, she has spent years working with intensely suicidal
individuals. Finding that no existing therapies addressed their
needs, she developed a new approach, called dialectical behavior
therapy, that The New York Times recently described as “one
of the most popular new psychotherapies in a generation.”
Linehan, professor in the UW
Department of Psychology, explains that dialectical behavior
therapy, or DBT, is based on the theory that problems develop from
the interaction of biological factors—a person’s physiological
makeup—and environmental factors, which together create difficulty
managing emotions.
“To reach the ultimate goal of DBT—creating a life worth
living—the therapy balances empathy and warm acceptance with
an unwavering focus on changing problem behavior,” says Linehan.
It took years for Linehan to fine tune her approach. When she arrived
at the UW in 1977, she used the standard cognitive behavior therapy
that was popular during that period to help suicidal patients. However,
she soon found out that this treatment, focused primarily on changing
behaviors, had some serious limitations.
“It didn’t actually occur to me that the treatment wouldn’t
work,” says Linehan. But she soon discovered that the therapy
led patients to feel invalidated and sometimes belligerent about
treatment, so she turned to an acceptance-based treatment. “That
still didn’t work,” she recalls. “Over time, I
figured out that I
had to synthesize the two approaches.”
With support from the National Institutes of Health, Linehan developed
a manual outlining DBT and conducted clinical trials in the 1980s.
All participants had been diagnosed for borderline personality disorder
and had attempted suicide two or more times. Parasuicide—including
attempted suicide or other intentional, non-fatal, self-injurious
behaviors—is considered a hallmark of borderline personality
disorder.
“There had never been a clinical trial treating this group,”
says Linehan. “There was no standard treatment beyond treatment
as usual in the community.”
The results of Linehan’s study, published in 1991, were “extremely
promising.” A second study, to be published in 2005, compared
DBT to treatment conducted by individuals who were designated as
experts in the community and found similar results.
DBT is a long process, leading patients through four stages of treatment.
The first stage involves helping patients gain control of their
lives. They attend two weekly sessions—an individual session
and a group session. The individual session focuses on enhancing
motivation, decreasing and managing crises, and helping the patient
develop a life worth living. The group session focuses on building
skills in a variety of domains, such as interpersonal skills, regulating
emotions, tolerating distress, and mindfulness. The primary goal
of the first stage is to reduce out of control behaviors and severe
problems in living.
“This stage is about getting the person under control, to
the point where he or she is living a life of quiet desperation
rather than loud desperation,” says Linehan.
For any of this to happen, there must first be radical acceptance—the
insistence that patients accept who they are, that they are not
who they want to be, and that they are willing to change. Once there
is acceptance, the therapist and patient begin skills training.
DBT teaches patients how to recognize and acknowledge their powerful
emotions—anger, despair—without acting on them.
“Most of the people I deal with have attempted to shut down
their emotions in maladaptive ways, such as using alcohol or heroin,”
explains Linehan. Through DBT, they learn to deal with their emotions
without harming themselves. “It is very targeted to the exact
behaviors that need to change,” says Linehan. “The skills
are very unique to DBT.”
The therapist works with patients to increase their motivation to
use their new skills, steering them away from destructive environments
and toward environments that reinforce the new skills. DBT also
emphasizes using the new behaviors in the real world. “We
give lots of homework assignments to ensure that this happens,”
says Linehan.
The stages that follow build on the work from the first stage. The
goal is to reduce patients’ sense of desperation, then get
them to the point where they experience ordinary happiness and unhappiness.
“For a lot of patients, that’s all they need,”
says Linehan. “But some ask at that point, ‘What’s
it all about?’ In those patients, we try to develop the feeling
of freedom and a capacity for joy.”
Linehan is now conducting a study with heroin addicts to test the
program’s effectiveness with this group. She also is looking
at the components of DBT to see if the whole packet is needed or
just parts of it. “We’re always focusing on how to make
it better,” she says.
For patients in dialectical behavior therapy, there is no quick
fix. No one has moved through all four stages, from suicidal to
joyful, in a year. But with hard work, such change is possible.
And that, says Linehan, is the goal.
“We’re not a suicide prevention program,” she
says. “We’re a ‘life worth living’ program.”
[Autumn 2004 - Table of Contents]
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