UW professor takes new approach to preventing suicide
She was raised to help the poor and the suffering. She would have become a priest if the Catholic Church had allowed it. She attended a Jesuit university. So maybe it’s not surprising that Marsha Linehan’s youthful ambition was to help those she thought of as “the most miserable people in the world” — people who wanted to kill themselves.
“I never wrote a college paper on another topic,” she says. “No matter what the course was, I figured out a way to write about suicide.”
Forty years later Linehan — a UW professor of psychology and director of the Behavioral Research and Therapy Clinics — has developed a new therapy to help suicidal people decide to live and even thrive. She calls her method dialectical behavior therapy, or DBT, and there is a Hegelian tension in it — one part urges Zen-like acceptance while another part promotes change. Linehan’s work has been called “one of the most popular new psychotherapies in a generation” by the New York Times.
The particular people Linehan treats have borderline personality disorder, an obscure but relatively common malady afflicting about 2 percent of the U.S. population. Think of the most volatile person you know, then multiply the emotional intensity several times and you have a description of someone with this disorder. With an inability to recognize and deal with their own emotions, borderlines careen rapidly from clinging to others to lashing out at them, resulting in lives littered with the wreckage of failed relationships.
But the damage goes beyond the personal sphere because borderlines put a tremendous strain on the mental-health system. They are at high risk for both suicide attempts and less lethal self-harm, such as repeatedly cutting or burning themselves. They are hospitalized often and are also prone to eating disorders and substance abuse. Many borderlines suffer from the after-effects of sexual abuse in childhood. (Although about 75 percent of borderlines seeking treatment are women, Linehan speculates that male borderlines may have directed their destructive impulses at others instead of themselves and thus may be in jail.)
Psychology Professor Marsha Linehan. Photo by Mary Levin.
“You can’t decide to not treat these people,” Linehan says. “When someone tries to commit suicide, you have to respond.” If she was looking for the most miserable people in the world, she certainly found a group who could compete for the title.
She also found a group that desperately needed a new treatment plan. Borderlines, Linehan says, often get worse in traditional therapy. Moreover, their behavior with therapists hasn’t won them many champions. They call therapists names and question their motives. They miss sessions and drop out on the slightest pretext. And there is the ever-present threat of suicide.
In return, therapists have sometimes stigmatized people with the disorder. Shireen Rizvi, a former Linehan graduate student, says her undergraduate abnormal psychology textbook illustrated the description of borderlines with a photo of Glenn Close in Fatal Attraction. “The idea of associating the most extreme and fictional case with borderlines is typical,” she says. “In clinical work, I’ve seen people diagnosed as borderline because you don’t like them or they cause problems for you.”
In the past some clinicians have even questioned whether borderline personality disorder is a legitimate diagnosis. Maybe these people were just manipulative; they could change their behavior if they chose to.
What Linehan believes is that the disorder arises from a combination of biological vulnerability — a hypersensitive temperament — and an “invalidating” environment, one in which caregivers don’t recognize or accept the child’s intense emotions. Although this often happens in an atmosphere of abuse and/or neglect, Linehan says it can happen in loving homes too, because these children require extra soothing and careful coaching in appropriate behavior.
She used her contacts to arrange a most unusual sabbatical. She spent three months studying with a female Zen master.
“The problem with a difficult temperament child is, if the parent doesn’t do that, the child escalates,” she says. Naturally, when the child ratchets up the tantrums, the family moves to repress the emotion, and a vicious cycle ensues. As Linehan puts it, “The child creates the family and the family creates the child.”
When Linehan started her research back in 1981, she planned to treat suicidal patients with cognitive behavioral therapy, a method that emphasizes identifying and changing dysfunctional patterns of thought and behavior. But she quickly found that this did not work with borderlines. The problem, she says, is that standard cognitive behavioral therapy is a “technology of change.” Therapist and patient assess the patient’s faulty thought patterns and agree on reasonable steps for changing self-destructive behavior.
But this approach made borderline patients feel their suffering had been discounted. “They were really sensitive to being told they were the problem, because most of them had been told their whole lives that they were the problem,” Linehan says.
Moreover, people with borderline personality disorder usually have multiple crises in their lives, so when Linehan tried to zero in on one problem, they would threaten to kill themselves over some other problem. And they didn’t have the skills to follow through on what they said they would do to help themselves.
Faced with the failure of her planned approach, Linehan simply opened her therapy sessions to scrutiny. Her research team watched her through one-way glass as she met with patients and gave her feedback about what was working and what wasn’t. Slowly, through trial and error, she came to realize that what was missing was acceptance. She needed to show more acceptance of these people who had been discounted all their lives, and they needed to accept their miserable present and often tragic past long enough for the treatment to work.
Acceptance, Linehan knew, wasn’t the strong suit of Western thinking. Trained in a contemplative Christian discipline called centering prayer, she was familiar with Zen Buddhist thought, and in 1985 she used her contacts to arrange a most unusual sabbatical. She spent three months studying with a female Zen master at Shasta Abbey in California and an additional three with a Catholic priest who was also a Zen master.
“It was utterly clear to me afterwards that I had found what the patients needed,” Linehan says. “I just had to figure out how to teach it to them.”
Her patients, she knew, weren’t going to sit on a meditation cushion for hours. And because they came from a variety of religious traditions (or no tradition at all), she couldn’t use spiritual language when talking to them. She had to find a way to “take the Zen out of Zen.”
Ever the pragmatist, Linehan designed a training program for her patients that would take place outside therapy sessions. Meeting as a group, they would get lessons on ways to change their self-destructive behavior and would be assigned homework to practice the techniques. The core skill, the one that is offered first and pervades everything else, is mindfulness.
As Linehan explains it in her treatment manual, everybody has a reasonable mind and an emotional mind. In between the two is what she calls “wise mind.” Wise mind is a synthesis of reason and emotion, but with something else added, something she calls intuitive knowing. To reach wise mind, patients are taught “what skills” — observing, describing and participating — and “how skills” — taking a non-judgmental stance, focusing on one thing in the moment, and letting go of being right to be effective. Patients are taught, for example, to notice and describe their thoughts, and to recognize when they are interpreting reality rather than seeing it. They might be asked to carry a counter and keep track of how often they make such judgments. The skills training system is, in fact, built around diary cards that patients fill out so their progress (or lack of it) will be evident.
The mindfulness skills taught in DBT aren’t just for the patients. During their sessions together, the therapist needs to demonstrate total acceptance of the patient. Even a bizarre behavior such as cutting themselves needs to be seen for what it is — an attempt at mood regulation. Rather than immediately questioning why a patient would do such a thing, a dialectical behavior therapist is likely to suggest to a patient that she substitute some painful but harmless behavior, such as grasping an ice cube, for the cutting.
“Carol,” a patient in a recent treatment program at Cascade Mental Health, south of Olympia, liked the therapy’s practicality. “These are skills you can learn by practicing,” she said. “You don’t have to become somebody else. In fact, the therapists say, over and over, that this is a disorder you cope with, as you are. You do that day by day, and sometimes minute by minute.”
Rizvi, who continues to study borderlines as a postdoc, did her graduate work with Linehan largely because she was so impressed with the acceptance that is the bedrock of DBT. “I still think it’s one of Marsha’s greatest accomplishments,” she says.
“You realize, though, if you were dead, that therapy is not going to work.”
Marsha Linehan, to a patient
The need to demonstrate acceptance presented Linehan with a dilemma, however. She couldn’t let her patients go on hurting themselves. Wasn’t the point of therapy to feel better? This is where the idea of dialectics entered the picture. Dialectics in philosophy is a synthesis of opposites. So the central dialectic in DBT is between acceptance and change. Therapists must fully accept their patients as they are, while encouraging them to change.
Therapists do this with warm, encouraging communication spiced with irreverence. Linehan outlines this approach in an unscripted training tape, where a “patient” named Kelly complains about her life and a former psychiatrist.
Kelly: I’m not afraid I’m going to kill myself; I will kill myself if things get too bad.
Linehan: Mm hmm.
Kelly: I mean, the way that the psychiatrist said it is, “Look: If you’re going to be dead anyway, why not try this?” And I think …
Linehan: You realize, though, if you were dead, that therapy is not going to work.
This irreverent remark is greeted by silence from the patient, a reaction that Linehan believes signals that the patient’s usual thinking pattern has been derailed, exactly what she wanted to do. Borderlines make suicide threats with the expectation of a particular response. DBT therapists try to react in a surprising way.
“What is known about this,” Linehan says, “is that people will process novel stimuli more deeply. Their typical train of thought is disrupted.”
Though Linehan considers it an offshoot of cognitive behavioral therapy, DBT adds several new elements. Patients are required to attend two sessions a week — one of therapy and the other of skills training. They are instructed to call the therapist if they need help between sessions, especially if they feel like harming themselves. Therapists, meanwhile, regularly watch each other’s sessions and meet as a team weekly.
“I think you’d be insane to do DBT without the team element,” says Tony DuBose, director of the Dialectical Behavior Therapy Center in Seattle. “It’s really hard work, and you’re often the target of the patient’s anger. So you need support from a group of people who can help you keep going. But you also need their collective wisdom to help you sort through this morass of problems that borderlines bring to the table so you don’t get overwhelmed.”
DuBose’s first experience with DBT came when he worked on an adolescent psychiatric ward that decided to use it. One girl came to the unit after about 50 incidents of self-harm that resulted in her being placed in seclusion. In the nine months she received DBT on the unit, DuBose said, she had only two such incidents.
Shari Manning, president of the South Carolina Center for Dialectical Behavior Therapy, had similar success when she conducted a pilot DBT program for just eight clients in a prison, and saved the state $234,000 in prisoner hospitalizations for self-harm in the first year. Despite incarceration, Manning says, prisoners can always find the means to hurt themselves — by taking apart razors they’re allowed to have, hoarding medicine, buying illegal drugs, cutting themselves with shards, etc. In three years of employment at the prison, she treated about 180 prisoners.
DBT has been the subject of a number of studies that have shown, among other things, that patients receiving this treatment had fewer instances of self-harm and hospitalizations, and dropped out of therapy less often than those receiving therapy as usual.
These days, Linehan is invited to speak and do workshops all over the world. DBT has been incorporated into the mental health systems of 15 states. About 3,000 therapists have gone through intensive training and 18,000 have attended briefer workshops. Next on the agenda for Linehan is to develop a system of accreditation for therapists so that potential patients will know who is qualified to use the method.
Linehan says there’s more to be done to streamline DBT and make it even more successful, but she’s fairly satisfied with her work so far. “I always said that in my life I’d go to hell and get people out, and I think I’ve done that,” she says. “Now I have to find a way to make sure that it continues, that we have a core of people who are willing to do the same thing.”