By Ken Duckworth, M.D.
This article originally appeared in the Fall 2015 Advocate, click here to see other articles that appeared in that issue. To receive the print edition of the Advocate, become a member today.
On Oct. 8, NAMI will honor Marsha M. Linehan, Ph.D., ABPP, with its annual Scientific Research Award event in Washington, D.C. Dr. Linehan is professor of psychology and of psychiatry and behavioral sciences, and is founder and director of the Behavioral Research and Therapy Clinics, at the University of Washington, where her primary research is in the development and evaluation of evidence based treatments for high-suicide-risk, multi-diagnostic and difficult-to-treat populations with serious mental health conditions. She is also the creator of dialectical behavior therapy (DBT), a well-researched skills-based treatment to help suicidal and drug-dependent individuals who live with borderline personality disorder and other related disorders.
I spoke with Dr. Linehan about the development of dialectical behavior therapy, what makes DBT special, and how her dog Toby has worked himself into her busy schedule.
Congratulations on being NAMI’s 2015 Scientific Research Award winner!
Thank you! To get it from such an important group that truly understands the field of serious mental disorders and what stigma means is really a great honor.
How did you first get interested in research?
As an undergrad, I thought that researchers were a bunch of cold people, and I didn’t want to be like that. Then in a psychology class, we were told that we were supposed to conduct a research study. I was in shock: We can do that? OK, I had an idea for a study about groups of people not being good at being able to evaluate things, and that this could be the root of prejudice.
I went from class to class testing my idea and showed that if you changed the race of the person being evaluated, you got different answers. I had a professor who believed in me — and all the other students. Doing more studies just continued to reinforce the positive experience. I decided cold and inhuman people didn’t run science after all.
What was the process that led you to conceptualize your signature treatment, dialectical behavior therapy (DBT)?
This is a perfect example of success through failure. I was a believer like you cannot believe in traditional BT [behavioral therapy]. Early in my career, when I was an assistant professor at the University of Washington, I got an NIMH grant and was going to test whether BT was effective for suicidal people. I had done suicide research, and I believed in BT and that it would work; it never occurred to me that it wouldn’t.
I worried that people in the treatment-as-usual part of the study would also get better in a randomized controlled trial. So I recruited highly suicidal difficult-to-treat people, as I wanted to show that my treatment was better than treatment as usual. If it wasn’t, what was the point of a new treatment?
But when I started the treatment, I blew it; it was a disaster. I hadn’t heard of borderline personality disorder at the time I developed the treatment. But if that first treatment had worked, not one person would know my name.
So behavioral therapy wasn’t working alone. How did you add some of the other key ideas in what is now DBT?
I tried BT alone, but people then asked, “Are you saying I am the problem? Are you blaming me?” “NO, NO, NO,” I said. So I decided to try an unconditional-acceptance approach. That failed, too. I realized I had to bring together acceptance and change at the same time, and both practice and teach radical acceptance of the past and of the present moment. The problem was I didn’t know how to practice or teach that. I knew it was a key, and I didn’t have it. So I took a leave and went to learn acceptance at an abbey and with a Zen master. After I got that understanding and both practiced and taught it, the treatment then worked.
That’s a remarkable journey. Can you break down the root of some key DBT skills?
I read every article that I could on BT, and to be honest, I get a lot more credit than I should for DBT. At least 50% of the skills I developed came from me reading treatment manuals. For example, I took elements from treatment for anxiety, which is an exposure treatment; people want to avoid what threatens them. If you want to get over a fear, you have to check the facts, and if it is not really dangerous, you have to stop avoiding it. This is the skill of opposite action.
The mindfulness skills came from Zen and contemplative prayer. I tried to translate what my teachers taught me. For example, learn to observe the present moment. Then learn to describe what you observe. If you didn’t observe it, you can’t describe it. This is important, because we often tell others what their motives or feelings are when of course we can’t observe either one.
How is acceptance working in practice in therapy?
One way is to learn that this one moment is enough; don’t add on the suffering of the past and the suffering of the future. The suffering of the present is enough. It’s the only thing that exists. I find that teenagers in particular love the skill I call “radical acceptance.” You suffer less if youjust radically accept the reality, whatever it is. With that skill, you can then focus your energy on what needs to happen.
What is the hardest DBT skill to learn?
Becoming nonjudgmental is very hard for many, because people think that if you stop judging others, you are approving. That isn’t true. You just need to observe and not go right into judgment.
Is there a role for medications in concert with DBT for some people, in your opinion?
This is what DBT says about meds: One, be sure your prescriber does not give you lethal doses of medications. Two, almost everybody is overmedicated, so see if you can get your provider to taper your medications down or off, if possible. The idea here is to replace pills with skills. Three, if you meet the criteria for a diagnosis where it is clear from research that you need to take a medication that has been tested and approved, take it as prescribed and don’t make changes without contacting your prescriber. Four, a DBT therapist does not make medication decisions unless they are an MD or a nurse practitioner.
How can parents best support their children who live with borderline personality disorder? Do they need to learn skills also?
In DBT, parents and adolescents go to skills training together. They learn the same skills, practice the same skills and have the same homework. Adolescents call their therapist for skills coaching, and parents call one of the group leaders.
Does DBT work for other problems like addiction?
Yes, we have good data on that. When treating heroin addicts, I developed a new set of addiction skills. For example, with the skill of dialectical abstinence, you have to both commit to absolute abstinence, and you have to have a relapse-prevention plan for use if you fall of the wagon. It’s the “dialectic” in “dialectical behavior therapy.” “Dialect” means the synthesis of two opposing sides.
There has been discussion of changing the name of borderline personality disorder. Where do you stand on the issue?
I think it’s one of the worst names ever. It is degrading to be told there is something wrong with your personality, with who you are. The disorder itself is a pervasive emotion dysregulation disorder across the spectrum of emotions. That is what this is. That is what it should be called. It is through skills that they learn that emotions need to be regulated and how to do so.
If a person needs to find a DBT therapist, how should they go about finding one?
First, a DBT therapist should be part of a team. If he or she is not on a team, then that person is not a DBT therapist. Ask them what their training is in DBT and who trained them. Ask if they get any supervision on their work. The Linehan Institute keeps a list of people who are trained by us. There are other good trainers, but in this field what is sorely needed is one standard national certification. We are in the process of finalizing the development of such a certification. We simply don’t have enough people trained. If you cannot find one or the waiting list is six months, I think a good practitioner in BT may be able to do it — if they are part of a team.
Can you tell us about your family? How did you balance your career with your home life?
My daughter Geraldine is Peruvian, and she came to live with me when she was 16. A temporary visit led to the last 22 years together. I live with her, her husband and now my famously beautiful and brilliant 2-and-a-half-year-old granddaughter. I have the family I always wanted. You have been a great friend to NAMI. Tell us about your experience with being part of the NAMI family. My goddaughter has schizophrenia, and I was her out-of-town caretaker and advisor. She went to NAMI-sponsored events, and they had a huge positive impact on her. She loved those groups. So I love NAMI.
You were featured in the New York Times for your own recovery journey. What was it like for you to become so public?
A patient once said to me, “Are you like us?” I asked, “Do you mean, have I suffered?” She said, “No, I mean, are you really like us?” I then realized that I was a coward. I wanted to say something about my life; I mean I have made it out of hell. I often think if I can make it, then you can make it. I then decided I don’t want to be a coward, so I am going to write something about my experience. I called Ben Carey, a writer at the New York Times, and said that I needed a writer who will write something that no one will read. He replied, “How is page one of the New York Times ?” What choice did I have? I didn’t want all this publicity; I just wanted to be less of a coward, but now it’s out there.
Lastly, do you have pets in your home? If so, can you share a story?
Of course. I have a dog named Toby Choclo. I didn’t know how much you could love a dog until I had one. He’s part of my routine. He is best friends with my granddaughter, who is a toddler. They chase each other all day long. It’s wonderful.
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