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Guiding People Out of Despair

Story by
Nancy Joseph

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.”