NAMI Honors Dr. Marsha Linehan, The Creator of Dialectical Behavior Therapy

By Ken Duckworth, M.D. | Oct. 05, 2015

Marsha LinehanThis 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.

Comments
Dorothea M Cintolo
I have been a patient for 14 yrs. My traumatic divorce triggered the sleeping giant / child abuse that I forgot due to horrific trauma as a child in all aspects, and Me being, especially gifted in Defensive, fight or flight responses, but had no blueprint for the corresponding face to a corresponding emotion. My Impulse was my Defense. I know that Your inspired works of the art of interpretting an emotional language I was denied as a child which handicapped me as an adult. I learned abruptly per the Law that I was going to answer to my behavior and I saw my behavior as Justice. Non Judgment was Non existent in my world. So thank you for DBT. It did save my life and the life of my son through Me accepting I was disregulated. Humiliation is used as a weapon when your a child and scary as the years go on. It heavily tips you over in confusion when it collides inside your mind. I am not able to organize my pain and it not be overwhelming. It also reduced my physical pain once I was brave enough to feel humiliation and vulnerability. It is a painful process and I have become a New person. Now another scary part of DBT is that change is a must, and it alters everything you know or do because of the Boundary growing process. Once accomplished in Mastery, Socially there is death. I am here now. I am scared but accept the aloneness before I want to venture out socially again. I am protective over this new woman, and I know what I dont want but dont know what I do want. Integration has been interesting. DBT is autonmatic but I do feel disconnected. I am allowing me time now and giving myself permission to truly take a breath and heal. I truly would like to like me. I did get the bad guys out. My son is safe. Just dont feel quite whole yet. Thank you
11/10/2017 9:10:38 AM

Katie
I have the same question Rick asked. How do you get a BPD person into therapy when they are always blaming the sole mate? Never their fault.
12/10/2015 7:22:03 AM

Candida Pizzoferrato
Interesting
12/7/2015 2:01:21 PM

Sage Recovery & Wellness Center
Thank you for honoring Marsha Linehan for this award! At Sage Recovery & Wellness Center in Austin, TX, we see the reward with our clients in our field with our DBT Dual Diagnosis (Substance Abuse & Mental Health) group here in Austin. Well aware of the need for a DBT group, we are fortunate to have our therapist intensively trained in Marsha Linehan's model. We have seen clients with emotion regulation issues, borderline personality disorders, self -harm behaviors in our practice gain healthy ways of coping with the help of a structured DBT group, mindfulness,meditation, Acu Detox, yoga therapy as part of our holistic model. It works and we are grateful for Marsha Linehan's contribution to the wellness of our clients!
NAMI, Thank you for the work you do for the mental health field! We support you and our message aligns well with yours about eliminating the stigma and getting the help you need to become in mind, body and spirit!
Sage Recovery & Wellness Center
www.SageRecoveryAustin.com
11/2/2015 2:09:51 PM

Pam
I have a son whom had been struggling with paranoid schizophrenia for many years.
How can he get your treatment?
We as a family are in counseling but he needs professional help.
10/31/2015 12:37:00 AM

Samantha
I am currently in a group in Portland Oregon and my therapist was trained at University of Washington. I personally find this whole DBT program to be a complete joke. What she have done is just common sense and is nothing special. She has just taken things from other therapies and from religion and made a program which in reality does not help as many people as she claims. I have read many blogs on other well know sites of where DBT did not help and most of these people had the same feelings I have about this program, that it is a joke. Radical acceptance is a joke if it is so easy to just let go then why would I be in this group. From what I have read this book and program is for most 6th graders and maybe even younger, it is very childish. I have lived with BPD since I was a child and I am 47 and have a lot of control over most of my emotion except when it comes to love and friendships. I had put so much effort and time into getting into this group that I even changed insurances so I could get in. The change of insurances cost me my neurologist. Now I am left to find someone
10/30/2015 12:57:05 AM

JannaM
Will there ever come a time when we don't ask women how they balance home and work lives? Or instead, when we START to ask men how THEY balance home and work lives?
10/29/2015 12:48:58 PM

Lillian Santiago
I have a daughter who's an heroin addict and would like to go for training on substance abuse. Please respond to my request. Thanks
10/29/2015 9:58:02 AM

Leslie
DBT has given me skills for every day life, I made it through the program the first time and I still after a few years from that I use the skills every day in some way or another. Thank you for sharing the skills, they literally are a life saver!!
10/29/2015 12:39:02 AM

Rick
How do you get a BPD into therapy in the first place when they don't think anything is wrong with them and they place all the blame on their partner/mate?
10/28/2015 9:35:41 PM

nancy mclernon
After years of sitting with a depressed Psychiatrist,after returning to my parents home following a sexual assault in another state,while living with my boyfriend. I felt I needed to go back and spend time with friends and family. The Dr.,asked question's but did a lot of silent sitting. I found a counselor who was very helpful in addressing trauma and loss. My boyfriend was upset,would not move to where i was. I became extremely divorced and the compartmentalizing I had used for years landed me back at no longer being the happy go lucky person I saw myself as and not being an angry person. I was taking on the belief system and trying to emulate a mentor who I felt was perfect in everyday. There had been a lot of punishment over not maintaining perfection which was my mother's need for control,who was alcoholic and depressed. We were paddled ,hit with belts etc… These memories rose up after my mother died hen I became very depressed and eventually ended up in emergency room 3 times after taking sleeping pills.I did not want to die but I could not cope with depression and feeling i may never be happy, carefree and active again. I lived in a cave and while I could see somethings gazing out I felt I was not a part of the world around me. I went into residential treatment,Rose Hill Center,Holly Mich. where I learned D.B.T. and had homework and individual therapy. The past going from all encompassing to daily plans and living in the moment. Working towards acceptance of past struggles,changes and loss and embracing them ,verses having these past reminders, repetitious thoughts steal the importance of living in the moment and strengthen confidence to feel comfortable and fearless making a plan for eve day life.
10/28/2015 8:35:42 PM

Lisa
DBT has been life-changing for me. Almost everyone that knows me knows what it is, since it's part of my daily life now. I only wish I'd have known about it and done the skills training group 20 years ago. NAMI made a good call honoring Dr. Linehan.
10/28/2015 7:49:37 PM

Kristen
I am bipolar, and people should also know dbt works really well for that. I would like there to be a more integrative system for mental health care: meds, new/promising diet research, talk therapy, dbt, exercise, spiritual work, it's all a la carte and very challenging for a lay person to keep up on. With your new position, perhaps you could look at that, too. Although I'm sure you'll be very busy.
You saved my life 2 ½ yrs ago. I am still in advanced dbt talk group stuff, and am working on integration so that skills are used automatically. So many people have "a life worth living" because of you. Thank you.
10/28/2015 7:10:30 PM

Karen Berger
Thank you for the work you have done that is clear and understandable.
10/18/2015 9:19:06 PM

Gigi Jarose Martinez
It would be an honor to be certified. In DBT. I was recently doing 1:1 with re*****ble psychiatrist and when I did groups at the jail I am a registered nurse certified ANCA certified behavioral health nurse RNBC and took all my courses for a CADC but I did not take the testing I don't know II must of panicked. Fear of failure!!! I have used Dbt and saw progress but I was not being supervised regularly. How can I get that Certificate. I do not have my masters.or completed bachlos. But life skills in personal addictions abuse PTSD . Suicide fellow nurses....best friends and the list goes on but I believe I am here to Contnue nonjudgmental choices for other to believe in and accept
10/15/2015 8:42:19 AM

Cindy
Hi Marsha
I have recently finished your DBT course her in NZ in the Waikato, and to be honest, these skills have saved me so many times from suicide, I try and catch the moment and distract, I use mindfulness a lot, but I'm sorry that "non judgemental" is very hard to catch on hold on, I have graduated last September but use my skills every day, thanks for an awesome course and believing in us when no-body else did
Cheers
Cindy
10/11/2015 8:34:05 AM

Cynthia Barber
DBT saved my life!,as well as gave me a life. I came away with courage to be on my own and become gainfully employed. My trainer/therapist saw in me a .... Something that she choose me to join a pilot group for DBT. It took me two rounds but I got it! She helped me teach others how to craft and feel reward and pride and reminded me I had abilities as well.
I truly can't thank you enough and I wish every age group could be taught these skills! It hurts to watch young folks suffer when the skills can make life so much more bearable..... Thank you so much for life's work and energy put into us! 🌹🌹🌹🌹🌹🌹🌹🌹🌹🌹🌹
10/6/2015 11:10:14 AM

Kakie
Great article! Thanks for sharing, NAMI.
10/6/2015 9:09:38 AM

Michelle
I would like to learn more
10/5/2015 11:06:36 PM

Denise
I was at the Sheppard Pratt Trauma Center when they introduced your work into my life. The only thing I can say, before anything else, is thank you for being a part of keeping me alive. I couldn't be here without your shares teachings.
10/5/2015 9:40:00 PM