December 2005 -

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.

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.”

Nancy Wick, ’97, is the editor of University Week, the UW’s faculty-staff newspaper.

The University of Washington is raising money to strengthen the DBT research clinic’s two principal missions—training the next generation of caregivers and giving hope to patients who come to the clinic as their last alternative. To get more information on Linehan’s work and to learn how your support can help, call 206-543-5701.

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