Practice Profile

Many psychologists shy away from working with suicidal patients, fearful of the risks involved. Not Marsha M. Linehan, PhD.

From a lesser source, those words might seem like folly, braggadocio or both. But Linehan is a highly respected practitioner, trainer and researcher in suicide prevention who has developed Dialectical Behavior Therapy, or DBT, the only replicated treatment shown to work for severely suicidal patients with complex diagnoses.

"It's unusual to find someone who is this creative and charismatic of a clinician, who is just as strong in her empirical work," says her longtime colleague, Vanderbilt University depression researcher Steven D. Hollon, PhD. "What has given DBT life is that it's tested. It's hard for critics to ignore what she has done."

Indeed, in recent years, the treatment has taken off in a big way. Some 9,000 people have been trained in the model both nationally and internationally, and many of Linehan's former students have set up DBT programs of their own, including Milton Brown, PhD, of Alliant International University; Alex Chapman, PhD, of Simon Fraser University; and Stacy Shaw Welch, PhD, of the DBT Center of Seattle. Meanwhile, other researchers are testing DBT with suicidal teens, people with narcissistic personality disorder and others.

Despite her impact, the straight-talking psychologist is modest about her success. "Getting well-known is a matter of timing," she says.

A matter of life and death

Linehan became interested in highly suicidal patients in the 1970s, the outgrowth of an early desire to help others and a taste for tough challenges.

"Suicide is one of the few areas in the field I find intrinsically interesting because it involves life and death," she says. "What could be more interesting than life and death?"

Over time, she gleaned that many of her suicidal patients had borderline personality disorder and were prone to unstable and erratic moods, stormy relationships and self-destructive behaviors. Perhaps as a result, people diagnosed as borderline make up about 20 percent of psychiatric hospitalizations.

Linehan found that traditional behavioral therapy approaches didn't work for them.

"When I started treating this population, change-based treatment alone turned out to be a disaster," she says. That's because these clients couldn't tolerate hearing that they or their actions were the problem—a message they tended to get a lot because of their challenging behavior.

So, she tried the opposite tack: helping them accept their lives, including their behaviors, their often painful pasts and the emotional anguish that marked their daily experiences. It was a major turning point, she says, because their inability to accept and tolerate their pain paradoxically held them hostage to it.

But pure acceptance wasn't the only solution, either, since patients remained overwhelmed by their emotions and hopeless that anyone could help them. So Linehan combined the approaches into DBT, a therapy that promoted a "dialectic" between helping clients to accept the reality of their lives and their own behaviors on one side, and learning to change their lives, including dysfunctional behaviors on the other. Underlying the approach was an emphasis on helping clients learn to both regulate and tolerate their emotions.

The treatment also incorporates mindfulness practices from Zen and Western contemplative practices, such as observing reality as it is without judging it, and being aware of the present moment as opposed to fixating on the past or future. In addition, she has broken down all aspects of the treatment into concrete skills, including those based on seemingly esoteric meditation practices.

"One of the phenomenal things about DBT is that Marsha has operationalized so many parts of adaptive human behavior," says Joyce Bittinger, PhD, a postdoctoral student at the University of Washington who has studied under Linehan. "The manual for doing DBT is really the manual for how to be a good therapist."

DBT in practice

On the ground, Linehan's approach is just as specific as her theory, and she insists on three safeguards.

The first is adequate training—something Linehan sees as pervasively absent in the field.

"In psychology in general the only teaching we tend to do about suicide is as part of a course," she says. "That's like trying to teach a surgeon how to do surgery by just reading books."

Her trainees attend an intensive weekend seminar where they learn crisis-intervention methods and confront their feelings about suicide; they also receive ongoing DBT training and supervision.

She also employs a team approach, where DBT therapists support one another in applying the treatment principles in their own lives so that they don't become overwhelmed by working with high-risk and often chaotic clients.

Finally, Linehan requires students to follow her two manuals, "Cognitive-Behavioral Treatment of Borderline Personality Disorder" (Guilford, 1993) and "Skills Training Manual for Treating Borderline Personality Disorder" (Guilford, 1993), which give comprehensive, flexible directives on assessing and treating these patients.

"I say to students all the time, 'You must let the treatment do the work,'" Linehan says. "If the treatment fails, the treatment fails. But you fail if you don't apply the treatment adequately."

Research on DBT demonstrates that the treatment works. For example, a study in the July 2006 Archives of General Psychiatry (Vol. 63, No. 7), showed that suicidal borderline patients randomly assigned to DBT were half as likely to make suicide attempts as those receiving expert "treatment as usual," according to blind raters. Meanwhile, in the many years that Linehan has been using DBT, only four of the 300 highly suicidal people seen in her clinics have taken their lives, she says.

Ordinary happiness

That said, Linehan's purpose is not just to help keep people alive, it is to help clients build lives worth living, she emphasizes. Her treatment involves helping people learn how to improve their lives—for example, by finding occupations they enjoy and learning the skills to develop long-lasting relationships. They can only do this by learning to accept their limitations, whether they are medical disabilities, emotional limitations or relationship imperfections.

"If you don't accept that your tire is flat, you're not going to be able to change it," as she puts it.

DBT, she adds, is based on the notion that everyone can build a life worth living. "There may be constraints on what your life can look like," she says, "but there are no constraints on whether your life is worth living."


To find out more about graduate training with Linehan, visit her Web site, http://faculty.washington.edu/linehan.