Marsha Linehan, Ph.D., is a professor in the department of psychology at the University of Washington and the director of the Behavioral Research & Therapy Clinics. She developed dialectical behavior therapy (DBT), originally created for the treatment of suicidal behaviors and since expanded to the treatment of borderline personality disorder and other complex mental disorders.
How did you come up with DBT as a therapy?
I realized that cognitive behavioral therapy, the treatment of the day, was not effective with certain patients. The approach “You have a problem, we can help you change” was not working. Clients are very sensitive to criticism and negative feedback. We all are. My clients would say, “You are saying what everyone says, that I am the problem.” They cried, attacked me, and hid behind the chair, would stalk out of the room or just quit.
How did you figure out that this treatment was effective?
With funding received from the National Institute of Mental Health in the 1980s, I selected patients with multiple disorders who were difficult to treat. I think this is one of the very first treatments developed by observation, instead of a proposed theory of what should work. We had a process of having people observe everything that was working. Being mindful in the Zen tradition and not worrying about being right, but by observing, we were able to record what was effective and what was ineffective.
How did traditional cognitive therapy evolve into DBT?
Cognitive therapy is at the core of DBT. We asked ourselves what we had to add to cognitive therapy to synthesize it, and that was acceptance. It became very clear to me over time how essential this was. We as therapists had to accept whom we were working with, rather than judge. That meant dropping all pejorative language, like “You are manipulating,” and describing behavior instead. Just like politicians, we infer others’ motives, which is a lot of what goes on in therapy. We say things like, “We’re not upset about what you did, but about the motive,” which is our belief about what that motive is. There is nothing more invalidating than when someone tells you what you’re thinking.
What is the second essential component to DBT’s success?
Humility. A lot of the problems in therapy come from the therapist. We needed to understand the dialectic between our clients and us. First, I had to see this myself and when I did, it was necessary to acknowledge those reactions back and forth, and see that things can blow up. Therapists are high-powered. It’s easy to say the client is the problem. I had to get therapists to see themselves as part of the problem.
What is the most challenging aspect of DBT for therapists or clients?
The radical insistence that we let go of judgments is most challenging. Not some, but all judgment. The emphasis of DBT is on mindfulness and on using skillful means to be effective.
Is there anyone who would not benefit from DBT?
I can’t think of anyone who would not benefit, because the skills are so global. The combining of mindfulness, distress tolerance, emotional regulation and interpersonal effectiveness has broad application. However, there are people who will not benefit from skills only. When you have a person with severe and complex problems, who exhibits out-of-control behavior or is highly impulsive, he won’t benefit from skills alone. These people need a case manager or a therapist to help manage them.
How will the parents attending your Life Skills Parenting event (March 17) benefit from learning these skills?
These are essential life skills. Parents uniformly state that DBT is transformative, for both their children and for themselves. You’re having the experience of what being more mindful — and more present in reality — can mean with your family and with coworkers.
Tell us about Miki, your little, one-eyed family dog.
I live with Geraldine, my 35-year-old adopted Peruvian daughter, and her husband, Nate. A friend got divorced and could not keep her dog. Once we got the dog, we talked about how life had changed. Nate is the person in my life I talk to most — to see if Miki is OK, and has been fed and walked. Geraldine makes sure Miki gets his prescription food and buys things like raincoats and bows — which Miki hates and won’t wear.