Dr. Marsha Linehan Interview with Daniel Flynn

So I'm here today with Professor Marsha Linehan from the University of Washington. And we're going to talk about dialectical behavior therapy. So Marsha, can you tell me a little bit about what dialectical behavior therapy is?

Dialectical behavior therapy, which I'm going to call DBT. DBT is a comprehensive behavioral treatment, which is to say it's a psychological intervention. And it's intervention, which was originally developed for very suicidal individuals.

And then it expanded to people who were not only suicidal, but self harming.

Then after that, it expanded to people who, either suicidal self harming or people who have very severe problems regulating emotions. And so it's a comprehensive treatment. And over the years, it's expanded to treat all sorts of disorders besides that, and is still being researched and still being expanded the essence of the treatment.

In other words, the reason it's called dialectical is because on one side, it really emphasizes change, you've got a problem, you've got to change that's on the one side. And on the other side, it equally emphasizes acceptance, which is no matter what problems you've got, you've got to accept yourself. And so one of the main focus of the treatment is to bring these together.

So it's a synthesis of opposites, which is what dialectics focuses on. So not only does a client have to focus on acceptance of themselves, and of others, because we've actually had people sent to us, solely because their families were going to divorce them because they were so judgmental. So you have to accept yourself and be non judgmental of others.

And you also have to work on change, but the therapist has to do exactly the same thing. So therapists have to help people change. But therapists themselves have to also find the valid, or all that is acceptable and radically accept the patient as they are. And with many of these patients, you're also having to accept slow episodic progress, because much of the time the progress is not as fast for very serious severe disorders as they are for less severe, somewhat easier to treat disorders.

Okay, so Marsha, one of the common questions that were asked is, do people need to have a specific diagnosis in order for them to benefit from dialectical behavioral therapy?

The answer to that is yes and no. So the treatment itself has two components. One is individual psychotherapy. And the other is training in specific behavioral skills across many different areas. Everybody can benefit from the skills we have parents coming in, we have executives coming in, we have going into the school system now. Corporations are interested in the skill. So almost anybody can benefit from the skills, it's hard to imagine why you would want individual psychotherapy if you didn't have more and more psychological disorders.

So it's it's probably...you know, if you want someone to talk to okay, but DBT is not really a someone you can talk to therapy. I can't imagine that it would be of particular use.

So can I ask you what will be the more common disorders that will be associated with this treatment, any person who's suicidal would qualify for the treatment, no matter what their disorder, so they can have PTSD, post traumatic stress disorder, major depression, etc.

The total treatment is really designed for individuals who have multiple disorders. So it's at its best, with people who have multiple disorders, mainly because there really aren't other treatments designed for people with lots of different disorders.

If you only have one disorder, and you're not suicidal, and you're not self harming, that DBT treatment will start to look like other evidence based treatments, and there's not a great need for this treatment.

If you're not really severe, or complex or difficult to treat, you're probably not going to come for the full treatment, but you definitely would come for parts of the treatment.

Marsha, can you tell me how long the full treatment is and explain what the stages are?

Well, the question of what is the full length of the treatment is it Really good question, because that's what we're all doing research on.

Right now we're doing research in Canada, we're doing research in United States, we're doing research in Europe, I know that you're doing research on that also. So the array, all the original trauma studies, were one year treatments, that does not mean that absolutely everybody's better after one year, but it does mean that most of them were.

So that's been the research, we're now looking at six month treatment. So Canada's looking at six months, I'm doing a really large trend study with very high risk for suicide, adolescence, and we're looking at a six months. So there's that.

Now, if you go to skills training alone, and we have a lot of data now that skills training alone, actually very effective. Those treatments can be anywhere from one hour, which we've done with college students who drank to regulate emotions, and was extremely effective with college, to do a one hour treatment, and all the way to just teaching people the skills which can be done in 12 weeks, 16 weeks, 18 weeks, 26 weeks. So there are various lengths, really depends on the severity of the person, and the how long it takes them to get committed to the treatment, be willing to work in the treatment, be willing to practice etc.

Marsha, many of the people that are referred to the program here in Ireland would have histories of releases deliberate self harm, what would be the typical length of treatment that will be required to help a person with repeated deliberate self harm?

You know, that's a very difficult question to answer. Because I've had people with repeated self harm, as well as repeated suicide attempts, even people who've ended up in intensive care. And for some of them, it's going to take a long time, we've had people who've been in this treatment for four to five years. These are usually the people who had very severe trauma at very early ages in their lives, that was long lasting into their teens or those those years. So that group of people, they're going to take a long time, we have other people who go much more quickly, some of our adolescents, for example, come in to a six month treatment.

And believe me as six months, they re roll they've got all their teams to be on and their choir to be on, and their friends to go see an 18,000 other things that they want to do, and they're no more suicidal, and they're finished with us, and they do fine.

Okay, so one of the other questions that we're commonly asked is, does the treatment actually work for everyone?

Let's face it, no treatment works for everyone. This treatment works for more people than it does work for and generally has better outcomes than any other treatment that we know of, for the problems that we address. But there's no treatment that works for everyone.

Marsha, can I ask you what is the commitment that is required of an individual if they're considering participating in a standard DBT program?

Well, it's not 100% clear that you have a commitment is required, what you have is your commitment that want it, which is to say DBT has always had the policy, that we don't take involuntary patients. So people are sent here by other people required to be here by the law, or something like that. They don't want to be in the treatment, we're not willing to treat them because our goals are the patient's goals. So what a person has to do is be there voluntarily, which is to say, I commit to doing this treatment.

With our adolescents, for example, we had many of the adolescents who were there so it because their parents were making them come. So we talked with them a lot. And we said, Listen, we're not willing to let you be here. You have to want to be here for because the treatment won't work otherwise. And in general, those who agree to be there, they may not have wanted to be there. But they said okay, fine, I'll do it. We check. So really has to do with what works best, not exactly what's required. There's not some law somewhere.

You mentioned earlier on that there are different components to the treatment. So you have individual therapy, and you have group skills sessions. Can you tell us a little bit more about the skills component?

So we in our skills, we have four core modules. The first module is a set of mindfulness skills, which to a certain extent, breaks up mindfulness meditation, and turns it into small chunks of behavior. And so we teach those, those are the core so they underpin every other set of skills that we have that we have in interpersonal effectiveness skills.

And these are skills which are how to ask for what you want.

Get What You Want without harming the relationship and without losing yourself as a state.

So those are core set of skills and interpersonal skills, then we have a set of emotion regulation skills, which are really designed to help you regulate emotions that you do not want to have, and build resilience so that you're less likely to become emotionally disregulated. So that's those skills.

Then we have another set of sales call distress tolerance skills. And the first half of those are called crisis survival skills, which are how to get through a crisis without making it worse by doing something dysfunctional or disruptive. That's part one.

And Part two is how do you live a life, that's not the life that you want without being miserable in? Okay, so that's those now interwoven through all these skills, what we call the supplemental skills.

So for example, we have an entire set of skills that are addiction skills, mainly because we've done a number of studies with heroin addicts, and it's been very effective. So we have our addiction skills, we have middle path skills, which are skills really designed for adolescents and their parents, because with with adolescence, we treat the parents and the adolescents together.

And we have other skills that have been developed for other things, there's sets of eating disorder skills, we now have a brand new set of skills developed by Tom Lynch, which are for individuals who have over controlled emotions, that's very exciting, because they're the newest that we've gone.

And so too, we have skills on how to find people and get them to like you are teenagers like those skills. And so we have a lot of sort of supplementary skills, we have a set of skills, it teaches parents how to validate their adolescence. So these are all that supplementary, which I'm not saying all of them, and in general, a supplementary are put in and I tell clients, we all tell clients that any skill you talk us into teaching you will teach you.

So two participants need to attend both group and individual sessions. And standard DBT. Yes, if you're want to say they're in DBT, standard, you have to attend above. So the only real exception is if a person has social phobia, really phobia about going into a group setting, then what we do is we let them start in individual as the therapist treats the social phobia.

And as soon as that's treated, and they go to the group,

Your other option is to get skills individually. The problem with that is there's almost never an available therapist who could do individual skills training in a program that I know of. And so, in general, you have to go.

So during the course of the 12 month program, you repeat the modules twice. Why is that? main reason we do that is when you really tweeting people very severe disorders, most of the time, they're too dysregulated, the first time you go to ear and understand half of what you're saying. So the skills are very understandable, but not if you're so aroused, that you can't think you can't listen, he can't pay attention, which does happen to some. So what we've discovered is if you go through at once, often people, they learn the skills, but not super well. And when they go through the second time, they say, Oh, that's what that was, I can do that. We do the margins twice.

Because at the beginning, in the first times that we did it, we discovered a lot of people come to group and they're so emotionally aroused, that their cognitive functioning sort of goes way down. with cognitive functioning way down, people can't pay attention. They can't process the information you're giving them. And they have a lot of difficulty learning the skills. What we do, therefore, is do it a second time.

And in the second time, what ordinarily happens almost always is people say, Oh, that's what that skill was, oh, okay, I get it. I can do it now. And then they learn them very easily. The second time through, we have right now, when we start new skills, programs with new people come in the oldest but good issues.

They say, Listen, don't worry, you're gonna have trouble understanding the first time but don't worry, you're going to get them they're easy to get. You just had to have patience. So I think that's they're right about that. Okay, can I ask you why is it important to keep your diary card regularly? Well, we do it I record because the research is very strong, that if you wait a whole week to tell someone what you did during the week, it's highly unlikely that you're going to be accurate. In fact, if you even wait a couple of days, you're usually inaccurate.

So we asked people to fill diary cards out so that they can track the behavior that we're paying attention to in their treatment.

So we have some standard diary cards, like everybody keeps track of how, what was your urge to harm yourself? What was your urge to kill yourself? What was your urge to use drugs? And did you harm yourself? Did you try to kill yourself? What was your use of alcohol? What was your use of illicit drugs? Did you use your medications as prescribed? And did you use over the counter drugs, and it's remarkable how effective this is.

Because then the treatment, when a person comes in for a session, they in the therapists review the diary cards to see how they're doing, are things going up?

Are they going down? We also ask each week, what's your level of misery each day. And so misery is a proxy for depression and other things.

And so it's very important, then we have a whole section where people can keep track of behavior they and their therapists think are important for them. That might not be for other people. But if you don't know what happened during the week is very hard to know what you're supposed to target in this session.

So Marsha, can I ask, why is it that you're not required to give the same level of detail and information and skills group, as you do to your individual therapist?

That's a really good question.

The main reason that we don't do it is because dysfunctional and addictive behaviors are contagious. And there's a lot of research on this. And we've seen in our own groups, that if one person starts talking about cutting, let's say, another person starts wanting to cut. This is one of the problems with inpatient treatment is one person sees another person cuts or they start cutting.

This is also a huge problem with Facebook, as you start telling everyone that you've been cutting and other people start cutting. And this is a, everyone understands this when we teach it, because everyone understands that for a drug addict, if you start talking about drugs, everybody starts wanting to use drugs. So you can't talk about drug use can't talk about cutting, you can't talk about suicidal Baby, you can't talk about eating disorders, but you can call them your target behaviors.

So that's one of the main rules. And it's one of the rules, I have to say, everybody understand you also can't throw your scars out on the table and do things like that. So the idea is that you have to really pay attention to the fact that you don't want contagious behavior.

So why is it important for people to have access to their their therapist using the phone out of ours?

There are two reasons for that.

Reason one is people often need coaching. If a person starts having a craving for drugs, or a strong desire to harm themselves, or wants to kill themselves, they need coaching. And what's very clear to me and to our whole group, is that the single best coach is always going to be the individual psychotherapist, because that's the one person who actually knows them.

The only exception to that is in our skills only program, we may have coaches who are skills, co leaders. But that's the main reason because people need coaching. And, as I say, to my therapists all the time, I'm sure you'd rather take a phone call and go to the morgue. So one of the reasons is to try to keep that rate of suicide down.

And just to be clear, I have never talked to an expert in suicide that does not take phone calls.

Now, the other reason is, is I have always felt it was surprisingly unfair, that in this particular relationship, in comparison to every other relationship anybody could get themselves into. The therapist has complete and total control over when you can talk about problems you're having with your relationship.

You know, when you're married, one person doesn't get to Sam, sorry, it's not going. And even you know, with friends, somebody can't say I'm sorry, you can only talk about that on Tuesday. But in psychotherapy, you can do that. And I've just always thought it was supremely unfair.

So I said, Look, clients often leave sessions really distressed thinking you hate them, or you don't love them or, or anger or something like that. And I've just never thought was fair, and they can't call you. So they can call you.

Now admittedly, they have to be skillful, or you can tell them you don't want to talk to them. But what you can't say is you can't call me at all unless they've done something so well. The wall there is reasonable for you to say when you act like that I'm not talking to you.

And therapists have to say that if they do do that, Marsha, sometimes our clients worry about terms like dialectical behavior therapy. And when they think about the treatment, they're worried that they won't be able to understand some of the terminology. What are your thoughts about that? This drives me wild. This is sort of the assumption that clients will not be able to understand, you would be amazed at what clients can understand.

Now, mentally, if you can go around using big words that nobody understands, you're going to have to define them. So I ineffective and competent therapists could have trouble. But in general, we use ordinary English words, translate in whatever language they're being translated into. And it's it's rather insulting, or rather fragile icing a client to think they can understand big words, I always ask any word that I think someone might not understand.

I say, do you understand? We have found, for example, in our adolescent program, I'm not kidding, we use the adult skills, which are reasonably complicated. And I hate to say this, but the adolescents understand them a lot better than their parents understand them, to be honest with you and ALS is teach them to the parents. So we've really never had any problem, we certainly have problems with people with dyslexia, reading handouts. And for many of them, you know, the words are flowing off the page or something. And so you have to know whether someone has any sort of cognitive disability.

And then you've got to match your way of talking and treating to that particular problem.

So for example, with my dyslexic, I was very careful to always read the whole handout that everybody else could read, I would read out loud, or I have other people read it out loud. By the way, I've never had anybody without dyslexia, not be able to read it out loud. And teenagers love to read it out, but they raise their hands right away. So you have to modify what you're doing. But it's remarkable how little modification people have to do. So I think this is the fear of therapists, not the fear of clients.

Something that clients often say to us is that what is the point in changing if the world around us isn't willing to change? What are your thoughts about that? assuming that's a genuine question, the client really wants to know, why should they change, I would point out to them, they're really making a difference. If other people change, actually, what counts is, do you need to change your life to be more effective, and you have to be happier.

So if you're going to do is compare yourself to others decide whether you're going to change, you're probably going to run into trouble down the road. So what you have to look at is the pros and cons of your changing. If there's a lot of pros, not so many cards in them, let us help you change. If you discovered that there's really nothing for you to change, you're not going to get anywhere, you won't be happier, nothing's going to be better. In five, you probably don't need us. Can participants fail a DBT? My answer is a really short answer on this one, no clients cannot fail. Now, that does not mean that therapists cannot fail. And it doesn't mean that the treatment can't fail.

So if a therapist gives the treatment by the book, is it here and has fidelity, and the client does not get better than the treatment itself failed?

That's obviously possible, no treatment helps everybody. On the other hand, if you have a person who didn't provide it by the book, didn't provide it competently, and the patient doesn't get better, then one could entertain the idea that the therapist failed.

And it's certainly the case that a fear therapist can fail as a therapist treating a specific patient. So Marshall, what happens after you're one of DBT, when standard DBT has finished, what happens for for participants at that stage, most of our clients, and at one year, many of our clients at the end of one year, believe they need a whole lot more therapy. It's been our experience. And often that therapist degrees.

So we have everybody all upset they have to end at the end of one year.

In our research studies, this become a major problem, except we then came up with a fabulous solution, which is that we tell people that although they have to end and the reason they have to enter in a research study is you had to be able to collect follow up data. Okay, so you have to generally they have to be out of therapy for six months. So the patient has to cry as their icon standard, I'm probably going to kill myself it's going to be a disaster acceptor, and half the time the therapists agree with them, except because it was research.

We had to let them go for six months. We told them though that at the end of six months, if they wanted to, they could come back into therapy.

So at the end of six months, were around waiting around for everybody to come back. Okay, it turned out that most people never came back. And they would call us and say they were done fabulous that they, in fact, had not needed more therapy. So then what we started doing, when people came in had a year, they would cry, the therapist would cry, and we would tell everyone Listen, if you leave, you can't come back in six months.

But our guess is when you leave, you're like, a butterfly and a hand a you are going to fly. And I can't count the people have called us up and say, you know, you are right, I flow. So our experience has been that many people will do fine, but it's scary for everybody. So I'm now entertaining, the idea of trying a concept of vacations from therapy. Because once you get attached, often the patients attach to the therapist, just as often therapist as the patient. Nobody wants to end. So it's possible that if we put in vacations, I have zero data on this.

But if we put in vacations, we'll find that a lot of people actually were ready to fly. If they are ready to fly, you always want to say you can have a booster session.

So for example, over all these years, I have a lot of people who call up and say can I just come in, just want to get a checkup, sort of, and people come in, I had one person whose baby died at age three and had been had all kinds of problems all his life. And she comes in to say I just want to know Am I normal or not. So I have an appointment with her we discussed it we discussed it was normal grieving was not normal grieving. And she leaves, I would say she comes in, I don't know where every six to nine to 12 months to check out, she'll come home every checkup. And I have a lot of other clients who do the same thing.

So I think it's, you know, what we tell clients is you may be out of therapy, and I may not be your therapist, but always be your ex therapist, and an ex therapist is a person in your life. In other words, it's not like I'm now out of your life. I'm just in as an ex therapists. And say you're writing a book on how to be a good ex therapist.

So how long will the results of DBT last?

Last? Jeepers Creepers, who knows, we've never done a multi year over many years follow up. And the federal government in the United States has not been terribly interested in funding that.

So my guess is that last as long as you practice your skills, many of them, I have many clients who've been in treatment with me who are now in fabulous condition, very happy, have families have good jobs are doing really well. So a lot of people are permanently healed. I just don't know what percent that is. There are other people who are always going to have some problems. Always be sensitive, perhaps always have some sadness, particularly people who have really tragic childhoods, you're going to always have a certain amount of sadness.

But do people continue to harm themselves? No. Are the people we've done a lot of work with with drug addicts? And are the people who are addicted to drugs going to go back to drugs? Many doubt? Does that mean no one goes back now? What can participants do to stay well, in the years after they finished DBT. The key to staying well period is practicing skills.

One, the other is keeping track of what you think that you need in your life, if I've learned anything from teaching patients, is that what patients think they need almost always is what they need. So the trick here is to not let somebody sell you on the idea that you don't need what you think you need. And to go after it.

That's, that's step one. Step two is to wrap except you may not get everything you need. So given that, that that's true, it's really important to keep working to try to get what you think you need, and not to give it up and think, okay, I'm doomed to a life of joy and happiness. And the trick to that is to recognize that you may get what you need, it just may look like it's something else.

So you got to keep your eyes open. And to a certain extent, you have to wear rose colored glasses. But you know, most people don't know this, but I'll give you a little tip. This is actually a lot of research on this. It turns out that depressed people see reality more accurately than happy people, because happy people distort. So a little distortion goes a long way a life. So trust yourself that you need what you've You need to keep trying to get it. In other words, you can't just sit back and wait for it to find you. But also be willing to take half a cake. When you don't get the whole cake. put on a pair of rose colored glasses you'll be fine.

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