Dr. Marsha Linehan is a contemporary theorist whose study of parasuicidal behavior led her to conduct research on and clinical practice with sufferers of Borderline Personality Disorder (BPD). Starting in the 1980s, Dr. Linehan developed an approach for treating BPD that incorporated Zen Buddhist practices into a cognitive-behavioral theoretical orientation. Dr. Linehan’s approach is called Dialectical Behavior Therapy (DBT). DBT is advised for use with clients who fit the criteria that Linehan has developed in an attempt to revise the DSM-IV’s model of BPD (Linehan’s criteria are emotional dysregulation, interpersonal dysregulation, cognitive dysfunction, and dysregulation of the self), and it focuses on the resolution of polarities and tension, particularly the polarity of acceptance/change.
Dr. Marsha Linehan and the Dialectical Approach to Treating
Borderline Personality Disorder
Much controversy surrounds the diagnosis of Borderline Personality Disorder (BPD). In some circles, it is considered to be the most overdiagnosed condition in the DSM-IV, a label that gets attached to the clients who do not get well, whose problems seem intractable and whose relationships with their therapists are full of conflict and negative feelings at both ends. Many social workers and psychologists refuse to treat clients who have been diagnosed with BPD. One of the more renowned psychologists who do not, who actually welcome borderlines in clinical practice, is Dr. Marsha Linehan. Dr. Linehan has developed a comprehensive model of BPD that includes a possible etiology for the condition, a persuasive argument for why its sufferers become so entrenched in their behavioral patterns, and a suggested treatment approach. She chose to call this model Dialectical Behavior Therapy or DBT, and its practitioners have been greeted with success where so many others have failed.
Section I: The Theorist and Her Influences
An introductory video for DBT, titled Understanding Borderline Personality Disorder: the Dialectical Approach, was published in 1995. It specifies in its introduction that Dr. Linehan is a professor of psychology at the University of Washington in Seattle, and also the director of a suicidal behaviors clinic there, and that she had been researching BPD for twenty years before the video was released. A cursory perusal of Internet sources reveals that, as of the date this writeup has been written on, Dr. Linehan still holds these positions, which means she is still an active, contemporary theorist (Google Search, 2004). Later in the 1995 video, Dr. Linehan makes clear during a presentation that she does not consider herself first and foremost an expert on BPD; rather, she identifies herself as a practitioner who studies and treats parasuicidal behavior. Dr. Linehan defines parasuicidal behavior as “any intentional, acute, self-injurious behavior with or without suicidal intent, including both suicide attempts and self-mutilative behaviors”, and states that between 70 and 75% of borderlines who are in treatment have committed at least one parasuicidal act (Linehan, 1995).
Dr. Linehan’s education was based in the established field of cognitive-behavioral psychology, which the video refers to as ‘a technology of change’, focused on changing behavior through learning and experience. However, while treating borderlines in the early 1980s, Dr. Linehan decided that the cognitive-behavioral model that she was working with was insufficient, and that she needed to incorporate an element she calls ‘radical acceptance’. Dr. Linehan makes clear in her videotaped presentation that ‘acceptance’ was a real buzzword in psychology around the time that she started to promote DBT, but she maintains that her idea of ‘radical acceptance’ is different. When most psychologists talk about ‘acceptance’, she states, they mean ‘acceptance as change’, accepting the client in order to create a change, accepting the client’s unfulfilled potential instead of the client’s actual being. Dr. Linehan believed that for her borderline clients to get well, therapy needed to involved a level of acceptance that would go above and beyond ‘acceptance as change’. For inspiration, she turned to Eastern psychology as translated into Zen Buddhist meditation practice. However, fearing that her colleagues due to their cultural biases would not take her work seriously if she were to call it ‘Zen Behavior Therapy’, Dr. Linehan also researched Western philosophical traditions. There she discovered dialectics, the approach in which thesis paired with antithesis brings synthesis. Dialectics seemed appropriately seasoned for the Western palates of the practitioners who would be reading her work, and thus, DBT was born.
Section II: The Concepts
Linehan’s most basic concept that a practitioner must agree with in order to practice DBT is that “Borderline Personality Disorder, at its core, is a disorder of the emotion regulation system” that pairs high emotional vulnerability with poor emotional modulation (Dawkins, 1995). Linehan believes that this disorder is biosocial in origin: a biological predisposition (which she claims is not due to genetics, but rather to other biological factors such as teratogens or early head trauma, and for evidence of this predisposition she cites the 1985 research of Cowdry regarding borderlines who have low thresholds for activation of the limbic structures in their brains) combines with an invalidating environment (one which “pervasively communicates to the individual that their private responses are invalid, inappropriate, or incorrect”) to create emotional instability.
This emotional instability manifests in five ways, which Dr. Linehan prefers to use as criteria for establishing the presence of BPD (as opposed to those laid out in the DSM-IV): emotional dysregulation—- emotional responses that are highly reactive and frequently center around depression, anxiety, irritability, and anger; interpersonal dysregulation-— fears of abandonment, and relationships that are chaotic, intense, and difficult; behavioral dysregulation-— extreme impulsivity, which often shows up in spending sprees, reckless driving, substance abuse, and binge eating; cognitive dysfunction-— periods of depersonalization, delusion, and dissociation that do not extend into psychosis; and dysregulation of the self-— chronic feelings of emptiness and problems of self-identity (Dawkins).
The practitioner who accepts Dr. Linehan’s theory regarding BPD’s etiology and her proposed criteria for assessing it is better-equipped to understand her explanation for why it is so difficult to treat, namely, because the function of all borderline behaviors that are not the direct consequence of dysregulated affect is to regulate affect, and they are extremely effective at executing this function. “Suicidal behaviors are almost made in heaven for affect regulation”, she notes (Dawkins), and since almost all borderlines believe that if they die they are going to feel better, this belief is the first thing that must be tackled in their treatment. The drug overdose that is the favored method for borderlines to attempt suicide regulates affect in that it puts the overdoser to sleep, and most of the time people feel better when they wake up than when they went to sleep; and Linehan dares to state in her presentation that the most popular self-injurious behaviors, cutting and burning, are very effective at regulating the emotions of anxiety and anger, although experts are stumped as to why this is. Linehan is also bold enough to note that other suicidal behaviors, such as jumping from high places or attempting to drown oneself, focus the mind on something besides emotion-—and distraction is a very effective affect regulation strategy. To be able to control emotion, you must control attention, she asserts. She also asserts that other parasuicidal behaviors change the environment, and wryly observes that the only reason therapists cannot endorse such very effective and functional behavior is that it has long-term negative side effects.
This sort of wry observation is stylistically in sync with DBT. The chief purpose of Linehan’s model of treatment is to help borderlines move past their tendency to bounce back and forth between extremes, between thesis and antithesis, to synthesis. These extremes usually occur along three axes: from emotional vulnerability to self-invalidation, from active-passivity to apparent competence, and from unrelenting crises to inhibited grieving (Linehan 7-10). To help modulate the client’s behavior, the therapist takes an approach that binds together strategies of problem-solving and validation, styles of irreverence and warmth, and underlying attitudes of change and radical acceptance (23).
Section III: A Personal Response (How Dr. Linehan’s Work Informs My Understanding of Human Development)
Clearly, Dr. Linehan’s work is meant to apply to a specific client population. Although I have been exposed to some material in the past that dealt with BPD, Dr. Linehan’s work is the first that I have come across that proposes an etiology for the condition, and what’s more, what she proposes makes a lot of sense to me, given what I have observed or discovered through interviews regarding the lives of individuals such as my cousin who have been diagnosed with this condition. I have nothing but respect for the cultural traditions that Dr. Linehan drew upon to enhance her treatment model; both Zen Buddhism and dialectics have been dear philosophical concepts to me for years now, ever since I was first exposed to them in high school. Dr. Linehan recommends that all clients should be assessed for borderline criteria (emotional dysregulation, interpersonal dysregulation, behavioral dysregulation, cognitive dysregulation, and dysregulation of the self) at the start of treatment, if for no other reason than the fact that they are in a phase of apparent competence may mask the beginnings of a new crisis, and while I am unsure as to whether I currently have enough expertise to assess a client well at this time, I am eager to continue in my research of Dr. Linehan’s work and to apply my findings to some of the students I am currently seeing on a weekly basis as part of my internship at a local high school. I have a caseload of approximately ten students, and two of these my supervisor has tagged as being potential borderlines, with the caveat that she feels neither of us is in the best position to make a formal diagnosis. I hope that next semester I will be able to incorporate a dialectical approach into my work with these two students in a subtle manner and see if the results are positive. In an interview with Dr. Linehan at the end of her 1995 video, she makes clear that when it comes to borderlines, whether they have been formally assessed or not, any improvement in their life circumstances is gratifying to the therapist in a very rare and special way. I look forward to experiencing that kind of gratification in my eventual clinical work; I plan on doing everything in my power to prevent the categorical denial of services to those who suffer from BPD.
- Dawkins, K (Producer). (1995). Understanding borderline personality disorder: the dialectical approach motion picture. United States: Guilford Publications.
- Google Search: Marsha Linehan biography. (2004). Retrieved December 4, 2004, from http://www.google.com/search?hl=en&q=Marsha+Linehan+biography&btnG=Google+Search
- Linehan, M.M. (1995). Understanding borderline personality disorder: the dialectical approach program manual. New York: Guilford Press.