Dr. Marsha Linehan is a contemporary theorist whose study of parasuicidal behavior led her to conduct research on, and clinical practice with, people who have 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 called her approach Dialectical Behavior Therapy (DBT). Linehan advises that clinicians use DBT with clients who fit specific criteria that Linehan developed in an attempt to revise the DSM-IV’s model of BPD: emotional dysregulation, interpersonal dysregulation, cognitive dysfunction, and dysregulation of the self. DBT 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 them in clinical practice, is Dr. Marsha Linehan. Linehan has developed a comprehensive model of BPD that includes a possible etiology for the condition, a persuasive argument for why those who have it become so entrenched in their behavioral patterns, and a suggested treatment approach. She chose to call this model Dialectical Behavior Therapy or DBT, and many of its practitioners experience success where so many others have failed.
The Theorist and Her Influences
Linehan published an introductory video for DBT, titled Understanding Borderline Personality Disorder: the Dialectical Approach, 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 of this writeup, Dr. Linehan still holds these positions, which making her an active, contemporary theorist (Google Search, 2004). Later in the 1995 video, Dr. Linehan makes clear that she does not consider herself first and foremost 'an expert on BPD'; rather, she identifies 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).
Linehan has an educational background in the established field of cognitive-behavioral psychology, which the video refers to as ‘a technology of change’ of behavior through learning and experience. However, while treating people with BPD in the early 1980s, Dr. Linehan became frustrated with the cognitive-behavioral model that she was working with, and decided 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.’ This is a strategy of accepting the client in order to create a change in them, or accepting the client’s unfulfilled potential instead of the client’s actual being. Dr. Linehan believed that for her BPD 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 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.
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; for evidence of this predisposition, she cites the 1985 research of Cowdry regarding people with BPD 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).
Accepting Linehan’s theory regarding BPD’s etiology and her proposed criteria for assessing it equips the practitioner 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 death would feel better than their current life, this belief is the first thing that must be tackled in their treatment. The drug overdose method that people with BPD usually prefer to attempt suicide by 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 do not know why this would be. Linehan notes boldly that other suicidal behaviors, such as jumping from high places or attempting to drown oneself, focus the mind on something besides emotion-—and distraction regulates affect quite effectively. To be able to control emotion, you must control attention, she asserts. She also asserts that other parasuicidal behaviors change a person's 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 synchronizes in style with DBT. Linehan wants people with BPD to 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).
- 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.