For her work in establishing the Dialectic Behavioral Therapy (DBT) model for use with chronically suicidal individuals suffering from borderline personality disorder (BPD), Marsha M. Linehan, Ph.D., is this year's recipient of the annual research award given by the New York City-based American Foundation for Suicide Prevention (AFSP). Linehan is professor of psychology and adjunct professor of psychiatry and behavioral sciences at the University of Washington.
Before receiving her award, Linehan-who is also director of the Behavioral Research and Therapy Clinics, a federally funded program that evaluates the efficacy of treatments for suicidal behavior, substance abuse and BPD-gave a lecture about her work. "I'm going to talk about how to create a life worth living," she told attendees. "How do you change the brain is the fundamental question of the day, especially in people who through their learning, trauma or intrauterine experiences end up with brains that create a life that is perceived as painful and not worth living."
Linehan noted that suicide has "been with us a long time" and that "all our drugs and treatments have not made a dent" in suicide rates. And, despite the fact that suicide is among the top 10 causes of death, there have been fewer than 25 randomized controlled trials of any treatment-biological or psychological-designed specifically for reducing risk of suicide among patients already identified as suicidal. Instead, she said, most treatment studies that examine characteristics associated with suicide exclude high-risk individuals.
Linehan noted that the Finnish National Suicide Project (Henriksson et al., 1993), which conducted psychiatric autopsies of suicides, indicated that depression accounted for 28% to 59% of suicides, whereas personality disorders accounted for 35% to 45%. "That's a stunning number," said Linehan, adding that an even higher percentage of those attempting suicide have a personality disorder and that BPD is the personality disorder most associated with both attempted and completed suicides.
"The basic idea is that BPD is a pervasive disorder of the emotion regulation system," she said. "BPD criterion behaviors function to regulate emotions or are a natural consequence of emotion dysregulation. From that point of view, suicide is a very powerful regulator, and nonfatal suicidal behavior is extremely effective in regulating emotions. For BPD patients, suicide is often the only effective behavior."
As a treatment-researcher, Linehan said her research began with the question "Why not commit suicide?" "The idea was to figure that out and then teach people who want to do it how not to want to," she explained. In the early 1980s, she developed the Reasons for Living Inventory (Linehan et al., 1983), listing six basic reasons people have for staying alive when thinking about suicide. According to Linehan, these include survival and coping beliefs, such as "life will get better," "I can cope" and "life has value," responsibility to family, concerns for children, fear of the act of suicide, fear of social disapproval of suicide and moral concerns about suicide. "I see a lot of people [with BPD] who don't have these things to hold on to," she said. "Fifty percent to 75% make a suicide attempt sometime."
With borderline patients in mind, Linehan developed DBT as a comprehensive psychosocial treatment program that blends together the most effective interventions in behavior therapy and balances them with treatment strategies that focus on acceptance and validation. "It is currently the only psychotherapy that has been shown to be effective in a randomized trial for BPD," said Linehan. "The emphasis on dialectics focuses treatment efforts on identifying and resolving the inherent tensions that both demand as well as impede change. The overriding dialectic is the necessity of acceptance of patients as they are within the context of moving them to change."
DBT occurs in four stages. In the first stage, the focus is to get behavioral control. "Out-of-control behaviors constitute those that are disordered due to the severity of the disorder or resulting from having multiple diagnoses, such as the suicidal borderline patient with co-morbid panic disorder and depression," said Linehan. "[The focus here] is on keeping the patient alive and in the treatment setting, and gaining required skills and quality of life necessary to work on any further goals."
Henriksson MM, Aro HM, Marttunen MJ et al. (1993), Mental disorders and comorbidity in suicide. Am J Psychiatry 150(6):935-940.
Koons CR, Robins CJ, Bishop GK et al. (1998), Efficacy of dialectical behavior therapy with borderline women veterans: a randomized controlled trial. Paper presented at 32nd annual convention of the Association for the Advancement of Behavior Therapy. Washington, D.C.
Linehan MM (1997), Self-verification and drug abusers: implications for treatment. Psychological Science 8:1-3.
Linehan MM, Armstrong HE, Suarez A et al. (1991), Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry 48(12):1060-1064. See comments in 50(2):157-158.
Linehan MM, Goodstein JL, Nielsen SL, Chiles JA (1983), Reasons for staying alive when you're thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol 51(2):276-286.
Miller A, Rathus JH, Linehan MM et al. (1997), Dialectical behavior therapy adapted for suicidal adolescents. Journal of Practical Psychiatry and Behavioral Health 3:78-86.
Stanley B, Ivanoff A, Brodsky B, Oppenheim S (1998), Comparison of DBT and "treatment as usual" in suicidal and self-mutilating behavior. Paper presented at 32nd annual convention of the Association for the Advancement of Behavior Therapy. Washington, D.C.