Escaping Hell: Marsha Linehan and the Creation of Dialectical Behavior Therapy

In 1991, a paper appeared in the Archives of General Psychology that held out the promise, at long last, of an effective treatment for people with Borderline Personality Disorder which carried the further potential of radically improving outcomes for individuals in danger of committing self harm or suicide. The paper was by Marsha Linehan, and the new method it outlined was Dialectical Behavior Therapy, or DBT, a practical approach to providing patients with the tools they need to regulate their behaviors in the everyday world in order to keep minor stimuli from erupting into major emotional events.

How DBT achieved results with patients that other psychologists and psychiatrists had given up as violent lost causes has a great deal to do with the story of Linehan herself, whose path to success as a psychologist was anything but assured. Born in Tulsa, Oklahoma, in 1943 to a perfectionist mother and a conservative oil industry father, Linehan grew up pummeled on all sides by feelings of inadequacy, particularly when she compared herself (as her mother often did) to her slimmer, more poised sister Aline. Aline never said the wrong thing, never had trouble attracting a boyfriend, never was at a loss for how to react in a social situation, but Marsha’s habit of speaking without thinking, and of behaving in ways outside the bounds of normalcy as conceived by her community, kept her from the parental adoration that was heaped on Aline.

How much of what followed was genetic, and how much of it was due to the constant messages she received at home that the person she was was not the person her parents wanted, is impossible to determine, but the magnitude of Marsha’s sudden collapse her senior year of high school was there for all to see. From being a well-regarded campus presence, she withdrew into the four walls of her room, crying for days on end, racked with headaches, and plunged into a depression that sapped her will to continue living. In April 1961, at their wits’ end for how to deal with her, and desperate to avoid the scandal of her potentially acting out in front of friends and family, Marsha Linehan’s parents committed her to the Institute of Living in Hartford, Connecticut. 

Here, Linehan’s compulsion to self-harm only worsened under a regime that included electroshock therapy, heavy and constant medication, freezing blanket treatment, and solitary confinement. She would cut and burn herself, and throw herself head first from her bed to do as much damage as possible to her skull, producing brain trauma that likely played a role in the erasure of long swaths of Linehan’s childhood from her memory. The experience was worsened by the fact that, as a child of a Catholic Oklahoma family in the 1950s, she was raised to believe in the literal existence of the Judaeo-Christian god, so that not only did she have to labor under the weight of her psychological problems, but also the distress that the god she believed in saw all her suffering, and was, day after day after day, doing nothing to help her, that her torment was seen and approved of by the being she loved with all her heart. 

The long scars of her Catholic upbringing would continue in later life, in painful years of attempting to recapture the unique high of feeling a revelatory and heightened personal connection with a supernatural being, only to feel depressed and abandoned when that connection did not come, but the flip side of the unnecessary harm that is caused when people experiencing a normal setback ascribe it to the direct displeasure or indifference of their deity instead of simply to bad luck or a quirk of biology is that moments of clarity can feel like they are not merely a good idea emanating from within, but are in fact coming from a divine source, and in the depths of what she described as the hell of her inability to control her actions, Linehan felt relief at last when she vowed to her god that, when she found her own way out of hell, she would then devote her life to showing others how to follow her path.

She stayed at the Institute until June of 1963, and decided that her only way to be able to help others escape the hell she had known was to continue her education, and leave the poisonous home environment that just fed into the worst of her feelings of personal inadequacy. She worked by day and took classes by night, quickly making suicide her particular field of study. In 1965, she left Tulsa for Chicago, attending Loyola University out of a fear that attending a non-Catholic university might jar her out of the faith that she believed central to continuing her mission. While here, she decided to become a lay religious, taking a vow of chastity and poverty without, however, going the extra step of full religious orders as a nun. She was attracted to the mystical side of Christianity, as well as to the side of Catholicism that was, in the 1960s, trying to push the denomination into a wider engagement with advanced social issues, including opposition to the Vietnam War, racism, and the exploitation of the urban poor. 

Intellectually, these were the years that saw Linehan shift from a belief in Freudian psychoanalysis to behaviorism, which entailed a shift from a method centered on making theories about internal states created by past trauma and towards gathering data about observable behaviors. Psychoanalysis had proven in the previous decades singularly unsuccessful in dealing with suicidal individuals, or most particularly with Borderline Personality Disorder, and Linehan believed it was because they were approaching the problem from the wrong end. These people’s main problem was that they could not adjust their behavior to match the actualities of the situation at hand. They needed tools to cope with reality, not years of theorizing about events they couldn’t remember.

Linehan’s first step in giving those tools came with a lucky break. In 1972, she was offered the chance to join the pre-eminent behaviorist research center in the world at Stony Brook, where Jerry Davison and Marvin Goldfried were taking the first steps in gathering reliable data about the effectiveness of behavior modification in extreme cases. Arriving there, Linehan proceeded to pursue her specialty of suicide research from a behaviorist perspective. That work, which she had to carry on in the face of active antagonism to behaviorism at her next institution, the Catholic University of America, finally found a fast and secure home at the University of Washington, where she began working in 1977. 

DBT was to receive its most extensive development and testing at U of W in the 1980s, as Linehan sought to combine the best aspects of classic behaviorism with new insights from practices of the Eastern tradition that she studied while on long Zen retreats in Germany and California. Her focus was on what workable strategies and practices she could teach her patients to give them a chance at consistently choosing behaviors that would allow for the leading of an existence which they perceived as worth continuing to live. Through trial and error, she determined that both approaches relying either entirely on accepting one’s current state and ones focused entirely on seeking to change one’s behavior met deep resistances in her patients, and so she developed what she came to call her dialectic approach, a four prong strategy with elements of both acceptance and change that would lead patients day by day to a higher and more sustainable synthesis.

DBT’s four skill categories, as Linehan developed them, are (1) Mindfulness, (2) Distress Tolerance, (3) Emotion Regulation, and (4) Interpersonal Effectiveness. The first two have to do with acceptance, of skills you can use to be fully aware of where you are emotionally at a given moment, and what you can do to help yourself bear the heightened distress that everyday life causes you. The latter two provide strategies for more effectively anticipating difficult scenarios, facing unrealistic fears, and engaging with routine situations to produce outcomes that are acceptable and improve life. What Linehan found was that her patients’ episodes of extreme emotion often stemmed from inabilities to effectively interface with people and the world around them. She had known from her own youth the constant strain put on her by feeling that she was always saying or doing the wrong thing in social situations, which caused people to reject her and prevented her from achieving those milestones that give life a feeling of meaning and progress. So she developed step by step protocols that patients could use in real life, often summarized in handy acronyms like the DEAR MAN procedure, for when you are trying to get another person to approve something that will help you: (1) Describe the situation, giving the history that has led up to you making your request, (2) Express clearly how and why you feel as you do, (3) Assert your wish by directly making your request, (4) Reinforce why what you want could also be of benefit to the person you’re asking it from, (5) Mindful pursuance of your request, not letting yourself get diverted from what you had brought up, (6) Appear confident so that it is harder to slough off your request as something you only half heartedly believe in, and (7) Negotiate and be willing to find a reasonable compromise that is informed by a consideration of the other person’s point of view. These might sound like common practices (though who among us doesn’t struggle with one step or another, honestly) but to people who struggle to perceive communication signs from others, or who are easily derailed by their own heightened emotional responses to situations, having a set of principles like that at hand to cling to has proven a crucial lifeline in navigating daily challenges. 

On the patient’s side, DBT is centered around developing and evolving one’s skills in self-evaluation and world interaction on the theory that, just as internal states influence behavior, it is also true that behaviors can change internal states, that persistent and regular positive interaction with surroundings will produce positive changes within that sum over time to a less fearful approach to the world and less negative sense of self-worth. The DBT therapist, meanwhile, is also expected to take a more than usually active role in their patients’ lives. While a psychoanalyst will only engage within the space of a consultation hour, controlling its direction and deflecting any attempts by the patient to engage with them personally, a DBT therapist is expected to make themselves available at all times, to engage with their patient as an equal, to share elements of their own life experience, and to work as a team with other therapists to bring as much support as possible to producing better real-world results for their patients. 

The initial data pouring out of the first DBT studies was massively encouraging, showing that two times as many psychoanalytic patients quit their treatment than did those receiving DBT treatment, that DBT patients were hospitalized for extreme episodes for a fifth as many days, and had an eighth as many acts of self-harm. These were statistically important numbers that the psychological and psychiatric communities could not ignore, as much as they tried to pin the success of DBT on outside factors like Linehan’s personal charisma as a therapist, or complain that, yes, it worked according to exterior measures, but it wasn’t really treating the deep problems within, as psychoanalysis and pharmaceutical treatment did. 

In the years that followed Linehan’s groundbreaking 1991 article and follow up text, Cognitive-behavioral Treatment of Borderline Personality Disorder (1993), more substantive criticisms of DBT have emerged, focusing on the relative expense and consequent inaccessibility of the method to people who, because of work and family demands, do not have the time to put into the method, and questions about whether the standards of Normal Behavior being sought might not be culturally constructed in a way that makes the method difficult to employ for individuals of non-Western backgrounds. And yet, the consensus, some 34 years after its debut, is that for those who have the ability to access it, it can lay out a road to a life that, if not easy, is at least consistently worth continuing. Some thirty randomized control trials have been performed to probe its efficacy across nine countries, and the results continue to validate the power of Linehan’s central insight - that a person empowered to to take control of their emotional responses, plan ahead for contingencies that might cause anxiety, and interact with the world is one able to build up a core of resilience that will put them back in control of their lives.

Linehan retired in 2019 and published her memoirs in 2020, calling on the aid of her friends and family to fill in the gaping memory holes of her youth to allow her to tell the story of her own ascent out of the hell of uncontrollable impulses and towards a life lived in service of a community that had been all but abandoned, tens of thousands of whom walk the Earth today that might not have without the system devised by her mind, and maintained by an international group of practitioners dedicated to Linehan’s principle that anybody, given the right tools and dedicated support, can be empowered to better their experience of life.

FURTHER READING:

Linehan’s memoir Building a Life Worth Living is a deeply honest, and thoroughly accessible account of her life and the experiences that caused her to weave together the unique elements of science and philosophy that lie at the core of DBT. Her 1993 book is still in print and though new copies will run you upwards of 70 clams, you can get a used copy pretty easily for a Jackson, and it’s worth it to do so. It is a book that invites you to follow along and understand in graspable language, rather than one that seeks to dazzle with misapplied or temporarily trendy jargon that ceases to be of interest or use a decade later. People will be reading it another half century from now and still getting useful ideas from it not only to treat those in the most dire need of help, but to improve the lives of anybody seeking to deepen their sense of self and better understand their interactions with others.