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How Marsha Linehan Developed the Central Feature of Dialectical Behavior Therapy

A descent into despair led to the birth of dialectical behavior therapy.

Dr. Marsha Linehan, used with permission
Marsha Linehan as a faculty member at The Catholic University of America in the 1970s.
Dr. Marsha Linehan, used with permission

I have done many hard things in my life. But the most devastating was coming to terms with a totally unexpected complete breakdown—the dissolution of the person I had always been.

I had been a happy-go-lucky, confident high school girl, popular among my classmates, often the one to initiate activities—organizing concerts, for example, or simply gathering a group for ice cream at the drugstore. I was always careful to make sure everyone’s needs were met, that no one was left out. I was elected and nominated to important class roles in junior year and senior year. I was the kind of girl who might be voted “most popular” or “most likely to succeed.”

But then, as my senior year progressed, this confident girl began to disappear.

I did not know what had happened to me. No one knew. At the age of 18, I was admitted to a psychiatric institution called the Institute of Living, in Hartford, Connecticut. My experience at the institute was a descent into hell, an out-of-control storm of emotional torture and absolute anguish. There was no escape. “God, where are you?” I whispered each day but got no answer. The pain and turmoil are hard to describe. How do you adequately convey what it is like to be in hell? You can’t. You can only feel it, experience it. And I did. I felt this inside myself, and I didn’t want to go on living anymore.

But I survived. And toward the end of my time at the institute, I made a promise to God, a vow, that I would get myself out of hell—and that, once I did, I would find a way to get others out of hell, too.

I was determined to find a therapy that would help suicidal people, people who were deemed beyond saving. I have felt the pain that my clients feel as they wrestle the emotional demons that tear at their souls. I understand what it is like to feel terrible emotional pain, to desperately want to escape by whatever means. Dialectical behavior therapy (DBT) was, and is, my best effort to date at keeping my vow.

The goal of any behavior therapy is to help individuals change behaviors, in particular behavior patterns that significantly disrupt their life at home and in the workplace, and to replace them with more effective alternatives. DBT is different; it’s designed to help individuals who are at high risk for suicide, are difficult to treat, have multiple serious mental and behavioral problems, and often are on the “no admit” lists of hospitals.

It’s also different because standard behavior therapy didn’t seem to work. Early in my research at the University of Washington, a client would come in, we’d talk, and she would tell me about her problems and why life did not seem worth living. We had to discover which of her problems was driving her suicidality. It might be her believing that no one loved her, that people hated her, or that she just wanted to die. I would say, “No problem. I can find a treatment for that.” I would then go through existing behavior therapy manuals to try to come up with the appropriate treatment.

The next week, I would review with the client what I thought was needed to solve the problem we had focused on, what changes we could make together. But a typical response to any attempt to change patients’ behavior was: “What? Are you saying I’m the problem?” They got upset, sometimes retreating into silence, other times yelling, throwing chairs, and stomping out of the room. “You’re not listening to me,” clients would say. “You’re not hearing what I’m suffering. You’re trying to change me.”

Most of the clients had experienced intense suffering. They had tragic stories. In addition, they were extremely sensitive to anything that appeared to invalidate their pain, anything that suggested that they themselves needed to change. To them, standard behavior therapy, which is focused on helping people change, was a red flag.

For these clients, it was as if they didn’t have emotional skin. As if they had suffered from third-degree burns all over their body. Even the lightest touch was excruciatingly painful, and they lived in environments where everyone kept poking at them. They perceived suggestions aimed at change as personal attacks or as further invalidation. It would whip them off the emotional charts.

I realized that what these people obviously needed was compassion—to validate them, to show that the factors driving their suffering made sense to me. I had to see the world from their point of view.

So I dumped the emphasis on change and went full-bore helping clients accept where they were in their lives. My new goal was to validate my clients’ tragic lives. I knew about unconditional positive regard, a set of strategies developed by the humanistic psychologist Carl Rogers. And I knew of supportive therapy, an approach that focuses on providing a strong therapeutic alliance, where the therapist is both trusting and validating. “No problem,” I thought, “acceptance is it. I am switching my strategy.”

The response to this was as volcanic as it had been to my focus on change. “What? You’re not going to help me?” the client would say. “You’re just going to leave me here, in all this pain?” More tears, more sitting mute, more walking out of the room.

I began dancing back and forth, back and forth, back and forth, trying to find the right balance in the dynamic between pushing for change and offering acceptance. It was like walking on a tightrope. Too much weight on either side and over you go.

One day, while I was talking to my executive assistant Elizabeth Trias about the therapy, she said, “Marsha, your treatment is dialectical!” Dialectics? I had never heard of it. So, I looked it up in the Merriam-Webster dictionary and found the following definition: “A method of examining and discussing opposing ideas in order to find the truth.” I like to think of it as “the tension, or synthesis, between opposites.” Dialectical behavior therapy seemed an appropriate name, reflecting as it does the tension between seeking change in people and encouraging them to embrace acceptance.

Everything in nature is a dynamic balance between opposing forces. Planet Earth would fly off into space because of centrifugal forces, but the sun’s gravity prevents that. Every movement of every limb is a tension between opposing forces, flexor and tensor muscles: Your biceps bend your arms while your triceps straighten your arms. These are concrete examples, but, more strictly speaking, dialectics is about seeking an answer through embracing opposites.

It had been this basic tension that caught Elizabeth’s attention. After her observation, I learned that dialectics has been the underpinning of much of social and natural science for the past 150 years. “OK,” I said to myself. “If it’s good for science, it’s good for me. ‘Dialectical behavior therapy’ it is going to be.” It was an epiphany, like learning that what I already knew was, in fact, true.

Dialectics is a cornerstone of DBT, but it’s far from the only element. The therapy encompasses distress tolerance skills, mindfulness, and radical acceptance. The practice involves an intimate relationship between therapist and client and therapist teams that support providers. But as soon as I encountered the idea of dialectics, I knew it encompassed a central tenet. Shortly after that, I called the university philosophy department and said, “Can you send someone over here to teach me and my students about dialectics?”

Dialectics allows opposites to coexist, you can be weak and you can be strong; you can be happy and you can be sad. In the dialectical worldview, everything is in a constant state of change. There is no absolute truth, and no relative truth, either: no absolute right or wrong. Truth evolves over time. Values that were held in the past might not be held in the present. Dialectics is the process of seeking the truth in the moment, drawing on a synthesis of opposites.

Many of us tend to see reality in polarized categories of “either/or” rather than “all” or “this and that.” We are often stuck in either the thesis or the antithesis, unable to move toward synthesis. We are not able to believe in both of these propositions: “I want to be with you, and I want time alone.” Or, “You forgot to pick me up at the ferry, and you still love me.” All of us face this. It is the inability to ask certain questions that gets us into trouble: “What am I leaving out here?” and “Where am I being extreme?”

Because everything is connected, blame is taken out of the picture. Because everything is connected, everything has a cause. From the nondialectical point of view, A is blamed for B—a one-way street. In the transactional dialectical world, A influences B and B influences A, back and forth, back and forth.

When you think in a transactional way, in which everything has a cause, there is nothing to blame. There is a reason for every action. If you know the cause behind a certain behavior—no matter how unpleasant or hurtful that behavior might be—then that behavior makes sense.

Many of my clients are severely traumatized by one or both of their parents. I believe that most people are better off loving their parents than not, no matter what the parents have done. So many of those traumatized by their parents still want to somehow love them. I try to help them grasp that both outrage and understanding can come together. Their parents’ behavior was reprehensible, but it was caused—meaning that the parents behaved as they did because of something that happened in their own lives. One can love a parent and disapprove of her or him at the same time.

The therapist must help to find the syntheses of opposites, to look for what is being left out. I have spent many sessions saying to myself, “Look for the synthesis. What am I missing?” A patient wants to go to the hospital. I don’t want him in the hospital. A battle ensues. What is the dialectic? The patient thinks he is likely to commit suicide if he doesn’t get into the hospital (a point I completely fail to understand); I believe he is likely to commit suicide if he does go into the hospital (a point the client completely disagrees with). What is the synthesis? We have to find a way for him to be safe either way. We have a problem to solve.

It took me a long time to grasp the dialectic inherent in planning a suicide or engaging in self-harm. Both make you feel better, and both make you feel worse. Both sides are true. When I can’t get an agreement from a client to stay alive forever, then I try for a certain amount of time. If she’s giving me a week, I try for two, and keep going until I am stopped. If I can’t get an agreement, I search for a synthesis: “If we can find a way to get your life to be experienced as worth living, would you be willing to work on finding that?” Almost all say yes.

Therapy is like being on a teeter-totter, with me at one end, and the patient at the other. Therapy is the process of going up and down, each of us sliding back and forth on the teeter-totter, trying to balance it so we can get to the middle together and climb up to a higher level, so to speak. This higher level, which represents growth and development, can be thought of as a synthesis of the preceding level. Then the process begins again. We are on a new teeter-totter, trying to get to the middle, in an effort to move to the next level, and so on.

The therapist must be able to speak for both sides: “You are miserable and want to die; I can understand how you feel, how painful your life is at times, and how hard it is to stay alive. On the other hand, I can also imagine the tragedy of your dying by suicide. I know you often think no one cares, but I am pretty sure you know that I care, that your cat cares, and, if you really think about it, that your parent cares. I totally believe that you can build a life that you will view as worth living. Even in your tears, you have to believe, let go of disbelief, and hold on to hope.”

Adapted from the book Building a Life Worth Living by Marsha M. Linehan, to be published by Random House, an imprint and division of Penguin Random House LLC, New York.