New York Times (7.13.04).
SEATTLE - "I've been going through
this since I was 11 years old," the young woman said, "I'm backed up
against the wall. Either I need to do this therapy or I need to die."
"Well, why not die?" the therapist asked. "Well, if it comes
down to it, I will." "Uh-huh, but why not now?"
This aggressive cross-examination is a signature technique of
what has become one of the most popular new psychotherapies in a generation.
For years, psychotherapists have had a wide
array of techniques to draw from in helping troubled patients. The most
commonly discussed recent therapies teach interpersonal skills for improving
relationships or cognitive skills for defusing upsetting thoughts. But even the
best therapies are worth little if patients are too defiant, too desperate or
too upset to accept help.
That is why clinicians and health
officials around the world are trying out a provocative approach called
dialectical behavior therapy. Developed at the University of Washington by Dr.
Marsha Linehan, a researcher and clinician who was the therapist in the above
exchange, dialectical techniques have proved effective in the most
difficult-to-reach cases, sometimes saving the lives of intensely suicidal
people.
Other therapies, Dr. Linehan said,
implied that the patients were the problem, and that they could change if they
wanted to.
"But these are people who have been
told all their lives that they are the problem," she said, adding,
"We needed a new approach."
Already, more than a dozen states have
incorporated the therapy in their mental health systems, as have scores of
forensic hospitals, drug treatment centers and prisons in the United States,
Australia, Britain and Germany. Word is moving fast, experts say, because any
well-defined approach that gets through to suicidal patients holds promise for
other hard cases: drug addicts, people with bulimia, severely depressed
adolescents, the defiant and the antisocial.
In a health field starved for innovation,
in which treatments are notoriously difficult to define, study and standardize,
Dr. Linehan's manuals and underlying philosophy represent the most significant
new effort in decades, some experts believe.
"It's an extremely hot therapy now
because it deserves to be," said Dr. Steve Hollon, a professor of
psychology at Vanderbilt University.
Other experts caution that the excitement
over the therapy has outpaced the science.
"It concerns me that so many states
are mandating this treatment when we only have yearlong studies, and we don't
know if it really eliminates the problem long term," said Dr. Drew Westen,
a professor of psychiatry, psychology and behavioral sciences at Emory
University.
Still, he said, "the therapy seems
to help patients regulate their emotions when they're spiraling out of control,
and that, to me, would be a real, enduring contribution to the field."
Dr. Linehan first developed the therapy
as a way to help people with borderline personality disorder, an enigmatic
and notoriously difficult condition to treat.
Borderline patients are often severely
self-destructive, cutting or burning themselves and attempting suicide. In
therapy, they are often manipulative, mercurial, at times chillingly mute. They
wear out therapists and try the patience of friends and family members. (The
needy, compulsive, violent character played by Glenn Close in the 1987 movie
"Fatal Attraction," who seduces a married man and then stalks him
when he rejects her, exhibits borderline behavior, some say.)
Some researchers believe that the
disorder develops as a result of uncertain attachments to parents early in
life. Others are searching for biological roots. One study, for example, found
that borderline patients exhibited hyperactivity in the amygdala, a part of the
brain involved in emotion regulation. Some patients, experts say, are helped by
mood-stabilizing drugs.
Yet dialectical
therapy neither involves drugs nor concerns itself much with biology. It
begins with an idea called radical acceptance, the insistence that
people in therapy accept who they are and that they are not who they want to
be. They cannot go back and repair their childhood, as awful as it might have
been. They have blown precious relationships for good. Most of all, they
experience waves of rage, emptiness and despair far more intensely than other
people do.
The therapist, in turn, acknowledges that
self-harming behaviors and suicide attempts actually make some sense. They are
expected responses to profound distress; though dysfunctional, they provide
relief.
"You're meeting them right where
they are if you say, 'I realize this behavior has been a good coping skill for
you,' " said Marjorie Burns, a therapist in Fort Wayne, Ind., who has used
dialectic techniques to help troubled adolescents, as well as people with
bipolar and eating disorders. "It normalizes the behavior in a way, and
shows some compassion."
But the patients also come to realize
they have only two choices: change or stay miserable. The woman who Dr.
Linehan treated, for example, said she saw the treatment as her only hope.
"So, in other words, all things
being equal, you'd rather live than die, if you can pull this off?" Dr.
Linehan asked the woman.
"If I can pull this off, yeah,"
she replied.
A few moments later, Dr. Linehan obtained
a pledge, a step crucial to the therapy: "So that's what I see as our No.
1 priority," she said, "getting you to agree, meaningfully of course,
and actually following through on staying alive and not harming yourself and
not attempting suicide no matter what your mood is." "Yes, I agree to
that," the young woman said.
Once a commitment is made, the
dialectical therapist holds patients to it and just as often has them explain
why they need to change their behavior, rather than making it solely the
therapist's responsibility. The process is somewhat collaborative, driven by
the patient as well as the therapist, and focused in the beginning simply on
staying alive.
One thing patients learn very early, for
instance, is to notice when their emotions begin to stir, allow themselves to
feel the storm whip up, then let it pass - all without doing anything. This
Zen-like self-observation, called mindfulness, is an exercise not in avoidance
but in feeling and enduring emotional pain. It dramatizes one principle of the
therapy: that what patients do can be independent of how they feel. Emotion
does not have to rule behavior.
"You can feel like a mental
patient, but that doesn't mean you have to act like one," Dr. Linehan
said.
While other clinicians might advise
patients to fight, ignore or question their distressing emotions to defuse the
sensations, dialectical therapists argue that those strategies are not much
good. Most patients have already tried managing despair and loneliness in these
ways, and they can't do it. That is why they keep landing in the hospital.
"With eating disorders, patients are
trying to fight thoughts about body shape and weight and it often just makes
them worse," said Dr. G. Terence Wilson, a professor of psychology at
Rutgers.
It is after they have pledged to change
and demonstrated the ability to weather emotional squalls that people can best
begin to learn the many specific social and behavioral skills that have proved
successful in combating depression, anxiety and other forms of psychic
distress. These include methods for disputing catastrophic assumptions, like
"I must be inadequate if I can't fix this myself" and social skills -
for example, judging when it is appropriate in a relationship to make demands
or to refuse them, depending on the type of relationship involved.
As they would in more traditional
cognitive or interpersonal therapies, people practice these skills and track
their progress by completing homework and diaries of their thoughts and
behaviors.
When people "slip" and feel on
the verge of harming themselves, they are instructed to call the therapist.
Afterward, in sessions, they must painstakingly reconstruct a moment-by-moment
narrative of how they went from feeling relatively fine to feeling desperate.
When, exactly, did they decide to harm themselves, what happened just before
that, and so on. The therapist insists that this recounting be done in a
neutral, matter-of-fact way, despite the rage or shame in the story - in
effect, teaching the patient to regulate the emotions that in daily life drive
them over the edge.
The theory is that by acting differently
from how they feel - projecting confidence when afraid, say, or indifference
when ashamed - people loosen the hold of the emotion even though its origins
have not necessarily been addressed at all.
Finally, dialectical therapists make sure
that the patients do not feel emotionally rewarded for attempting suicide or
harming themselves. When some people overdose or cut themselves, they land in
the hospital, where they are cared for, removed from the stresses of daily
living and sometimes pampered. In these cases the therapist works with the
person and the hospital to remove this reinforcement, denying hospitalization,
if possible, or at least making the stay less pleasant.
Hospitalization can work in the opposite
way as well. A woman and mother of three named Barbara, who lives in
Connecticut and would give only her first name out of concern for her privacy,
regularly cut and hurt herself well into her 50's, for reasons she could not
explain. In the past, she said, she got no help from therapy. But dialectical
therapy was different. "One reason I did the work is that I knew if I refused
I'd be dropped from the program and referred back to the hospital," she
said.
In more than half a dozen studies,
researchers at the University of Washington and elsewhere have tracked the
progress of some 150 people at high risk for suicide with borderline
personality disorder who received dialectical therapy, which typically includes
one hourlong individual session a week, plus one weekly group session of more
than two hours. They have also followed similar groups of patients who received
treatment as usual, seeing a series of therapists who each tried something a
little different.
After six months to a year, depending on
the study, those who had dialectical therapy made significantly fewer suicide
attempts, landed in the hospital less often and were much less likely to quit
therapy. Pilot studies testing the therapy to treat suicidal teenagers,
juvenile offenders, depressed older adults and women with eating disorders have
also been encouraging.
It is not yet clear from this evidence
exactly what is causing the changes in behavior. The amount of careful
attention therapists are giving clients, the charisma of individual therapists
or even the high motivation of the therapy team could all be critical
components.
Nor is it clear from the studies how much
better people who receive the therapy actually feel, day to day, once the
treatment has ended.. For long-term recovery, said Dr. Otto Kernberg, a
professor of psychiatry at Weill Medical College of Cornell University and an
expert on personality disorders, it may be that people with borderline disorder
need psychotherapy that also gives them insight into the unresolved
psychological conflicts that may lie behind their emotional turmoil.
Dr. Westen, at Emory, said, "My
guess would be that the problems they have in the experience of the self, the
emptiness and abandonment they feel, probably aren't going to change much in
one year."
For dialectical
therapists, these debates are important but secondary. Their patients,
they say, can and should learn to have lives that are enjoyable, rather than
merely tolerable. But for now, most have already accomplished something that
many others have not. They are out of the hospital, and they are alive.