Rethinking BPD: A Clinician's View

Marsha Linehan: I want to start something just because I'm afraid I'll talk too much and not be able to tell you this, but it fits into this anyway, so I'm going to tell a little story to start, which is this fabulous patient that I had for many years. She had been in and out of hospitals forever and was in New York in a hospital for two years and they sent her to me on an ambulance plane and she came and I told her it was okay, I would see her while she was there. her in a rehab center in Seattle because she was very suicidal and many other things and she would run through the streets in her nightgown with knives and they would find her behind dumpsters and alleys almost dead.

So I treated her for quite a while and we finally got her through college, which was a big deal. This was more than my usual one year research treatment, but she actually finished college, moved and got a job in San Francisco, sorry, Los Angeles as a teacher and she was calling me because I wanted to teach her some of the skills. students. I love her so much and that's why I was depressed not long ago. She calls me from time to time and we talk, so I came down and we were having lunch and she was telling me how horrible her life was because she not only had borderline personality disorder but she was also schizoaffective and so she was saying how hard it was for her. was being psychotic and teaching and it was problematic, so he had to take a leap and was now giving private lessons.

She was so sad that I cried because it was so sad that this had happened to her and she said, Marsha, don't be so angry, this is so much better than being on the edge and I think that says a lot. You know that being psychotic schizoaffective trumps borderline personality disorder. So I'm going to talk a little bit about, people have talked about my treatment, dialectical behavioral therapy, just to give you, you know, someone told me, Marsha, your job is to give us hope, so I'm going to give you hope. Because I'm not alone anymore, I was for years.

The only person doing research on borderline personality disorder treatment and most of my life the only person doing it on suicidal behavior, but now we've gotten other people to do data, there's mentalization treatment, all these young people They are doing things. , so there is a lot of hope, but this is what I know best, so I'm going to talk about it. Dialectical behavioral therapy, where it started and I'll tell you what I found. So I started, I always wanted to work with suicide and I decided I was going to work with suicide at the NIMH and those days helped the young researchers tremendously.

They talked to you and you would do your research with them. I really feel like to be honest with you; NIMH co-authored most of what I've done. They have been very helpful all the time. So I wanted to deal with the high risk of suicide with multiple suicide attempts and self-harm and I called all the hospitals in Seattle and said I wanted the worst they had because I wanted to be sure that if my people got better they would be able to tell the difference between them. and his control condition, so I got a small grant to develop a treatment for suicidal behavior and I learned behavioral therapy and I was totally sure that it would cure everyone and I didn't have the slightest doubt, but I ran into a lot of problems .

My first problem was that the people I was treating had extreme sensitivity to rejection and invalidation and that made a change-focused treatment, which was definitely behavioral therapy in 1980, unsustainable, so I switched to acceptance-based treatment. . Although that was also a disaster because the extreme suffering made an accepting approach unsustainable. The patient would say, well, aren't you listening to my suffering? Won't you help me change? And I was like no, no, I'll help you change, I'll help you change and they were like, are you saying I'm wrong? Are you saying that? And I would say no, I'm not saying that!

This is how it happened. So I came up with an approach really by accident, just working with all these people, which was eventually called dialectical, but dialectical is walking the mental path in many ways, where it's a synthesis of change strategies, this is by the therapist. , change on the part of the therapist and acceptance strategies on the part of the therapist, that is my job. However, the next problem was that I was dealing with people who had an extraordinarily low tolerance for discomfort and that made it difficult to focus on any one problem area or one part of a problem or one disorder, since you know they have multiple disorders or a frequently impossible topic of therapy.

The crisis is surpassing any capacity for sustained work towards change. So we are constantly on each topic, you go through ten topics because of avoidance and the inability to tolerate. So in the end the solution was to develop an approach that taught patients affect acceptance skills that included discomfort tolerance and there is a whole teaching module that I do called discomfort tolerance. How to tolerate crises and not make them worse, but also how to radically accept life that may not be the life you want, but that doesn't mean you have to suffer your whole life and change skills, all of which came from behavioral therapy.

I stole every one of them. But then I had another problem, which was that the constantly changing clinical presentation along with frequent crises caused all the therapists to be confused and chaotic and the therapy became very chaotic. You have to remember that this was in the '80s, when all behavioral treatments were protocol-based treatments: this was done in the first session, this one in the second session, this one in the third session, those were all of them. There was only one treatment manual, literally one, and that was the psychodynamically oriented treatment manual and it didn't do that, so I modeled it after that.

I had patients who met criteria for both many Axis I and Axis II disorders. Although I didn't know they met the criteria for those things at the time because I remember I was focusing on suicide. So my solution was to develop an approach for treatment that combined protocol-based interventions; In other words, all of our patients receive skills training, which is this week, you get the skill we're teaching this week and next week is the We'll be teaching next week, combined with a goal-based agenda, where the goals said: Let's get organized and solve this problem first, this problem later, this problem and the life-threatening behavior, of course, came first.

At that time, a life-threatening threat was suicide, but since the BPD is in so many prisons, homicide must also be considered life-threatening behavior. So that brought those two things together. But then the next problem I had was that the therapists became emotionally dysregulated in treating these patients and that led to excessive fear, excessive anger, hostility, the therapists getting angry with the patients. They tried to control the patients. You know it's really scary to have a person who could be dead at any moment and you can't stop them from dying. Therapists would then try to take control, reject the patient, or attack the patient.

This is group one of therapists and the therapists in group two were the ones who had excessive empathy and fell into the puddle of despair with the client and just abandoned the therapy completely and everyone cried together. So I had to solve that and the way I solved it was by defining a treatment team as part of the treatment. I didn't really create a treatment team; I defined a treatment team as part of therapy because I'm going to tell you something that you may not know, I don't think many people know. To my knowledge, there has never been a single randomized trial conducted without a team as part of the therapy, whose role is to keep all therapists performing the treatment they are studying in that clinical trial.

As far as I know, there are two things that are always done: evaluation of results and sum of the group: either you have a supervisor or a team that keeps you doing the therapy and then we wonder why when you take a therapy to a community it doesn't do it. . work. Because? Because we don't take all the therapy to the community. We take all kinds of things, but we leave the team that keeps you doing the therapy and the assessment out of what translates, so I said to myself, okay, I'll just redefine the therapy and say that if we did a team and the research we will call the team part of the therapy since I developed the therapy, you can't say you are doing the therapy if you don't have a team and that's essentially how it was treated and the role of the team is to treat the therapist and keep them in the model.

Do I think it's important all the time? Possibly not. Do I think it is important with high-risk, out-of-control, difficult-to-treat, multiple-diagnosed suicidal patients? Yes, therapists burn out. The next problem to solve was that I wanted to get another scholarship to study what I was doing, but I couldn't get it unless I had a mental disorder and I was committing suicide and I didn't have a mental disorder, so I thought it was okay. Someone told me in a re

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that they were studying borderline personality disorder. My entire manual was written without the word Borderline Personality Disorder even once because I had never heard of this disorder.

Then I heard about the disorder and had to choose between Borderline Personality Disorder or Major Depression. So since most people meet the criteria for borderline, I said I would do it and my advocate at NIMH told me, I'll never forget it because I said okay, I'd choose borderline and not depression. He said: Marsha, you're making the biggest mistake of your entire career. Never forget. I said: Well, I'll do it anyway. It turned out that it wasn't a big mistake, but it was obviously a problem. Once I did that, I had to have a model of the disorder and there was no model that the behaviors could live with because of course at that point I discovered that the only people who thought borderline personality disorder existed were the psychoanalysts who, of course, Good Behaviors don't read psychoanalytic material and when I read it it didn't make much sense because the model, the theory, was completely divergent from any theory I could deal with or what I consider a behavioral science, so , but you need to have a theory to carry out the treatment.

I had a theory of suicide but now I needed a theory of the limit and I needed one capable of, I had three criteria, only three, capable of guiding effective therapy, it has to be non-pejorative, generate compassion, it has to be compatible with current events. I research data so that my theory does all that because when the data changes, I simply change the theory. The basic model that I fought my entire career for this model, but I think I'm really winning the data, but I'm not going to give you data about it because it's not part of this talk, but it could.

Borderline personality disorder is basically a pervasive regulation disorder and it is a pervasive disorder of the emotion regulation system in which an emotion is considered as a system, not as feelings, but as a total system that is a response complete personal, but it is an emotional response and therefore has action as part of thought and physiology, etc. and that the criterion behaviors of borderline personality disorder, if you really look at them and really study them, work to regulate emotions, some of them, for example, suicidal behavior, are extraordinarily effective in regulating emotions and average. person, I kid you, doesn't really believe that if they commit suicide, they won't feel so bad when they're dead.

I pointed out to my clients that there is no evidence of that particular point about you. Or suicidal behaviors have natural consequences of emotional dysregulation. You can't have good relationships if you're not regulated, if you hate a person one day and love them the next, want to go to the movies with them one night, don't want to go the next, etc., etc. In other words. , relationships, the sense of self, most of the criteria it contains have to do with the foundations of emotion. So the solution was to develop a pathogenesis treatment. This I have to say is a disorder of biological regulation;

I have no doubt that there is a biological basis for this disorder and I don't believe you can create borderline personality disorder without biology. I could be wrong on that, but that's my experience watching all this time. Combined with what I call invalidating the social environment, now if there are other features of the environment on top of that, invalidation covers a lot of territory so far. I haven't had to change the theory, but that's because I change the definition of override as necessary. , but my real point is that we need more research on this, we are very, very limited in our research here.

But it is very similar to Patterson, like other research on thedevelopment of other disorders where it is the same and therefore the disorder is transactional. The transactional and the dialectical are incompatible with guilt, to be clear, because person A creates person B, but person B creates person A, so it is not that the family creates the disorder, Disorder creates family and family creates disorder, not the family but the environment. So we have this extra transactional time, creating a mess based on both characteristics, not necessarily family, by the way. So what did I add to the standard types of behavioral therapy?

I'm going to continue because I looked at the time and it was supposed to be over in a minute. Change acceptance synthesis, just remember I started a long time ago, most of this stuff is there now, but it wasn't that. Principled integration of evidence-based treatments. I strongly believe in incorporating protocols into a principles-based approach as new therapies are supposed to be developed all the time. Focus on behaviors during the session, stages focused by severity and threat. BPD is organized into control-based stages of treatment. Suicide risk and assessment protocol, there is reason to believe now that this may actually control for many of our findings, much to my disbelief.

Evidence-based treatments and skills, in other words, I stole all my skills from evidence-based treatments and mindfulness. Definition of team as part of therapy and self-disclosure of the therapist. So what do the clinical trials say? No one really disagrees at this point with the effectiveness of this treatment. So that's not the fight right now, that was the fight for years, but it's not the fight anymore, everyone agrees that the treatment works. The question now is why does it work? We have nine randomized controlled trials on borderline personality disorder. DBT is moving so far away from borderline disorder toward other disorders that it is unclear if it is actually a treatment for borderline disorder, as it is a treatment for substantial dysregulation.

For low-level, non-serious things, you would never need DBT. There are many good treatments for that. The real strength of DBT is when you have a really severe dysregulation, then DBT works, or it's high risk, difficult to treat, multiple diagnoses, multiple things. That's when DBT becomes important; otherwise it becomes something else. Our data is that we commit suicide attempts, self-harm, depression, hopelessness, anger, substance dependence, impulsivity. Now psychoanalysts fought with me for years saying that you only treat the symptoms, the behaviors, of course, they don't even use the construct, but still. So I used one of the psychoanalytic measures and made them promise to stop saying that if I got the results, and I did.

Therefore, the introject, which is the psychoanalytic construct, also changes. This is just suicidal behavior plus self harm, yellow is the people who didn't get DBT. There have been many internal validity checks in these studies, this is the percentage of suicide attempts. What I want to talk about for a moment is what matters. In other words, do you need all the treatment? Standard treatment is individual DBT, plus skills training, plus phone calls to the individual therapist for behavioral counseling, plus a team. In all the investigations that I am going to talk to you about now, each of them has a team and has some type of training, but not necessarily with the individual therapist.

First thing I want, oh whoops. Well, what happened was that the slides were not put here, I'm going to tell you our data. This is a fabulous study, funded by the NIMH. This is very important. What we did was a study on standard dialectical behavioral therapy DBT; more or less common and we took highly suicidal people with a suicide attempt in the last year and self-harm or suicide attempt and the eight before they came and a borderline personality disorder. Most meet between 8 and 9 criteria. Well, most of them are working, etc., so we did it. A third of them received standard behavioral therapy, the same thing I tell everyone they have to do to say they're doing DBT.

The other one entered a treatment in which we wanted to see if skills training was important. Well, we gave one group all the treatment, except they didn't get skills training, we gave them a group psychoeducation activity like you get in community health, so that's group two. We'll call it individual therapy group only because they didn't get skills, no skills group and then we took another group and we wanted to say, Is individual DBT, the way it's done, that important? Maybe we can get rid of that and just train people, so we did, but because people were so highly suicidal, I thought I had to have someone who could deal with crises, so we gave them intensive case management.

Washington State Cases Treatment Manual, this is important to get that part. Washington state was manualized and we had a supervisor and they had a team. So they had skills training, intensive case management, but the intensive case managers only took calls during office hours, this expensive element, but we gave a really good suicide crisis management plan to the crisis clinic in Seattle, which is one of those phone lines. that every town has. Now the other thing that happened in the study was I got really worried, I just thought I can't let people die just because I want to do a study, so I gave the University of Washington, which is actually DBT, evaluation risk and management protocol, which is a well-known treatment designed to get people to want to treat suicidal people by giving them something that says that after a session they should check if they did it.

It makes you check if you're at risk and if you should think about hospitalization, but the way it's set up is it tells you all the reasons not to hospitalize yourself, which you can check off to say, "I didn't do it and it would give Your reasons, I didn't do it." something else, and I would give you your reasons. So everything is set up to get the therapists not to hospitalize and do top-notch risk management, mainly because I didn't believe the treatment was working. If I had known what I know now, maybe would not have done this.

So what happened? First, all treatments were effective in reducing suicidal behavior and were equally effective, suggesting that the commonalities are more than likely what? Risk management protocol and team and some characteristics of having someone who can handle a crisis well, a kind of crisis management and it was top of the line. However, when you look at the result of mental health, something different happened, this is the biggest of shocks of my life: it's the skills that count. It has a great effect on reducing depression, a great effect on reducing anxiety and for the individual the therapy is useful for that, not useless but not as good.

In other words, because I was sure that standard therapy would be the best, it never occurred to me to think about anything other than that the only good thing is that it has half as many dropouts. So if you want to keep people in therapy, that's great, but why keep them if you can make them better without keeping them? That's the way I see it, so we're still analyzing the data. The upshot of this is two things: One, the skills are probably critical and you've heard this from your colleagues here who said, teach me how to live and that's exactly what you're designed to do.

They are designing him to enter eighth grade now. We've translated skills from five to twelve year olds, there's mindfulness training in kindergarten now, we do skills training for friends and family, so I think I underestimated this huge value of skills training. Now, the other thing we do in DBT is take them off psychological medication and keep them out of hospitals, so it's possible that the treatment we have for suicidal behavior has reduced hospitalizations. You know there isn't the slightest bit of evidence that any hospitalization has kept anyone alive five minutes longer, but we all hospitalize and the whole treatment is usually that therapists are afraid of not being hospitalized because they're afraid of getting sued.

So we have this incredible fear in our therapists and when you can get therapists to be safe, which I've obviously been able to do, you can reduce it. Now I'm not saying that the standard might not be better in some ways, just by looking at it during monitoring you might know that it's coming back to life, but what I mean is that there is no rigorous research that focuses on analysis of components. and destroying the treatments, we are not going to get anywhere and horse racing therapy is not going to help us. Managed care should help;

Insurance companies should do it, but science has to figure out how to improve treatments. I have a lot here about training, but I'm going to skip it because I think I'm out of time and I don't want to go over it, but now we're looking at skills training being used to treat resistant depression. studies on eating disorders or skills training, so it's becoming widespread and we need to look at that because even in our study with borderline drug addicts, what we found was that DBT was a little bit better with drugs, but I don't know if it's worth it spend money on medication, but it's actually better for depression and anxiety.

So let me tell you one thing, one last little thing. This is where we're not good, just to be clear in case you thought we were good at everything, standard DBT is really good at most disorders, except it's terrible at anxiety disorders, unless you specifically target anxiety disorders and DBT does, but only afterward does suicidal behavior reduce. Now we're in our lab, Melanie Harned, a research scientist who works with me and Martin, we were collaborating and working to bring long-term exposure to DBT and the data we have so far suggests that we can make a lot of progress and deal with anxiety disorders, etc That also means we need to have these principled treatments and research on how to incorporate a module for this.

So thank you, thank you very much.