Marsha Linehan - Interview

so I'm here today with professor of Washington and work behavior therapy so Marsha can you tell me a little bit about what dialectical behavioral therapy is dialectical behavior therapy which I'm going to call DBT from now on for short DBT is a comprehensive behavioral treatment which is to say it's a psychological intervention and it's an intervention which was originally developed for very suicidal individuals and then it expanded to people who are not only suicidal but self harming then after that it expanded to people who either suicidal self harming or people who have very severe problems regulating emotions and so it's a comprehensive treatment and over the years it's expanded to treat all sorts of disorders besides that and is still being researched and still being expanded the essence of the treatment in other words the reason is called dialectical is because on one side it really emphasizes change you've got a problem you've got to change that's on the one side and on the other side it equally emphasizes acceptance which is no matter what problems you've got you've got to accept yourself and so one of the main focus of the treatment is to bring these together so it's a synthesis of opposites which is what dialectics focuses on so not only does the client have to focus on acceptance of themselves and of others because we've actually had people said to us solely because their families were going to divorce them because there was so judgmental so you have to accept yourself and be non-judgmental others and you also have to work on change but the therapist has to do exactly the same thing so therapists have to help people change but therapists themselves have to also find the valid or all that is acceptable and radically accept the patient as they are and with many of these patients you're also having to accept slow episodic progress because much of the time the progress is not as fast for very serious Cynthia your disorders as they are for less severe somewhat easier to treat disorders okay so Marsha one of the common questions that were asked is do people need to have a specific diagnosis in order for them to benefit from directive of behavior therapy the answer to that is yes and no so the treatment itself has two components one is individual psychotherapy and the other is training in specific behavioral skills across many different areas everybody can benefit from the skills we have parents coming in we have executives coming in we have it's going into the school system now corporations are interested in the skills so almost anybody can benefit from the skills it's hard to imagine why you would want individual psychotherapy if you didn't have one or more psychological disorders so it's it's probably you know if you want just someone to talk to okay but DBT is not really a someone you can talk to therapy so I can't imagine that it would be of particular use so can I ask you what would be the more common disorders that would be associated with this treatment any person who's suicidal would qualify for the treatment no matter what their disorder is so they could have PTSD post-traumatic stress disorder major depression etc the total treatment is really designed for individuals who have multiple disorders so it's AB is best with people who have multiple disorders mainly if is a really aren't other treatments designed for people with lots of different disorders if you only have one disorder and you're not suicidal and you're not self harming the DBT treatment will start to look like other evidence-based treatments and there's not a great need for this treatment so if you're not really severe or complex or difficult to treat you're probably not going to come for the full treatment but you definitely would come for parts of the treatment okay so Marsha can you tell me how long the full treatment is and explain what the stages are well and the question of what is the full lift if the treatment is a really good question because that's what we're all doing research on right now we're doing research in Canada we're doing research the United States we're doing research in Europe I know that you're doing research on that also so the array all of the original treatment studies were one-year treatments that does not mean that absolutely everybody is better after one year but it does mean that most of them were so that's been the research we're now looking at six-month treatment so Canada is looking at six months I'm doing a really large Trina study with very high risk for suicide adolescents and we're looking at a six months so there's that now if you go to skills training alone and we have a lot of data now that skills training alone actually very effective those treatments can be anywhere from one hour which we've done with college students who drink to regulate emotions and was extremely effective with college to do a 1-hour treatment and all the way to just teaching people the skills which can be done in 12 weeks 16 weeks 18 weeks 26 weeks so they're various lengths it really depends on the severity of the person and the how long it takes them to get committed to the treatment be willing to work in the treatment be willing to practice etc so Marsha many of the people that are referred to the program here in Ireland would have histories of repeaters Ripert self-harm what would be the typical length of treatment that will be required to help a person which piece of deliberate self-harm you know that's a very difficult question to answer because I've had people with repeated self-harm as well as repeated suicide even people have ended up in intensive care and for some of them is going to take a long time we've had people who've been in this treatment for four to five years these are usually the people who had very severe trauma at very early ages in their lives that was long lasting into their teens or those those years so that group of people they're going to take a long time we have other people who go much more quickly some of our adolescents for example come in to a six-month treatment and believe me as six months there a rule they've got all their teams to be on and their choir to be in and their friends to go see an 18,000 other things that they want to do and there are no more suicidal and they're finished with us and they do fine okay so one of the other questions that we're coming be asked is does the treatment actually work for everyone let's face it no treatment works for everyone this treatment works for more people that it doesn't work for and it generally has better outcomes than any other treatment that we know of for the problems that we address but there's no treatment that works for everyone Marsha can I ask you what is the commitment that is required of an individual if they're considering participating in a standard DBT program well it's not I'm being clear that you have a commitment tests are required what you have is your commitment that's wanted which is to say DBT has always had the policy that we don't take involuntary patients so people are sent here by other people required to be here by the law or something like that they don't want to be in the treatment we're not willing to treat them because our goals are the patient's goals so what a person has to do is be there voluntarily which is to say I commit to doing this treatment with our adolescents for example we had many of the adolescents who were there solely because their parents were making them come so we talked with them a lot and we said listen we're not willing to let you be here you have to want to be here for because the treatment won't work otherwise and in general those who agree to be there they may not have wanted to be thick but they said okay fine I'll do it we tuck so it really has to do with what works best not exactly what's required there's not some law somewhere okay so you mentioned earlier on that there are different components to the treatment so you have individual therapy and you have group skills sessions can you tell us a little bit more about the skills component so we in our skills we have four core modules the first module is a set of mindfulness skills which to a certain extent breaks up mindfulness meditation and turns it into small chunks of behavior and so we teach those those are the core so they underpin every other set of skills that we have then we have in interpersonal effectiveness skills and these are skills which are how to ask for what you want get what you want without harming the relationship and without losing yourself as esteem so those are core set of skills that are the interpersonal skills then we have a set of emotion regulation skills which are really designed to help you regulate emotions that you do not want to have and build resilience so that you're less likely to become emotionally disregulated so that's those skills there we have another set of sails called distress tolerance skills and the first half of those are what called crisis survival skills which are how to get through a crisis without making it worse by doing something dysfunctional or destructive that's part one and part two is how do you live a life that's not the life that you want without being miserable in it okay so that's those now interwoven through all these skills what we call the Supplemental skills so for example we have an entire set of skills that are addiction skills mainly because we've done a number of studies with heroin addicts and it's been very effective so we have our Dixon skills we have middle path skills which our skills really designed for adolescents and their parents because with with adolescents we treat the parents and the adolescents together and we have other skills that have been developed for other things there's sets of eating disorder skills we now have a brand new set of skills developed by Tom Lynch which are for individuals who have over controlled emotions that's very exciting because they're the newest set we've got and so to us we have skills on how to find people and get them to like you are teenagers like those skills and so we have a lot of sort of supplementary skills we have a set of skills that teaches parents how to validate their adolescents so these are all that supplementary which I'm not saying all of them and in generally supplementary are put in and I tell clients we all tell clients that any skill you talk us into teaching you will teach you so do participants need to attend both group and individual sessions in standard DBT yes if you're want to save your in DBT standard you have to attend both so the only real exception is if a person has social phobia really phobia about going and a group setting then what we do is we let them start an individual as the therapist treats the social phobia and as soon as that's treated and they go to the group the other option is to get skills individually the problem with that is there's almost never an available therapist you could do individual skills training in any program that I know of and so in general you have to go so during the course of the 12-month program you repeat the modules twice why is that main reason we do that is when you're really treating people with very severe disorders most the time they're to just regulated the first time you go to ear and understand have a water sign so the skills are very understandable but not if you're so aroused that you can't you can't listen you can't pay attention which does happen to some so what we've discovered is if you go through it once often people they learn the skills but not super well and when they go through the second time they say oh that's what that was I can do that we do the modules twice because at the beginning in the first times that we did it we discovered a lot of people come to group and they're so emotionally aroused that their cognitive functioning sort of goes way down with cognitive functioning way down people can't pay attention they can't process the information you're giving them and they have a lot of difficulty learning the skills what we do therefore is do it a second time and in the second time what ordinarily happens almost always is people say oh that's what that skill was oh okay I'll get it I can do it now and then they learn them very easily the second time through we have right now when we start new skills programs with new people come in the oldest but good is usually say listen don't worry you're going to have trouble understanding the first time but don't worry you're going to get them they're easy to get you just have to have patience so I think that's they're right about that okay can I ask you why is it important to keep your diary cards regularly well we do a diary card because the research is very strong that if you wait a whole week to tell someone what you did during the week it's highly unlikely that you're going to be accurate in fact if you even wait a couple of days you're usually inaccurate so we ask people to fill diary cards out so that they can track the behavior that we're paying attention to in their treatment so we have some standard diary cards like everybody keeps track of how what was your urge to harm yourself what was your urge to kill yourself what was your urge to use drugs and did you harm yourself did you try to kill yourself what was your use of alcohol what was your use of illicit drugs did you use your medications as prescribed and did you use over-the-counter drugs and it's remarkable how effective this is because then the treatment when a person comes in procession they and the therapists review the diary cards to see how they're doing are things going up are they going down we also ask each week what your level of misery each day and so misery sort of a proxy for depression and other things and so it's very important then we have a whole section where people can keep track of behavior they and their therapist think are important for them that might not be for other people but if you don't know what happened during the week is very hard to know what you're supposed to target in a session so Marsha can I ask why is it that you're not required to give the same level of detail and information and skills group as you do to your individual therapist that's a really good question the main reason that we don't do it is because dysfunctional and addictive behaviors are contagious and there's a lot of research on this and we've seen in our own groups that if one person starts talking about cutting let's say another person starts wanting to cut this is one of the problems with inpatient treatment is one person sees another person cut so they start cutting this is also a huge problem with Facebook as you start telling everyone that you've been cutting and other people start cutting and this is a everyone understands this when we teach it because everyone understands that for a drug addict if you start talking about drugs everybody starts wanting to use drugs so you can't talk about drug use can't talk about cutting you can't talk about suicidal behavior you can't talk about eating disorders but you can call them your target behaviors so that's one of the main rules and it's one of the rules I have to say everybody understands you also can't throw your scars out on the table and do things like that so the idea is that you have to really pay attention to the fact that you don't want contagious behavior so why is it important for people to have access to their their therapist using phone out of hours there are two reasons for that reason one is people often need code if a person starts having a craving for drugs or strong desire to harm themselves or wants to kill themselves they need coaching and was very clear to me and to our whole group is that the single best coach is always going to be the individual psychotherapists because that's the one person who actually knows them okay the only exception to that is in our skills only program we may have coaches who are skills co leaders but that's the main reason because people need coaching and as I say to my therapist all the time I'm sure you'd rather take a phone call then go to the morgue so one of the reasons is to try to keep the rate of suicide down and just to be clear I have never talked to an expert in suicide that does not take phone calls now the other reason is is I have always felt that was supremely unfair that in this particular relationship in comparison to every other relationship anybody could get themselves into the therapist has complete and total control over when you can talk about problems you're having with your relationship you know when you're married one person doesn't get to say I'm sorry it's not going and even you know with friends somebody can't say I'm sorry you can only talk about that on Tuesday but in psychotherapy you can do that and I've just always thought it was supremely unfair so I said look clients often leave sessions really distress thinking you hate them or you don't love them or or anger or something like that and I've just never thought it was fair that they can't call you so they can call you now middle E they have to be skillful or you can tell them you don't want to talk to them but what you can't say is you can't call me at all unless they've done something so off-the-wall that it's reasonable for you to say when you act like that I'm not talking to you and therapists have to say that if they do do that Marsha's sometimes our clients worry about terms like dialectical behavioral therapy and when they think about the tree they're worried that they won't be able to understand some of the terminology what are your thoughts about that this drives me wild this is sort of the assumption that clients will not be able to understand you would be amazed at what clients can understand now admittedly if you're going to go around using big words that nobody understands you're going to have to define them so I an ineffective incompetent therapist could have trouble but in general we use ordinary English words translate in whatever language they're being translated into and it's it's rather insulting or rather fragile izing a client to think they can't understand big words I always ask any word that I think someone might not understand I say do you understand it we have found for example in our adolescent program I'm not kidding we use the adult skills which are reasonably complicated and I hate to say this but the adolescents understand them a lot better than their parents understand them to be honest with you and the ILS has teach them to the parents so we've really never had any problem we certainly have problems with people with dyslexia reading handouts and for many of them you know the words are flowing off the page or something and so you have to know whether someone has up any sort of cognitive disability and then you've got to match your way of stalking and tweeting to that particular problem so for example with my dyslexic I was very careful to always read the whole handout that everybody else could read I would read out loud or I have other people read it out loud by the way I've never had anybody without dyslexia not be able to read it out well and teenagers love to read it out they raise their hands right away so you have to modify what you're doing but it's remarkable how little modification people have to do so I think this is the fear of therapists not the fear of clients something that kinds often say to us is that what is the point in changing if the world around us isn't willing to change what are your thoughts thus assuming that's a genuine question the client really wants to know why should they change I would point out to them they're really dummy any difference of other people change actually what counts is do you need to change through your life to be more effective you to be happier so if what you're going to do is compare yourself to others decide whether you're going to change probably going to run into trouble down the road so what you have to look at is the pros and cons of your changing if there's a lot of pros not so many cons and then let us help you change if you discover that there's really nothing in for you to change you're not going to get anywhere you won't be happy or nothing's going to be better than fine you probably don't need us gun participants fail at DBT my answers are really short answer on this one no clients cannot fail now that does not mean that therapists cannot fail and it doesn't mean that the treatment can't fail so if therapist gives the treatment by the book is adherent and has fidelity and the client does not get better then the treatment is self failed and that's obviously possible no treatment helps everybody on the other hand if you have a person who didn't provide it by the book didn't provide it competently and the patient doesn't get better then one could entertain the idea that the therapist failed and it's certainly the case that a therapist can fail as a therapist treating a specific patient so Marshall what happens after year one of DBT when standard DBT has finished what happens for four participants at that stage most of our clients end at one year many of our clients at the end of one year believe they need a whole lot more therapy there's been our experience and often that therapist agrees so we have everybody all upset they have to end at the end of one year in our research studies this become a major problem except we then came up with a fabulous solution which is that we tell people that although they have to end and the reason they have to end in a research study is you had to be able to collect follow-up data okay so you how - generally they have to be out of therapy for six months so the patients are crying say oh I can't stand and I'm probably going to kill myself it's going to be a disaster acceptor and half the time the therapist agreed with them except because it was research we had to let them go for six months we told him though that at the end of six months if they wanted to they could come back into therapy alright so at the end of six months were round waiting around for everybody to come back okay it turned out that most people never came back and they would call us and say they were done fabulous that they in fact had not needed more therapy so then what we started doing when people came and had a year they would cry the therapist would cry and we would tell everyone listen if you leave you can't come back in six months but our guess is when you leave you're like a butterfly and a hand and you are going to fly and I can't count the people it's called us up and say you know you're right I flew so our experience has been that many people will do fine but it's scary for everybody so I'm now entertaining the idea of trying a concept of vacations from therapy because once you get attached often the patient's attached to the therapist just as often therapist attached to the patient nobody wants to end so it's possible that if we put in vacations I have zero data on this but if we put in vacations we'll find that a lot of people actually were ready to fly if they are ready to fly you always want to say you can have a booster session so for example over all these years I have a lot of people who call up and say I just come in just want to check out get a checkup sort of and people come in I had one person whose baby died at age three and had been had all kinds of problems all his life and she comes in and said I just want to know am i normal or not so I have an appointment with her we discussed it we discussed it was normal grieving what's not normal grieving and she leaves I'm essentially I'm saying I don't know every 6 to 9 to 12 months to check out she'll come in so I'm here very check up and I have a lot of other clients who do the same thing so I think it's you know what we tell clients is you may be out of therapy and I may not be your therapist but I'll always be your ex therapist and an ex therapist is a person in your life in other words it's not like I'm now out of your life I'm just in it as your next therapy thing you're writing a book on how to be a good actor best so how long will the results of DBT last Jeepers Creepers who knows we've never done a multi-year over many years follow-up and the federal government in the United States has not been terribly interested in funding that so my guess is that lasts as long as you practice your skills many of the I have many clients who've been a treatment with me who are now in fabulous condition very happy and families have good jobs are doing really well so a lot of people are permanently healed I just don't know what percent that is there are other people who are always going to have some problems always be sensitive perhaps always have some sadness particularly people who have really tragic childhoods you're going to always have a certain amount of sadness but do people continue to harm themselves no are the people we've done a lot of work with with drug addicts and are the people who are addicted to drugs going to go back to drugs many don't does that mean no one goes back now what can participants do to stay well in beers after they finish DBT the key to staying well period is practicing skills one the other is keeping track of what you think that you need in your life if I've learned anything from teaching patience it's that what patients think they need almost always is what they need so the trick here is to not let somebody sell you on the idea that you don't need way you think you need and to go after it that's that's step one step two is to rapidly cept you may not get air thing you need so given that that that's true it's really important to keep working to try to get what you think you need and not to give it up and think okay I'm doomed to life of unhappiness and the trick to that is to recognize that you may get where you need it just may look like it's something else so you've got to keep your eyes open and to a certain extent you have to wear rose-colored glasses but you know most people don't know this but I'll give you a little tip this is actually a lot of research on this it turns out that depressed people see reality more accurately than happy people because happy people distort so a little distortion goes a long way alive so trust yourself that you need what you think you need keep trying to get it in other words you can't just sit back and wait for it if I do but also be willing to take a half a cake when you don't get the whole cake put on a pair of rose-colored glasses you'll be fine

Channel: HSE Ireland

Views: 72,948

Rating: 4.9311194 out of 5

Keywords: Marsha M. Linehan (Author)

Id: fR7Oi0cyoVo

Length: 30min 25sec (1825 seconds)

Published: Tue Dec 02 2014