Monday, November 07, 2005
With Toughness and Caring, a Novel Therapy Helps Tortured Souls
July 13, 2004
By BENEDICT CAREY
nytimes.com
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.
July 13, 2004
By BENEDICT CAREY
nytimes.com
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.
# posted by Cate @ 7:37 PM 
