Dialectical Behavior Therapy (DBT): Where We Were, Where We Are and Where Are We Going

thank you very much. That was an amazing
introduction, I have to say. This is going to be my first
talk ever for 45 minutes. And so that was very
long and I’m not counting it as part of my talk. [LAUGHTER] Just to let you know. Well, thank you for coming. I really appreciate it. I always like to talk
about my research, as probably every researcher
in the world does. And I’m going to be
talking about suicide. And I’m just noticing that
I’m missing– here it is. I’m going to talk about suicide,
as you no doubt can see, because that’s been
the research I’ve done really my entire career. I want to just comment to you
to start with about what it’s like to be a suicidal person. And suicidal people,
it’s like being a person locked in a closet
with white walls that go all the way up to the ceiling
and red hot pain on your feet and up through your heart. The suicidal person
looks for a way out. They try everything to
get out of that room. But they can’t find the room,
the door to let themselves out. And so ultimately they
find only one door, which is the door of suicide,
which they go through. Many years ago in my own
life, I decided, first of all, I was very interested suicide. And I decided that I was
going to spend my life going into hell, because that’s
where all these people were, to get them out of hell. And the talk tonight
is really a review of my best effort to
date to do exactly that. I can’t say that I’ve
been so successful that we don’t need so much more work. But this is the best that
I’ve been able to do so far. So I’m going to
share that with you. Now, as you’re looking here,
you see all these names at the bottom. I hope that you can see them. We’ve got Anita, we’ve got
Trevor, we’ve got Chelsea, we’ve got Kevin. These are my graduate
students at the moment. And everyone who’s had
a researcher professor knows that nobody gets
anything done without students. And these are the students
who’ve supported me so much over this time. And they’re doing, to
be perfectly honest with you, the most exciting
research in the world. And if I have time at
the end, I will tell you. I almost want to do
it now, but then I might not be able
to finish my talk, because they do
such exciting stuff. But I’ll try to
squeeze it in later. So these are my
conflicts of interest. You can see right away. I feel like Hillary now. [LAUGHTER] You can see right
away that you should take with a grain of salt
everything I have to say, given that I have
a lot of conflicts. OK I get money and funding
from the National Institute of Mental Health
to do my research. I receive training
and consultation fees from Behavioral Tech, which
is a trainee companies that I founded. I receive compensation
as an owner of Behavioral Tech
Research, which is group that develops products. And I receive royalties from
the sale of my DBT books. So now that you know that,
we’ll just go right on. I’m going to talk about
dialectical behavior therapy, which is an evidence
based therapy for high suicide risk. First I’m going to tell
you how it got the name. Because those of
you who’ve ever seen the book have seen the book
and know that the name of book is Cognitive Behavior Therapy. And that is not what
the treatment is. The treatment is dialectical
behavior therapy. But my editors wouldn’t
let me put that name on because they said no one would
buy the book if it was said to something like
dialectical, which nobody knew what it meant, including me. And I’ll talk a little
bit as we go on about how it happened to be dialectical. So where did everything start? My work on this
particular treatment started when I came to the
University of Washington. And I got a small grant
from the National Institute of Mental Health, who
were wonderful to me, I’ve got to tell you. I mean, no one has treated me
better than they have, really, over the years. But at that time,
I was very young. And they liked my idea. So they gave me a
little bit of money to see if I could
do anything with it. Because I told him that
I wanted to figure out a treatment for suicidal people. So they gave me the funding. And I was a complete and total
believer in behavior therapy. I’d been trained
in behavior therapy by the best, a whole group
of Gerry Davison and Marv Goldfried. And if ever there was a believer
in behavior therapy, it was me. And I figured that I
wasn’t really going to find out whether it worked. I was going to prove
that it worked. You can tell I wasn’t too
scientific in those days. And so that was the basic idea. So I figured, I don’t know
how long I thought it’d take. But I didn’t think it was
going to take that long, because I figured the treatment
was just going to work and I’d get all those people
to stop being suicidal and I’d go do something
else with my life. Probably stay in suicide, but
my treatment was going to work, so I wasn’t really worth. So that was a big mistake. Because immediately
the treatment blew up. That’s the best way to put it. I was treating people to
develop the treatment. I had to treat people. But I figured I had a treatment,
it was behavior therapy. The problem was that the
people I was treating, they experienced me
as being judgmental, as telling them what
to do, et cetera. Mainly because I was acting
like a behavior therapist. So they would come in. I would say, what’s
your problem? I figured out their problem. I’d say, OK, no problem,
I’ll see you next week. They would come in
next week and then I would say things like, OK, so
I see that this is the problem. I can help you change. They said, what? You’re saying I’m the problem? I said, no, no, I’m
not saying that. Absolutely I’m not saying that. Absolutely I’m not saying that. And they would scream
and yell and cry and the whole nine yards. So I thought, OK,
that’s not a problem. My degree’s in experimental
personality theory. So I knew all kinds
of other things. And I thought, OK,
I’m going to do an acceptance based treatment. I’m going to do
one of those ones where you’re just always
listening and paying attention, validating, understanding,
all that kind of stuff. I thought, this must
be what I need to do. So then I started doing that. That was an even worse disaster. They said, what, you’re
not going to help me? I said, of course I’m
going to help you. Yes, I am going to help you. So I had to solve that
problem, of course, because it couldn’t go
forward without solving it. So I had to do the next thing. I figured out that I needed
new therapies strategies. So what did I need? I needed a synthesis. I needed a technology
of change and I needed a technology of acceptance. I realized right away I
needed a spaciousness of mind to dance with movement,
speed, and flow and also because the
client would come in and they’d have one problem. They’d say, my problem
is my boyfriend. And I really don’t know
what to do about it. And I say, OK, well
let’s work on that. And say, yeah, I know, but
the problem is he moved out and now I can’t pay my rent. And I say, oh, well, let’s
work on how to do the rent. At which we start working
on that and they say, well, I’m killing myself anyway. I don’t think it
makes any difference. I say, all right,
let’s work on that. So I realized that I had
to be able to really move with the client. So I also realized
at the time that I had to get radical acceptance
of the clients themselves. Now why did I have to do that? Let me tell you how I got
these patients for my research. I was very afraid that
my treatment would not be as good as treatment
as usual in the community. So I figured that I couldn’t
just do a regular study. Because what if everybody
got better on their own and I couldn’t show my
treatment was better? So I decided what
I would do is try to get the worst of
the worst, the most difficult of the difficult. This
was so that I’d be able to show that my treatment was better. So I called all the
hospitals in town and I said, what are the
worst patients you have and the suicidal, the
most difficult to treat, and the ones you really
don’t want to treat? Would you send those
to me for my research? I was this little
nobody from nowhere. They said, right. We’ll send them right to you. And that’s how I got them all. Because they were very
difficult to treat. And the problem was
I had no experience before this of ever dealing
with anybody like this. I had dealt with people where
you had sort of simple problems and treatments worked
and they all got better. And all of a sudden
I had these people who had a very slow and
episodic rate of progress and a real high risk of suicide. And I realized that I had to
figure out how to accept that. And then I came
upon the knowledge that I needed to
also get humility. Because it turned
out that it was clear the problems were transactional. In other words, it wasn’t that
they were screwed up and I wasn’t. I had my own part to
play in the relationship. And I started to
realize that also. And just to let you
know what happened with the treatment,
that particular finding, was that to get on a DBT
program, to be a DBT therapist, you have to sign things that
you agree to, to get on a team. Because you have
to be on a team. I’ll talk about that later. But to get on the team,
you have a lot of things that you have to agree to it. And one of the things that
all DBT therapists have to agree to, this
is the truth, you have to agree that in reality
most therapists are jerks. And that most of the things
that our clients say that we do, we actually do. This is true too. So this was a good agreement. So the solution was to
apply change strategies and acceptance strategies. And I had learned
those primarily from many behavior therapy
strategies for the change strategies. And then acceptance strategies
I learned in many other places. And I’ll talk a little
bit more about that. But the main acceptance
strategies are validation. And the core of
change strategies are problem solving of one
[? square ?] to the other. The next problem was I
discovered that my clients had very low distress tolerance,
frequent crisis, high arousal, and it made sustained work on
anything almost impossible. You could tell that from
the story I told you. At the time of developing
this, distress tolerance was not a topic of
research, unfortunately. Because I would have just stolen
all that research and used it. So I realized that
I had to figure out a way to teach the clients
radical acceptance of one set of problems to
work on another set. Because you can’t
work on everything at the exact same time. So all of us have to tolerate
something to do something else. I treat patients who have the
most unbelievably tragic pasts that you could possibly imagine. I’m not going to go into it,
but believe me, it’s tragic. And the facts of the matter are
we all have to accept our past, mainly because you
can’t change it. And we have to
accept the present because you can’t do
anything about that either, because the present
is now gone anyway. So I had to teach them that. But then we have
to also recognize that there are
limitations on the future. That all of us have some sort of
limitations of what we can do. And I had to help my
clients with that. So I had to figure
out how to do that. Then I realized that
I had to teach them distress tolerance, which
is basically the ability to tolerate distress without
impulsively moving to suicide or other destructive behaviors. You’d be amazed how many
suicides is actually impulsive. There’s a lot of
research now showing a large number of suicides where
people thought about killing themselves for five
minutes beforehand and that’s the only
thinking they never did. And this is people who lived
just by the grace of God. In other words, who
threw themselves in front of a train who
somehow managed to live. So it’s really interesting
how impulsivity itself is such a problem when it
comes to suicidal behavior. The other thing is,
you may not know this, but the average
suicidal person also, and particularly the
ones I was treating, often feel they’re alone. They feel lonely. That’s one of the
major problems. I might talk about
that again later. They feel unconnected,
unrelated, not loved by anyone, not acceptable. They have extraordinary
amounts of shame. And so I realized that I had
to teach them to experience on their own their
connection with others and the universe and
their essential goodness. Those of you who
know DBT know that we say there’s no good or bad. But essential goodness means
that you’re not a bad person. And I had to figure
out a way to try to teach them how to recognize
that particular fact. It’s very difficult. And also
their essential validity, which means they too have
a right to raise their hand and ask a question. They belong on this earth
just like the rest of us do. Now just me telling
you that I had to do all that tells you
who I was dealing with. Because none of the people
that I was dealing with believed any of this. So that was one of
my major problems. So what I did, and I began,
and I will talk later about it, because it’s so important
to this treatment. I don’t have time to tell
you the skills I had them on and I took them off. But the solution was to
develop a dialectical approach where I started teaching
my clients change skills. And DBT has a whole
set of change skills. Organize that we teach
that our clients. But we also have an entire
set of acceptance skills which primarily are
skills that are now viewed as mindfulness skills. Mindfulness at the time, DBT
was the first psychotherapy to put mindfulness
into the therapy. And as probably
most of you know, it’s absolutely everywhere now. But this was the first
one to put it in. Jon Kabat-Zinn had
before me put mindfulness into medical treatment. But this is the
first psychotherapy. And it was to teach clients all
the practices of mindfulness and acceptance of
which there are many. So we have a whole set
of skills on that too. So the next sets
of problem I had was the ever changing
clinical presentation, which you’ve probably gotten
a little taste of already. Frequent crises and new problems
resulted in confused therapists and a chaotic therapy. Mainly it was, what are you
supposed to pay attention to when was the problem. And these were not clients
who have one or two problems. They had a zillion problems. And so I needed a way
to tell therapists, OK, this is the level
of importance of what. So what I did was I developed
an individualized target based agenda, which I’m going
to show you in a minute. So that meant that I
made a list of these are the level of importance
of various things. Keeping people alive, of
course, being the top one. And we also put in a set
of protocol based agenda. So an individualized
target one is that you pay attention to
what’s happened to the client since you saw them last. And protocol based
agenda is you already have a schedule for
what you’re teaching. And you teach that
independent of what’s going on with the client. Mainly because you almost
always are doing the protocol based in groups in DBT. So we needed multiple
interventions and a host of behavioral
skills could easily lead to memory
overload and confusion about what to do when. So therapists had to do
so many different things at many different points
that I needed a way to get them so they could
remember what they were doing. So this is where I developed
a hierarchical hierarchy of what was important. So the most important thing
was behavioral dyscontrol. You’ve got to get
behavior under control. And the top problem
in behave dyscontrol was life threatening behaviors. So in general DBT
therapy always started with trying to figure out
a way to get the person not to kill themselves
before you saw them again. And the way we
usually do that is, you know, you’d
be very surprised. If you ask a person who
wants to kill themselves whether they think they’re
going to be better off dead, almost every single
patient will say yes. They actually think they
were going to be better off. Now the facts of the matter are,
and I always tell them this, there’s 0 data that that’s true. [LAUGHTER] And in fact, there’s
some religious that say that you’re
going to be worse off. I’m not kidding. One of the religions says
that if you kill yourself, you have to start your whole
life over again and do it over. And if anything we keep me from
doing it, that would do it. [LAUGHTER] So I tried to help them
see that they don’t really have the data they need to make
a good decision about suicide. So we have all sorts of things. We go from behavioral
dyscontrol to quiet desperation. That’s when you’re
still totally miserable, but you’re not acting
out all the time. Problems in living,
or when they have just what I call ordinary
problems of living. And then we have incompleteness. I don’t think I have time
to tell you about that. But ask me when you do
questions, because we’re at my all-time best. So don’t forget when
we get questions. All right. The next problem
I had to deal with was treating individuals
at chronic high risk. Often leads to
treatment based on fear. This is a major problem in
this country in particular where people can be sued. And they can lose in suits. And so the standard of
care at the time and now, just to let you know in case you
didn’t know, is 0 data for it. And hospitalization
has no data whatsoever that it reduces suicide. In fact, there’s more data
suggesting it may be iatrogenic than there is anything else. And if I were giving
a talk on that topic, we would spend all
of our time on it. It’s my favorite topic,
but I’m not going to. But the facts of the
matter are there’s not any data that shows that
hospitalization has ever kept anybody alive for five minutes. And it predicts very high
risk for suicide afterwards. And if you ask me some
question about that at the end, I’ll tell you the data on DBT. Because DBT is a very
almost never hospitalizes. So you got to
remember that suicide is a problem solving for
the client and a problem for the therapist. I’ve never had a client come
in who said, listen my problem is I want to kill
myself and you want to help me not to kill myself. I’ve not even once
in my whole career. Most people say I want
to kill myself, period. So I had to develop a DBT
risk assessment and management protocol. So I developed a
protocol and also a checklist that went with it. And at the very end of the talk,
you’re going to see something. If you’re interested,
you can actually get a copy this for free
by going onto my website. It’s on there. And so at the end,
you’ll see how to get it. So I didn’t ignore
standard of care completely, because that would
be, I think, irresponsible, or I thought it was at
the time irresponsible. But I did develop a DBT risk
assessment and management protocol, which gives a lot of
information to the therapist, but also gives
therapists a checklist. And we know that
people do checklists can stay fidelity better. But then therapist’s
emotion, disregulation often lead to
excessive fear, anger, hostility resulting in attempts
to control the patient. Believe me, one of
the biggest mistakes you can make as
a psychotherapist with suicidal people is you
start trying to control them. It makes it worse almost
always, never better. But you definitely
want to do it. Because you get afraid
and then the therapists fall apart themselves. They reject and have burnout. And one of the biggest
problems of the people we treat is DBT doesn’t allow
people to be kicked out of therapy for the behavior
that brought them in. But is that me? My time’s up? No, it’s a client calling me. Well, I’ll just
have to let it go. [LAUGHTER] I’ve already talked to this
client once about a half an hour ago. Sorry about that. Not much I can do. Let’s hope that
it stops ringing. Thank you. But then on the
other side you have people with excessive
empathy that often leads to falling
into the pool of despair with the client. And you see this a lot. These are the therapists
who fall in the pool and start reinforcing
the very behavior they’re trying to get rid of
by being more sweet and all of that kind of stuff. So I had to come up with a
solution for that, of course. So what we did,
that’s when I came up with the idea of developing
DBT as a team treatment. Because the function of a
team, among other things, is that people meet at a team,
they meet once a week minimum. Not really minimum,
but in general minimum. And that function of
the team is to keep the therapist’s infidelity. And the other function of it
is to support the therapist and help the therapist,
especially in high risk, difficult times. And in a general, team members
form the backup therapists when anyone’s out
of town or anything else, mainly because they’re
the ones who know the client. So I made up the therapy, so
I got to make up the rules. And you can’t say
you’re a DBT therapist if you’re not on a team. But the team can be one that
you do by phone or other things. So the other huge
advantage of this is that it lead to
dissemination of the treatment and to fidelity. And so we can talk about that
later if you have questions. So then I had another
problem, which was I now had showed that
my ideas have promise. So now I wanted to
get a real grant. The problem was, this is not
true now, but it was true then. To get a grant, they told me I
had to have a mental disorder. Now remember I’m dealing
with suicidal people. So I didn’t give them
mental disorders. But other people told me they
thought they were Borderline, but I’d never heard of
Borderline Personality Disorder. So I didn’t know that’s
what I was treating. Borderline Personality
Disorder, you’re going to hear a lot more
about it from Martin, who comes after me. One of the reasons he’s coming
is he’s the world expert on it. I had never heard of it. But then I started
looking it, up once they told me they thought
that’s what I was treating. And So I had a choice of either
Borderline Personality Disorder or depression. At that time nobody believed in
Borderline Personality Disorder who was a behavior therapist. That was considered
sort of weirdo stuff. But they look like they
met criteria to me. So I decided to take patients
who have Borderline Personality Disorder. NIMH told me I was making the
biggest mistake of my life. I did it anyway
and it was probably one of the best decisions
I’ve made in a long time. So the solution was
to have a diagnosis but also pay attention
to problem behaviors. But then I had to develop
a model of the disorder. I mean, you have to
have a theory if you’re going to call it a disorder. You have to have
some sort of theory. And I didn’t find any
theories of the disorder that met any criteria I
would want to meet. So I needed one that was capable
of guiding effective therapy, had non pejorative and
engendered compassion. And I needed
something compatible with current research data. Now, the good thing
about me, my stuff’s always compatible with research. Because the minute new research
comes, I just change my theory. [LAUGHTER] So that’s how I’ve kept up. So my theory then was that
borderline personality disorder is a pervasive disorder of
the emotion regulation system and that the criterion
behaviors of it, which are problematic
criteria behaviors, those behaviors
function to regulate emotions or a natural
consequence of emotion dysregulation. So this all came from just
the people I was working with and figured out
these appear to be what the key problems are here. So the solution was to provide
a biosocial, biological regulation disorder. So I saw the treatment as a
biological regulation disorder. I figure there’s
inheritance here somewhere. Together with invalidating
social environment. And I got the research on
invalidating social environment and the biology,
but Martin, I hope, is going to talk
about some of it. The next thing
that happened was I had patient populations that
differed due to differential diagnosis problems, et cetera. In other words,
we started having all sorts of other
people wanting to have this treatment,
different cultures. So we had to figure out
what to do about that. So the solution
here was to start stretching DBT without
changing it to a non DBT. So the idea was we’ve made
a lot of modifications to the treatment to fit
different cultural groups like Native Americans,
Alaskan Natives, et cetera. And a lot of my grad students
are working on it now. I’ve got grad students working
on DBT for transgender people, for example. So you can see that there
are a lot of modifications have to be made. But at the same time,
we have to figure out how to stay inside the
treatment and keep everything that you can. So the idea is you don’t change
anything until you find out that you need to change it. Now, the next
problem I had, this was not a good problem to have
because my wonderful treatment here did not treat anxiety
disorders anywhere near as well as standard
behavior therapy. This is the first thing I
found that wasn’t as good a standard treatment. So this is a big problem. So it’s here. And you’ll see here,
on substance dependence DBT brings it down by 87%
and major depression by 68%. By the way, there’s no other
treatments that are better. And eating disorders by 64%. Now you get to panic disorder
and other anxiety disorders and PTSD. And all of a sudden, we’re not
as good as very everybody else. So what was the problem
with our treatment? Well, it turns out that the
only way to treat anxiety is going to be with
prolonged exposure. So you have to do an
exposure treatment. In other words, itself is a
type of treatment all by itself. And although I pulled
in every other therapy that I’d ever learned, I
had not pulled in this. And it turned out it was
unbelievably important. I was very lucky
to have– whoops. I was very lucky to have
Melanie Harned who’s a research scientist, in our center. And she is an expert
in prolonged exposure, thank the Lord. So she took on the
task of figuring out how to treat this
group of people with exposure when we had
to also worry about the fact that they might not be
able to tolerate it. This is probably
the saddest thing I’ve been through in this field
largely was when I found out that the strategy
that she developed, which worked like
a charm, was this. It was we told the
patients that if you will stop trying to
kill yourself and stop harming yourself, we will give
you an effective treatment. Now imagine that. Imagine that no one
else had offered them an effective
treatment before us. And I found it so sad. You find so many
people with disorders who get suicidal because
no one helps them, because no one offers an
evidence based treatment to them. So this worked like a charm. And we’re still using, I
wouldn’t call it perfect, but nothing’s perfect. The next problem
was DBT was viewed as a treatment for
mental disorders only and in particular
for Borderline Personality Disorder. And there’s all kinds of stigma. I’m not kidding. People would talk to
me in the grocery store because people would think they
were Borderline Personality Disorder. I had people, particularly
in the military, come see me and they made me promise not
to let the military find out that they’d come to
treatment with me because they were worried
about losing their insurance and everything else. So it is unbelievable the stigma
of this particular disorder. I mean, it’s slightly
understandable but really unbelievable. I tell my patients, I say,
you go to the emergency room, for God’s sake’s don’t tell them
you’re Borderline Personality Disorder or they
may not treat you or they start thinking
that you really don’t have anything
wrong although you’re having a heart attack. They’ll think it’s
all in your head. So don’t tell them. So this is a major problem. So I had to do
something about that. I decided let’s
find out if DBT only works for Borderline
Personality Disorder suicidal people and people with
really serious disorders. So now we’ve been doing
a bunch of research. We continue with Borderline
Personality Disorder, but we’ve added all the other
disorders that are around. And we started
developing DBT skills, which is a major part
of the treatment, for friends,
family, and schools. And that has had a huge effect,
particularly in schools. Where in schools, the
biggest effect this has is to cut down
suicidal behavior. But almost anyone can
learn from these skills. And we’ve realized. I use these skills all the time. Everybody I know uses
the skills all the time. The rest of us of our clinic
use the skills all the time. So that was very important. So where are we now? Let’s look at the data
to see where to go. So this is going
to be fast on data because I have other things
I want to talk about. Is DBT effective? Yes. [LAUGHTER] I mean, the a are no
one disagrees now. I’ve been in a battle
my whole career. I’ve had almost
all my studies have been in response to criticisms. Your treatment doesn’t do this. I say, OK, I’ll study that. Yes it did. OK, next. So there are 17
randomized control trials. Internationally DBT is the only
treatment viewed as effective for Borderline
Personality Disorder. In other words, they
have enough studies done on it to say that
this in fact is effective. This is my very first
set of research. I was so excited when
I did my first study. And showing that the yellow is
the control condition suicide attempts. And the blue is the DBT. So you can see right away
a big difference there. Let me get out of here. This is when people
said, oh well, any expert would be just as good as you. And I said, OK, I’ll
do a study on experts. So we called round, found out
who are the best treatment people were in Seattle. Wrote them all and said you’ve
been nominated as an expert therapist. Would you like to be a research
therapist in my research? Every single person agreed. We brought them in and
we compared them to DBT. And what we found was suicide
attends 50% lower in DBT. Visits to emergency
rooms 53% lower in DBT. And inpatient hospitalization
73% lower than DBT. Then we were accused of
saying that all we treated was symptoms. Now, behaviors don’t
even have a construct of symptoms in the first place. That’s a psychiatric term,
not a behavior therapy term. But nonetheless, they said that. So I said, OK,
give me a measure. And if I can get a good finding
on it, you will be quiet. And so I spent about a
year writing and saying, come on, send me a measure. Finally, they sent me a measure. I actually told them
they would shut up. And they gave it to me and
I have about six of these, but I’m only showing you one. And DBT by far was better
than other treatments at what was viewed by them as
the key components of treatment that’s really primarily
from the psychoanalyst. So they stood up and
cheered when I told them I had found the data. So I appreciated that was
humility on their side. Then we looked at we
teach behavioral skills. We have a lot of change skills,
a lot of acceptance skills. We have mindfulness skills, a
lot of different mindfulness skills. So the question was, do people
use the skills that we teach? So we did research on that. And this, what you’re
going to see this really, really interesting. Oh no. She’s calling again. OK, when I get off I’ll go talk. Oh thank heavens. So do clients the skills? Now the red one here is the DBT. So you see that the DBT clients
use the skills all the way up and also continue to use them
after in the post treatment. Now, what’s really interesting
is that control condition also is using behaviors. We had written up
the skills so they didn’t sound like DBT
skills, but they covered the terrain of DBT skills. And what you see that’s the
most interesting about this is that the control
conditions did use the skills during
treatment and then they quit using
them in follow up. Of course, that’s really
important information to have. So the question is,
are skills important? I would say of everything
in our treatment, the one thing you
absolutely cannot get rid of in our treatment
actually is the skills. So we did a lot of research
looking at whether it mediated, that is to say, was it the
factor driving other things. And DBT skills
mediated increases in emotional
regulation, improving interpersonal
relationships, reduction of suicidal behaviors, and
about five or six other things. It’s probably the
only thing that you can’t remove from the
treatment and still have the treatment working. I’m not going over that research
because it would take so long, but we did a whole study
looking at what would happen if you took skills away. And that’s a bad idea. So of course everyone
complains this treatment must be too expensive. This treatment is not expensive. It saves money. It saves an unbelievable
amount of money. There’s multi-site examinations
of the efficiency and cost of DBT in the United
States and Great Britain and many other places. And it’s at least 50% lower
cost than any other treatment, particularly within
the United States. It’s true with the military. And so the main
reason the treatment saves so much money is that DBT
rarely hospitalizes patients. It’s an outpatient
treatment where we very rarely hospitalize. We have a lot of
data on that which you could ask me at the end. So where are we going? I just want to tell you. We need more effective
dissemination of DBT. We’re developing
computerized DBT. We have a computerized
DBT skills, which turns out to be as good as
in person DBT skills training. We’re really happy about that. And the reason I’m happy
is I had a mother call who we didn’t let in the study
because her daughter was psychotic. Mother calls and cries and
says, how can you do this? My daughter can’t go to
groups and learn skills, but she got to learn them. I said, OK. We got permission from
[INAUDIBLE] subjects, gave her the skills. She called and told us how
much it helped her daughter. You immediately
realize how important it’s going to be to computerize
our treatments for so many people who
can’t get to therapy or can’t tolerate therapy. We want to computerize
our entire treatment. Right at the moment I
have a graduate student who just got funded. We’re doing research now. She is doing research for high
risk for suicide alcoholics. And turns out that she
also did the research and found out that high
risk for suicide alcoholics don’t want to come
see a therapist. But they’re very willing to
come to an online treatment. So she’s gotten funding
from NIAAA to do that. And that’s exactly
what we’re doing. So that’s exciting. What else is needed? We need a more robust field
of suicide researchers. So many people
willing to print books on how to do a treatment
that has no data whatsoever. I mean, this is
extremely common. So I had a friend
who was doing that. And I happened to be
eating lunch with him and he told me he was
publishing this book. And I said, what are
you talking about? You can’t do that. He said, why not? And I said, you
don’t have any data. You can’t do that. You’ve got to do research first. That’s not right. He said, well I don’t
know how to do research. I said, OK, fine,
come to Seattle. I’ll teach you how
to do research. So he did. And we brought a
whole group of people in at the University
of Washington and we did a whole
program on training them on how to do
research on suicide. And I was just at a
huge meeting for people who are interested
in suicidal behavior. And I asked how many
of the therapists in this room who
are researchers know how to do research on suicide. It was very few. How many if I run a program
and train you would you come? And I’m not kidding,
must have been 200 people raised their hands. So I’m hoping that I can
put this together and put another program together
to help with that. We also need just
better research itself. Not just learning research, but
we need to do better research. And so the University
of Washington started and formed
a international DBT strategic planning meeting. Basically the bottom line is
if you’re a researcher in DBT, you’re invited. You can bring your graduate
students and your post-docs. All you have to do is
say that you do research or you want to do research, then
you can come to our meeting. And the meeting addresses
what research is needed now. And Martin Bohus, who’s going
to be your next speaker, is on the executive
group of that and has worked a lot with us. But we have people
all over Europe, all over Canada, South America. And it boils down to if
you want to do research, you come to see us. And we will help you. And we have all kinds of
small groups with young people to try to teach them
how to do research. There are rules
though for coming. I forgot that. I should tell you. So the rules are
they have to sign a pledge that,
one, they will not withhold any ideas they have. Two, they will not take anybody
else’s ideas and use them. Three, if anybody
has really bad data, they will not say bad things
about them when they leave. And four, I think we have
more than that, but four, the most important is they
will do the dishes at my house. [LAUGHTER] And they do do the dishes. Because everybody comes to
my house to have dinner. So we have, I don’t know,
we’re up to 70 people I think or something. I mean, it’s a big group. But I’m telling all of you
all in here, anybody in here is a researcher, who
wants to do research, has graduate students doing
research, wants them to do it, this is the place to come. You’re here for the
best of the best. You just have to sign
and agree to get in. The next question
is we have to answer the question of sending highly
suicidal people to hospitals, is it iatrogenic. NIMH now sends me every paper
that suggests that it’s true. The data is unbelievably
overwhelming. Suicide’s the number
one cause of death on psychiatric inpatient units. The first day you’re getting
out is a very high suicide risk day. There is not one study that’s
ever shown that it’s effective. And yet people are
so afraid of being sued that they put people in
hospitals for that very reason. I’m fighting this like mad. So we have to do the research
though to prove it really well, substantial, to
make people secure. I spend a lot of time
helping people be secure and keeping people out. But we’re going to have to
have the data, much better data than we’ve got now. So we have to conduct
that and we have to talk NIHM into funding it. Fortunately, I’m at the
University of Washington. It’s probably one of
the few universities in the country that would
actually let scientists do that research. I’m going to talk
about that in a minute. We have to stop fragilizing
our graduate students. Almost every graduate
school I know of will not let their
students treat suicidal patients, high
risk for suicidal patients. Now if we don’t do
that, who is going to treat these people
in the real world? So we have very
few people who know how to treat suicidal
who will do it who will take serious people. They’re so afraid and that’s
how they end up in hospitals. So University of Washington. Now, we can do better. Because I at the
University of Washington have a training
program where I train students for extremely high
risk for suicidal patients. We have an adolescent
program where we have adolescents at high risk. My graduate students
are treating them. We have an adult program and
my students are treating them. They have done wonderfully. This is not true that grad
students can’t do this. We need to get the interns
in psychiatry into this and we need to get this. What we have to do
now is figure out how to get this to
other universities. And I have a curriculum for
it which is on my website. People can download it for free. But we need to figure out how to
let everybody know it’s there. So this is that. The next thing, we’ve got to
address IRBs and the university fears. I am not kidding. I am so unbelievably lucky
to be at the University of Washington. Because I have never
once been turned down for anything at all. And that is because
human subjects here has been really wonderful. And they have not turned me. I have not ever once been
told I could do something. I’ve had to rewrite
things every single time. That’s true. But they have worked with me. You can’t believe
how rare this is. I have a lot of friends who
tell me their universities won’t let them do it at all. I call people and
say, OK, let’s do this where we would
do a randomized trial on hospitalization. Our university would
ever approve that. So we’re really lucky
to have this university. What I’m trying
to figure out now is how to get what this
university is willing to do out to these other universities. And that’s what’s got to happen. [APPLAUSE] [MUSIC PLAYING]


  1. Yes you have to do the research to prove it, it's totally individual and in my service the opinions are divided, nevertheless a crisis plan should be in place, if not with admissions, with crisis teams and engaging properly with the patient, not just go to see if they breath in oxygen, which is what they do in the UK, most of them anyway.

  2. If people were doing their job properly on in patients wards and in crisis teams they wouldn't be so many deaths, most of the staff are unskilled.

  3. I find the comfort of a mother's love, to the best of my imagination, watching and listening to Marsha. She is warm, funny, honest, smart, humble and loving.

  4. I have found DBT to be the most effective therapeutic intervention, and possibly the only effective one. It's been many years since I was so fortunately placed in that outpatient DBT group, and I'd love to revisit the literature and maybe buy some of Dr. Linehan's books.

  5. I'm loving your information. I am thinking, as you speak, that much of your "therapy" is about both the therapist and the client accepting reality and staying in the moment. It's a good foundation to live life and to have peace of mind and at some point, even happiness!

  6. What a brilliant lady! What a blessing to have someone with such intelligence, creativity and compassion! God bless you.

  7. Finally, somebody knows what she is doing….You find the most knowledgable about an issue is the one who say i donot have all the answers……….. Good lecture

  8. I need to add a comment to The Forum in this video, That was the worst education given to Working psychologists, Of the hours I've spent researching available information on Mental Health

  9. Thank you for this presentation, but how in the world are there only 20 comments… and less then 500 likes

  10. Joking isn't the best idea with someone who's crying for help. You have zero evidence that I'm gonna be better after killing myself? Ok, let me grab the knife and you'll see in a minute if I'm still suffering. NEVER EVER joke with suicidal people.


    To try to find resources, I went to NEA BPD, a Linehan Institute page (not working now), NAMI, Physcology Today, UW, and other sites. There are a plethora of resources for mental health professionals to get DBT training. Where are the resources to get help?

    Like many who either have BPD or like me haven't been diagnosed, I have had a very tough time finding qualified help. As a high functioning professional person, this is embarrasing and as stated here; there is such a stigma. I have links in the mental health community and feel like I'm going to be known by calling around.

    My area has very few professionals that indicate a true specialty in DBT. I have found five in my area. One is booked way out, two of them only work with teens and younger. I'll be callling the other two today. I assume that there are more, but I don't know where to find them.


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