DBT founder sees much success with a treatment built through failure

The creator of Dialectical Behavior Therapy (DBT) opened Foundations Recovery Network's Moments of Change conference with an historical account of the treatment that sounded very much like a call for balanced approaches to addiction services.

Marsha Linehan, PhD, who clearly has many clinical disciples among the attendees of the Sept. 28-Oct. 1 conference, started her opening keynote by saying DBT was built through addressing “multiple failures for which I had to figure a solution.” Launched in 1980 to assist patients at high risk of suicide, DBT managed to merge the seemingly irreconciliable strategies of acceptance- and change-focused therapy and is now widely used in the treatment of addictions.

Linehan, a longtime University of Washington psychologist who credited her institution for always allowing her to work with some of the most challenging patients, discussed many aspects of her DBT work that might appear surprising to the traditionalist in treatment. She said the contingency management strategy that she has employed has used only positive outcomes—there has never been punishment involved for drug use. She added that her therapy has taken aspects of both abstinence and harm reduction approaches.

Linehan also emphasized that the intent of DBT work is truly client-empowering. Emotion regulation focuses on “what the clients want to change,” she said.

Historic choice

Well before evidence emerged to show DBT's effectiveness for patients with substance use disorders, Linehan had to designate a targeted patient diagnosis in order to secure research funding from the National Institute of Mental Health (NIMH). Her options at the time were depression and the more complex BPD. She joked to the Foundations audience in Palm Beach, Fla., that had she chosen depression, researched by so many, no one would know her today. It is always better to be the only researcher in a niche area, she said.

Today, research has shown that the highest remission rates for behavioral illness with use of DBT occur for patients with substance use disorders. “There is no one who doesn't think DBT is effective now,” she said.

Linehan said she is now extremely enthusiastic about ongoing advances in DBT delivery, including online formats for emotion regulation and for alcoholic patients who are suicidal.

Her brief comments about heroin addiction reiterated the call for balanced strategies, with medication offered in tandem with therapeutic support. She said of medication-assisted treatment in these cases, “There's really no chance that it's going to work without it.”