Champions of Psychology: Marsha Linehan

APS Fellow Marsha Linehan is a Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington. She is also Director of the Behavioral Research and Therapy Clinics, a consortium of research projects developing new treatments and evaluating their efficacy for severely disordered, multi-diagnostic, and suicidal populations. Her primary research is in the application of behavioral models to suicidal behaviors, drug abuse, and borderline personality disorder. She is also working to develop effective models for transferring science-based treatments to the clinical community.

Linehan is the developer of Dialectical Behavior Therapy (DBT) a treatment originally developed for the treatment of suicidal behaviors and since expanded to treatment of borderline personality disorder and other severe and complex mental disorders, particularly those that involve serious emotion dysregulation. She is also founder of Behavioral Tech Research, Inc., a company that develops innovative online and mobile technologies to disseminate science-based behavioral treatments for mental disorders.

She has received several awards recognizing her clinical and research contributions to the study and treatment of suicidal behaviors, including the Louis I. Dublin Award for Lifetime Achievement in the Field of Suicide, the Distinguished Research in Suicide Award (American Foundation of Suicide Prevention), and the creation of the Marsha Linehan Award for Outstanding Research in the Treatment of Suicidal Behavior established by the American Association of Suicidology. She has also been recognized for her clinical research including the Distinguished Scientist Award from the Society for a Science of Clinical Psychology, the award for Distinguished Scientific Contributions to Clinical Psychology (Society of Clinical Psychology,) and awards for Distinguished Contributions to the Practice of Psychology (American Association of Applied and Preventive Psychology) and for Distinguished Contributions for Clinical Activities (Association for the Advancement of Behavior Therapy).

APSSC: What led you to choose psychology as a career?

M.L.: After giving up the idea of being a theologian, I went for pre-med and applied to medical schools. My aim was to be a psychiatrist in a state hospital where I thought I could help the people most in need of help. Shortly after applying for medical schools, I realized that there did not appear to be any data that mental health treatments of the day — this was 1967 — were helpful. I suddenly realized that if this were true, I would spend my life trying to help mental patients but failing at it. So I decided I should become a researcher and develop treatments that worked. I then realized that training in psychology is training in research, and medical schools do not focus on training researchers. So I withdrew my applications to medical school and applied to graduate schools in psychology.

APSSC: How did you go about developing your current research interests, and how have they influenced you as a person and a professional?

M.L.: I always wanted to help the most miserable people in the world, and, at the start of my career, I was convinced that people who want to die must be the most miserable. So, I decided to focus my career on suicide. After reading the first book on suicide, I was completely hooked on the topic. How and why people choose either death or life was intrinsically interesting, and, even now, it is one of the few topics in psychology I can read just for pleasure. I became a behavior therapist when I found that changing attitudes did not change behavior (which was a terrible shock to me). I ultimately got funded to test my ideas on treating suicide. I had been trained in behavior modification, and, frankly, it never occurred to me that behavior therapy would not reduce suicidal behavior. So, to be sure I could show that my treatment was effective, I decided to get subjects who attempted suicide a lot so I could show that I could get them to attempt less often. I called inpatient hospitals and said, more or less, “send me your worst.” But then my treatment blew up: The patients were always mad at me, went mute, walked out, or attacked me. I had never heard of borderline personality disorder, but it turned out that was the disorder I was working with. So, I started modifying the treatment, and, over the years, dialectical behavior therapy emerged — synthesizing radical acceptance on the one side with change on the other side. Bringing into behavior therapy a focus on acceptance of and by the client was the catalyst for the term dialectical. Learning acceptance myself so I could teach it to clients sent me into almost 30 years of Zen training with a Benedictine monk who is a Zen master. That experience transformed me and my life. Teaching my graduate students and fellows to treat high-risk suicide patients and to love the most difficult to treat individuals has been a joy in my life. I have perhaps had less sleep but much satisfaction.

APSSC: What suggestions do you have for choosing an area of study within a field as large and diverse as psychology?

M.L.: Follow your passion and do what you are good at.

APSSC: How did you go about selecting a graduate program?

M.L.: My advisor told me that I would get no research training in a clinical program and that I should get a degree in social psychology and then do post-doctoral training in clinical. So that is what I did. I applied to Yale and to the University of Illinois. I was a college nominee to the University of Illinois, so no one even considered that I would not get in. I was rejected from both. My undergraduate school, Loyola of Chicago, said, “Stop crying, we’ll take you,” and I accepted.

APSSC: What were the most rewarding aspects of graduate school for you?

M.L.: I was extraordinarily cared for by the faculty, particularly by the chair of the department. They have been my role models all of my career, but I have never lived up to them fully.

APSSC: How does a graduate student work towards becoming a first-rate researcher?

M.L.: You have to learn everything you can about research design and methodology, get a really good, broad education in psychology as a whole, be courageous and fight for your own ideas, and be more interested in finding out if your hypotheses are right than in proving that you are right. Throw in honesty and humility, an ability to get along with the colleagues who are essential to a career, and prayer.

APSSC: What are some of the common mistakes you see graduate students and young professionals making?

M.L.: You cannot change the world by pleasing others all the time. Students have enormous power if they stand up and none if they stay seated. So, I believe a common mistake is to try and figure out what others want rather than to fight for what you believe in. (Alas, I am a child of the ‘60s.)

APSSC: What advice would you give to graduate students who want to have careers in academia?

M.L.: If you want it, go for it. Realize you have to work harder than you imagined you would, at least until you get tenure, and that you need to take the best job you can get for your first job, even if it is not in a location you like, to get the opportunity to end up somewhere you really want to be.

APSSC: Writing and publishing are often anxiety provoking events for graduate students. You have had many years of experience as a writer, editor, and reviewer; what do you know now about this process that you wish you would have known earlier in your career?

M.L.: I did not learn how to write in graduate school and had no experience writing for major journals until well into my career. I wish I would have had more critical feedback on writing much earlier.

APSSC: One of your most famous achievements is standardizing a successful treatment program for one of the most notoriously treatment-resistant disorders: borderline personality disorder. What led you to begin to apply Eastern philosophies to work with suicidal clients and, later, with clients with borderline personality disorder?

M.L.: I realized that I had to learn acceptance to teach it to both therapists and patients (and I knew I had to teach it). I had a background in Christian contemplative prayer, which also stresses acceptance. So I asked the people I knew in the spiritual direction field who would be a good teacher for me, so I could learn acceptance and then teach it. I had no idea what Zen was at that point. The two names that were sent to me by more than one person were a Catholic priest and a woman Zen master. I asked myself: Which was I, a Catholic or a woman? I went to the woman first for three months, at Shasta Abby, and the Catholic priest second, for three months at a monastery in Germany. The priest, Willigis Jaeger, as it turned out, was also a Zen master. I knew almost immediately at Shasta Abbey that I had found what I was looking for. I ultimately became a student of Willigis and for years went to Germany twice a year. Willigis is trans-confessional, teaching everyone from fundamentalist to atheists. I needed a way to teach that was completely inclusive of everyone and accessible to every spirituality and no spirituality. I needed an approach to acceptance that would fit therapists as well as patients. I had found it, so I set about translating what I had been taught, including meditation, and how the teachers interacted with me, into behavioral terms and treatment strategies. Then I got it approved by my teachers and gave it a name — mindfulness — that was used in both psychology and in contemplative practices.

APSSC: What were some of the specific problems and hurdles you faced in the course of providing empirical support for dialectical behavior therapy? How might today’s new researchers learn from your experiences?

M.L.: Once the treatment was developed, the biggest problem was getting money to evaluate it. It is essential to get to know funders, visit them when possible, and learn as much as you can from them. You also need to have a lot of colleagues who know your research, like you, and think you are good. This requires going to meetings and talking any mentor you have into introducing you to people. Getting on committees is also a good idea. Working with people who are better than you is always good. The next big problem was being able to counteract the enormous amount of criticism I got from non-behavioral therapists. Many of the attacks were ad hominem. To deal with this, you have to be very good at selling your ideas and your research methodology, be resilient and able to bounce back when smashed down, and do your best to not attack those who attack you. Working with highly suicidal individuals has its own risks. You have to view yourself as an educator of human subjects committees. Most importantly, you have to fight for what you believe in.

APSSC: Psychology is continually faced with the challenges of integrating science and practice, as recent publications by APS and the New York Times have highlighted. What are your thoughts on resolving this dialectic?

M.L.: I think that the most compassionate thing a therapist can do is provide a treatment that works to help clients achieve their own goals. I find that one of the most tragic things in life is the number of individuals who are not provided with treatments that work. I believe the only solution to this is to improve teaching in graduate schools and to work with government, insurance, and provider groups to require therapist training and certification in evidence-based treatments. If Great Britain can do it, surely we can do it.

APSSC: How has what you’ve learned through your research influenced how you live your life?

M.L.: My research has opened a million doors for me: great students, wonderful clients, fabulous colleagues, tenure that gives me financial security, a wonderful team to work with, and a constantly renewed belief in overcoming hopelessness. It has also made my life so busy that simply filling out this interview has been put off too many times.

APSSC: Is there a question that you wish I had asked? What would your answer have been?

M.L.: Would I select another career if I had a chance? Answer: NO, I love what I do. ♦