Recently, I read Dr. Marsha Linehan’s autobiography, in which she tells how her personal journey led to the creation of Dialectical Behavior Therapy (BDT) as an effective treatment for a variety of conditions including chronic suicidal behaviours. I loved the book and strongly recommend it to mental health professionals and clients. Reading it I had the feeling of being part of that selected audience who attended her first speech about her own experiences as a mental health patient having been committed to a psychiatric institution during her last adolescent years. On that occasion, in 2011, she was already a renowned professor and behaviour scientist and went public with her testimony to contribute even more to her patients’ and students’ hope in building lives worth living.
DBT is the first evidence-based treatment for highly suicidal individuals, including adolescents. It started in the 1990s as an experimental alternative for women diagnosed with Borderline Personality Disorder (BPD) and has expanded to attend a variety of clients since then, always followed by robust research. Today the training in DBT emotional skills, which is part of the standard treatment, has been taught to people who are not mental health patients, including at schools, to enhance emotional well-being and prevent chronic emotional dysregulation among children.
DBT is known as a type of Cognitive Behavioral Therapy (CBT). But the funny thing is that, in her biography, Marsha admitted her insistence with her first book’s publisher to not label the therapy under CBT umbrella.
The publisher of the book had said the title should include the phrase ‘cognitive behavioral therapy’. I said ‘absolutely not. We are not doing cognitive behavioral therapy; DBT is something different’ (…) In the end, we compromised and called it Cognitive-Behavioral Treatment of Borderline Personality Disorder.
(p. 312)
She explains that DBT is actually rooted in a mix of influences such as Person-Centred Therapy by Carl Rogers -she actually calls him “one of my heroes”, Zen Buddhism, Behavioral analysis and Emotion-focused techniques. Dialectics is the core principle -and yes, the concept was inspired in the Marxist philosophy. In the context of DBT, dialectics means a constant effort to find the sense of opposed stances and synthesize opposed poles, such as acceptance and change, willingness and willfulness, emotions and reasoning.
To develop the complex and effective formula of DBT, Marsha and her team studied and experimented with different theories and techniques such as T-groups from Social Psychology and helplines based on humanistic psychology. They were very pragmatic, focused on what worked independently of any institutional or political polarization at the Academic level. In the end, DBT standard treatment was established as a complete program composed of group works for emotional skills training, individual therapy, phone coaching for preventing crises and consultation teams for the therapists.
But of course, Marsha’s academic journey was not easy. After leaving the psychiatric ward, she went back to night school before getting accepted into university. At the time when she started her Ph.D., psychoanalysis dominated inpatient programs with individuals who had attempted suicide and/or engaged in self-harm, and few pieces of research with that population were carried in completely separated settings mostly by a sociological perspective. Marsha was not involved in a clinical Ph.D., contrary to the pathway of the majority of clinicians who would later work at hospitals and outpatient services. She wanted to do scientific research in order to understand why existent interventions for that population did not work as expected. So she was enrolled in research programs focused on behaviour analysis, and then looked for partnerships and grants to be able to test her developing treatment within mental health services. With DBT, she not only synthesized extreme conceptual poles but also approached radically separated environments.
In her biography, Marsha tells us about her confrontations with the most established psychiatrists and psychoanalysts of that time who were references for the treatment of Borderline Personality at hospitals and had important positions in funding boards. Important to mention that all of them were male assisting a large majority of female patients categorized as having “anger issues”. Her friend Charlie Swenson contributed in Marsha’s book telling one of those confrontations in which he was present:
Then Bob Michaels said ‘look how much you are making out of such little data.’ Marsha shot back, ‘And how much data are there in psychoanalytical treatments of patients at this point?’ (…) They treated her that way because they saw she was really good. You don’t get that unless they feel challenged.
(p. 303)
So, after reading Marsha’s book, I’ve got inspired to reflect on my own encounter with DBT. Because it was not a usual one. I was not a Cognitive Behavioral Therapist as the majority of Brazilian DBT therapists are. I work by a psychosocial approach and by an existentialist-phenomenological approach. Still, before assuming myself as a clinician, all I wanted to do was to be a scientist in the field of social psychology and gender studies.
But I fell in love with DBT because of a couple of young female patients who were diagnosed with Borderline Personality Disorder and had tried different therapies and medications before meeting me in 2015 and 2016. They were particularly ostracised by the mental health system in Brazil and came to me because of my writings on Feminist Psychology. I was not an experienced clinician; actually, I was working hard to finish my Ph.D. and launch my career as a university professor at the Department of Social Psychology at the same university where I had graduated as a psychologist. But I saw women suffering so much and I could not help them if I stayed only in my academic role, criticizing the psychiatric system.
I took a pragmatic way and didn’t care if CBT in my context was considered an individualistic approach not fitted to a population with so many social inequalities. In Brazilian academic settings, psychology theories became so polarized that many of my professors did not even compliment their peers from different theoretical approaches. For many years, CBT was considered anathema among psychologists working with disadvantaged populations. Public mental health centres worked primarily by psychoanalytical and/or psychosocial approaches, even if they cannot offer much to BPD patients and people suffering from suicide ideation and self-harm.
However, while teaching, writing my thesis and working with my private office, I started studying everything that could help me to help those women. That’s when I found Marsha’s papers and realized how her biosocial theory of Borderline Personality Disorder articulated very well with the Feminist Psychology and Phenomenology I was working on within my research. In DBT Emotional Skills Handouts for therapists, Marsha actually states that the treatment comes from a feminist perspective. Also, according to her biosocial theory, biological vulnerability to psychopathologies combined with systemic invalidation during the development is the main cause of high emotional dysregulation. Emotional dysregulation is the inability to experience and cope with intense or difficult emotions in a healthy manner. Different problematic behaviours can occur when the individual tries to avoid or eliminate those emotions, including self-destructive and compulsive behaviours. High levels of emotional dysregulation sustained for a long time or combined with traumatic events can prompt BPD.
Therefore, an alternative explanation to BPD among women would be that girls under repetitive invalidations of their emotional expressions and desires because of gender stereotypes and oppression are at greater risk to develop the disorder. This reminds me of Iris Marion-Young’s phenomenological essays on girls’ corporeal experiences under patriarchal culture. Marsha herself tells us in her biography how she was an atypical outspoken girl in her family and city and how she felt constantly invalidated by her parents.
For my patients with Borderline Personality, this approach also helps a lot to deconstruct the myth of them being the sole cause of their behaviours and suffering. Many times, they come with a history of hearing how they ruined their families because of their compulsive self-destructive behaviours. So, it changes immensely the perspective when the therapist is aware of the function of systemic invalidation based on gender and other stereotypes and can include environmental changes into the patient’s treatment, such as educating parents and communicating with schools.
Feminist Psychology is not only for girls and women. It is a source of constant reflection on the power imbalances that permeates our practices as mental health professionals. Being aware of our role in systematic emotional invalidation of any individual or group is a core principle of it. DBT opened the way to the voices of the most invalidated and oppressed clients of the mental health system.
Carol Pombo 