Hopefully, the first few weeks of the new year have been kind to you.
In the midst of celebrating the new year and contemplating the old one, it occurred to me that 2023 marked the 20th anniversary of the publication of Dr. Marsha Linehan’s landmark book, Cognitive-Behavioral Treatment of Borderline Personality Disorder.
The book describes in detail the treatment she developed for BPD. Despite the title, the actual name of her treatment is Dialectical Behavior Therapy, now widely known as DBT.
And with the publication of that book…
The World of Borderline Personality Disorder Changed.
For a long time - well before Dr. Linehan’s work emerged - people with Borderline Personality Disorder were highly misunderstood, inadequately treated and unfairly stigmatized. In fact, until the advent of DBT people with BPD were believed to be incurable and so difficult to deal with that most mental health providers refused to treat a patient with a BPD diagnosis.
The Stigma Was Egregious.
In the 2016 book Beyond Borderline: True Stories of Recovery from Borderline Personality Disorder, Perry Hoffman, PhD, the founder and president of the National Education Alliance for Borderline Personality Disorder (NEA-BPD), wrote that “Borderline Personality Disorder has been called the leprosy of mental illnesses and a disorder with surplus stigma. It may actually be the most misunderstood psychiatric disorder of our age.”
However, from the day Dr. Linehan’s book first appeared, things slowly, but steadily began to improve for millions of people worldwide who suffer with BPD.
What is DBT and What Does It Do?
If you are not familiar with Dialectical Behavior Therapy or Borderline Personality Disorder, BPD is defined as an emotion dysregulation condition. Even the slightest provocation can trigger a much more severe reaction in a person with BPD than in most other people.
Dr. Linehan’s motive for developing DBT was to help people with BPD more effectively manage their emotional reactions when they got out of control.
BPD, DBT, Marsha Linehan & Me
The publication of Dr.Linehan’s book also marked a milestone in my life. Marsha’s publisher, Guilford Press, hired my production company to create a two-part video series about DBT and BPD to augment Dr. Linehan’s book.
That presented quite a challenge for me since the book was written primarily for professional metal health providers. I have been a medical and mental health journalist for nearly 40 years and know my way around the realm of research. But in 1993 there were few resources about Borderline Personality Disorder in the literature. Much of what was there included the results of Linehan’s early studies about Dialectical Behavior Therapy and BPD traits that shaped the content of her book.
A related challenge was the length of the book itself - more than 500 pages! Given the relatively short production schedule devised for the project, I needed an efficient and effective way to grasp the essential information about BPD and DBT in order to construct an accurate educational program that reliably conveyed the book’s content.
So I called Marsha to suggest that a weekly phone conversation would be very beneficial way for to get up to speed on emotion dysregulation, BPD and the application of DBT skills. She casually responded that I shouldn’t worry about that and just show up with cameras and we’d work things out as we went along.
In video and film production, that is often a recipe for disaster.
But despite not knowing her very well, her confident manner won me over and we did, in fact, manage to make it all work. The videos, Understanding Borderline Personality Disorder and Treating Borderline Personality Disorder were extremely well received by professionals and also by affected ‘civilians’ looking for answers to their many questions about BPD.
And with that, our 30 years of creating DBT/BPD content with Marsha and many other pioneers in the field began.
The Final Episode
More recently, I bookended my history of working with Marsha by documenting her presentation on the origins of DBT, The Personal Story of DBT, and how her personal mental health issues influenced the treatment.
At the Institute of Living (IOL), a psychiatric hospital in Hartford, Connecticut, an audience of 300 professionals, patients, friends and members of her family listened raptly as she described having been sent to IOL as a patient at the age of 17. What was supposed to be a 2 month stay turned into 2 1/2 years agonizing years.
All attempts by IOL therapists to tame her wild emotional outbursts and self-harming behaviors proved futile - no amount of counseling, medications, electric shock therapy or being placed in isolation worked. IOL sent her home and advised her parents to consider placing her in a state mental health hospital for long term care.
While still at IOL, Marsha, at her most desperate and disturbing state of mind, made a solemn vow that if she was able to get out of her living hell, she would return and help other people find relief from their own mental health struggles. Which, of course, is exactly what she did.
That story, and many others in her extraordinary life and career, are described in greater detail in her recent memoir, Building A Life Is Worth Living.
The Future Looks Promising
The advent of Dialectical Behavior Therapy seemingly opened a floodgate of other advances in understanding, treating and empowering people impacted by Borderline Personality Disorder. Here are a few of them:
RESEARCH ON DBT. In the last 30 years, Dr. Linehan, and several other independent researchers, have demonstrated via rigorous clinical trials that DBT is highly effective in reducing difficult BPD-related behaviors such as intentional self harm, suicide attempts, depression, anger and substance abuse when compared with other available treatments. In fact, DBT became known as “The Gold Standard” of treatment for people struggling with extreme emotional dysregulation.
OTHER PSYCHOTHERAPIES. In the aftermath of DBT’s debut, other approaches in the treatment of BPD began to emerge. These included Metalization Based Treatment (MBT), Transference Focussed Psychotherapy (TFP) and Schema Therapy, among others. But these interventions have not been as broadly researched or as widely available as DBT.
IMPROVED IMAGING TECHNOLOGY. Imaging technologies such as Functional Magnetic Resonance Imaging (fMRI) allow research scientists to detect very slight changes in blood flow in areas of the brain associated with emotional dysregulation in a person who has BPD.
EPIGENETICS. There is currently no specific medication available for the treatment of BPD. However, with the emergence of the science of epigenetics - the study of how behaviors and environment influence the way genes work - new compounds are in development that may temporarily correct genetically based disruptions in the areas of the brain that are involved in emotion regulation and other traits of BPD.
AVAILABLITY OF BPD. DBT training organizations have had a significant impact on people with BPD and mental health providers who treat BPD. Behavioral Technology, or BTech, the organization Dr. Linehan formed to disseminate DBT, has trained thousands of mental health professionals around the world
Another organization founded by Marsha is The DBT-Linehan Board of Certification (DBT-LBC) which identifies and certifies providers and programs that provide DBT to people in ways that strictly adhere to Linehan’s evidence-based research.
There are also a number of online opportunities for individuals and groups to learn and practice DBT skills. And many reliable DBT self-help books available, including more than 30 on Amazon alone.
PEER SUPPORT AND PERSONAL EMPOWERMENT. Peer oriented organizations that focus on BPD are now well established in the US and other countries. These organizations promote awareness, advocacy and education of BPD and DBT through a wide range of innovative support programs for people with BPD, their families, partners and friends. Here are some that I personally know of and highly recommend:
The National Education Alliance for Borderline Personality Disorder (NEABPD) offers their Family Connections and other BPD/DBT educational programs as well as conferences in the US, Australia, Italy and other countries around the world.
Emotions Matter, headquartered in New York City, provides many innovative support programs in person (e.g., group walks, art shows, cabaret nights) and online (webinars, DBT lessons and classes).
The Sashbear Foundation provides in person and online BPD awareness and family education programs across Canada, including a trans-continental series of urban walks through major cities.
The Center for DBT and Families at McLean Hospital was recently founded by Dr. Alan Fruzzetti, McLean’s Director of Training in Family Services , and staffed by DBT experts. Their mission is teaching DBT to parents of children with BPD and providing consultation services to DBT professionals via Zoom meetings and webinars.
Dr. Fruzzetti, who co-developed the NEABPD Family Connections program with Dr. Perry Hoffman, has long been an advocate of DBT/BPD education for family members.
YOUNG PEOPLE ARE MORE ACCEPTING OF BPD. The wide popularity of social media platforms has minimized a great deal of the stigma earlier generations faced. On our BPDvideo.com website and social media platforms we get more than one million views a year, including many adolescent and young adults.
Notable BPD researcher Mary Zanarini, ED.D of McLean Hospital and Harvard Medical School shared this observation with us about working with groups of adolescent that participated in one of her BPD research studies.
How Things Are Now
The effort to perceive BPD as a treatable mental disorder rather than a permanent character defect has been a long uphill struggle. However, as a result of all the awareness efforts, technical innovations and educational initiatives that have emerged since the publication of Dr. Linehan’s first book, attitudes toward BPD have been steadily moving along a more tolerant trajectory than ever before.
After more than a century a great deal of the unfair stigma, uninformed diagnoses and ineffective treatments are steadily being replaced by evidence based research and greater support for people impacted by BPD.
Thank You Marsha
The sea change in the ways that BPD and people with BPD are now perceived can in many ways be tied to the groundbreaking work of Marsha Linehan and her Dialectical Behavior Therapy.
Dr. Linehan is now retired and no longer teaching, writing or conducting research studies. Despite concluding her professional career, the positive impact of her work on the lives of people living with BPD will continue for a long, long time.
I feel very grateful to be both a professional colleague and a personal friend of hers.
Wonderful!