DBT: The therapy with the most user involvement ever….

TW – Self Harm

Yesterday I did something I haven’t done for a long time.  I sat down and read a book cover to cover.  The book in question was Marsha Linehan’s, Building a Life Worth Living and while I’m going to suggest that it’s audience is going to be limited to people interested in this area, I found it captivating. 

Keir provides supervision, therapy, training and consultancy around what gets described as “personality disorder” via www.beamconsultancy.co.uk

What will probably be a surprise to most people is the level of lived experience of self harm, suicide and institutional care Linehan experienced.  She describes being an intelligent, popular girl with no obvious problems until the age of 18 when she started having recurring headaches with no obvious physical cause.  After a period of her doctor scratching his head she was sent to the local psychiatric hospital for 2 weeks evaluation and so began her descent into hell.  Marsha feels she didn’t meet any of the diagnostic criteria for Borderline Personality Disorder before going into the hospital but like many people I’ve worked with, something about her reaction to the restrictive environment and the staff reaction to her reaction meant that pretty soon she ticked a few boxes.  She began cutting, burning, overdosing, and smashing her head on the floor.  She blames her severe memory loss on this and the ECT she was compelled to receive.  Her 2 week stay lasted 2 years and 1 month including a hospital record of 3 months in seclusion.  It was here that she made a solemn and holy vow that she was going to get out of the suicidal hell she was trapped in and make sure she could get others out of hell too.  

It’s not plain sailing from here and we read about further suicide attempts, the threat of prosecution for attempting suicide and a Kafkaesque moment where the crisis line couldn’t talk to her on the phone to help her stop self harming, so sent the police around to take her to a psychiatric hospital.  The more she protested that she was now ok, the more they wanted to detain her.  

For all the criticisms DBT receives – many of them justified but many of the ones I read being about it being poorly implemented – there is little denying that this therapy originates from someone who has lived it.  Does that justify ways of interacting with people that have been described as rude, cruel and childlike?  Perhaps not but we are often encouraged to listen to the voices of those with lived experience and this voice has been given more volume than most.  

The rest of the book tells an interesting tale of her drive (and she does sound driven) to help people who were recurrently suicidal that the rest of the psychiatric world wasn’t interested in.  She describes a battle to help those who were marginalised in institutions that were frequently disinterested and misogynistic.  She recognises some interpersonal problems and being viewed as a difficult woman, a description attached to many articulate, intelligent passionate people I know.   She describes putting a therapy together that initially didn’t work.  She had up to 8 people watching her at a time, constantly making changes to develop a way of working that helped people to accept themselves while pushing them to change.  

In the book I recognised some refutations of some of the common criticisms I hear of DBT and Linehan herself.  Firstly that she only ‘came out’ as having lived experience after she had made her money with the therapy.  As well as her taking a vow of poverty early in her life and spending much of her income housing the homeless, she was advised by two leading international researchers that telling the world about her experiences would cripple her chances of getting funding to prove DBT worked.  

Another criticism is that DBT wasn’t developed for people ‘with BPD’.  She is clear from the offset that she wanted to help people like her stuck in a cycle of suicidality.  It was late in her career that she learned about the existence of a diagnosis called BPD and she stated her therapy was for the people who got that label because that was the label given to those she wanted to work with.

“I don’t think of myself as treating a disorder.  I treat a set of behaviours that gets turned into a disorder by others”

I was captivated by this book although I think I’m more interested in this area than most.  For those who have an interest in what gets described as personality disorder it is very interesting.  For therapists and service users who want a story of how someone can get out of hell, it’s useful for that too.  There is a lot of God and spirituality in this book which some might find off putting.  Given that it has played such a dominant role in her life, I was surprised how relatively little it is a part of DBT.

A cynic might see the book as an advert for DBT but I think it’s better explained by someone who is fanatical about their life’s work.  I don’t think it is a particularly literary work, but I did find myself moved by a number of passages, literally to tears on occasion.  I certainly see DBT in a new light having read the biography and if you’re interested in personality disorder, DBT, user involvement or mental health in general, this is a good read for you.  

Keir provides supervision, therapy, training and consultancy around what gets described as “personality disorder” via www.beamconsultancy.co.uk


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