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  • [MUSIC PLAYING]

  • [APPLAUSE]

  • MARSHA LINEHAN: Well thank you very much.

  • That was an amazing introduction, I have to say.

  • This is going to be my first talk ever for 45 minutes.

  • And so that was very long and I'm not

  • counting it as part of my talk.

  • [LAUGHTER]

  • Just to let you know.

  • Well, thank you for coming.

  • I really appreciate it.

  • I always like to talk about my research,

  • as probably every researcher in the world does.

  • And I'm going to be talking about suicide.

  • And I'm just noticing that I'm missing-- here it is.

  • I'm going to talk about suicide, as you no doubt can see,

  • because that's been the research I've

  • done really my entire career.

  • I want to just comment to you to start with about what it's

  • like to be a suicidal person.

  • And suicidal people, it's like being

  • a person locked in a closet with white walls that

  • go all the way up to the ceiling and red hot pain on your feet

  • and up through your heart.

  • The suicidal person looks for a way out.

  • They try everything to get out of that room.

  • But they can't find the room, the door to let themselves out.

  • And so ultimately they find only one door,

  • which is the door of suicide, which they go through.

  • Many years ago in my own life, I decided, first of all,

  • I was very interested suicide.

  • And I decided that I was going to spend my life going

  • into hell, because that's where all these people were,

  • to get them out of hell.

  • And the talk tonight is really a review

  • of my best effort to date to do exactly that.

  • I can't say that I've been so successful that we

  • don't need so much more work.

  • But this is the best that I've been able to do so far.

  • So I'm going to share that with you.

  • Now, as you're looking here, you see all these names

  • at the bottom.

  • I hope that you can see them.

  • We've got Anita, we've got Trevor, we've got Chelsea,

  • we've got Kevin.

  • These are my graduate students at the moment.

  • And everyone who's had a researcher professor

  • knows that nobody gets anything done without students.

  • And these are the students who've supported me

  • so much over this time.

  • And they're doing, to be perfectly honest

  • with you, the most exciting research in the world.

  • And if I have time at the end, I will tell you.

  • I almost want to do it now, but then I

  • might not be able to finish my talk,

  • because they do such exciting stuff.

  • But I'll try to squeeze it in later.

  • So these are my conflicts of interest.

  • You can see right away.

  • I feel like Hillary now.

  • [LAUGHTER]

  • You can see right away that you should

  • take with a grain of salt everything I have to say,

  • given that I have a lot of conflicts.

  • OK I get money and funding from the National Institute

  • of Mental Health to do my research.

  • I receive training and consultation fees

  • from Behavioral Tech, which is a trainee companies

  • that I founded.

  • I receive compensation as an owner

  • of Behavioral Tech Research, which is

  • group that develops products.

  • And I receive royalties from the sale of my DBT books.

  • So now that you know that, we'll just go right on.

  • I'm going to talk about dialectical behavior

  • therapy, which is an evidence based therapy for high suicide

  • risk.

  • First I'm going to tell you how it got the name.

  • Because those of you who've ever seen

  • the book have seen the book and know that the name of book

  • is Cognitive Behavior Therapy.

  • And that is not what the treatment is.

  • The treatment is dialectical behavior therapy.

  • But my editors wouldn't let me put that name on

  • because they said no one would buy the book if it was said

  • to something like dialectical, which nobody knew

  • what it meant, including me.

  • And I'll talk a little bit as we go on about how

  • it happened to be dialectical.

  • So where did everything start?

  • My work on this particular treatment

  • started when I came to the University of Washington.

  • And I got a small grant from the National Institute

  • of Mental Health, who were wonderful to me,

  • I've got to tell you.

  • I mean, no one has treated me better than they have, really,

  • over the years.

  • But at that time, I was very young.

  • And they liked my idea.

  • So they gave me a little bit of money

  • to see if I could do anything with it.

  • Because I told him that I wanted to figure out

  • a treatment for suicidal people.

  • So they gave me the funding.

  • And I was a complete and total believer in behavior therapy.

  • I'd been trained in behavior therapy

  • by the best, a whole group of Gerry Davison and Marv

  • Goldfried.

  • And if ever there was a believer in behavior therapy, it was me.

  • And I figured that I wasn't really going

  • to find out whether it worked.

  • I was going to prove that it worked.

  • You can tell I wasn't too scientific in those days.

  • And so that was the basic idea.

  • So I figured, I don't know how long I thought it'd take.

  • But I didn't think it was going to take that long,

  • because I figured the treatment was just going to work

  • and I'd get all those people to stop being suicidal

  • and I'd go do something else with my life.

  • Probably stay in suicide, but my treatment was going to work,

  • so I wasn't really worth.

  • So that was a big mistake.

  • Because immediately the treatment blew up.

  • That's the best way to put it.

  • I was treating people to develop the treatment.

  • I had to treat people.

  • But I figured I had a treatment, it was behavior therapy.

  • The problem was that the people I was treating,

  • they experienced me as being judgmental,

  • as telling them what to do, et cetera.

  • Mainly because I was acting like a behavior therapist.

  • So they would come in.

  • I would say, what's your problem?

  • I figured out their problem.

  • I'd say, OK, no problem, I'll see you next week.

  • They would come in next week and then

  • I would say things like, OK, so I see that this is the problem.

  • I can help you change.

  • They said, what?

  • You're saying I'm the problem?

  • I said, no, no, I'm not saying that.

  • Absolutely I'm not saying that.

  • Absolutely I'm not saying that.

  • And they would scream and yell and cry

  • and the whole nine yards.

  • So I thought, OK, that's not a problem.

  • My degree's in experimental personality theory.

  • So I knew all kinds of other things.

  • And I thought, OK, I'm going to do

  • an acceptance based treatment.

  • I'm going to do one of those ones

  • where you're just always listening and paying attention,

  • validating, understanding, all that kind of stuff.

  • I thought, this must be what I need to do.

  • So then I started doing that.

  • That was an even worse disaster.

  • They said, what, you're not going to help me?

  • I said, of course I'm going to help you.

  • Yes, I am going to help you.

  • So I had to solve that problem, of course,

  • because it couldn't go forward without solving it.

  • So I had to do the next thing.

  • I figured out that I needed new therapies strategies.

  • So what did I need?

  • I needed a synthesis.

  • I needed a technology of change and I needed

  • a technology of acceptance.

  • I realized right away I needed a spaciousness of mind

  • to dance with movement, speed, and flow

  • and also because the client would come in

  • and they'd have one problem.

  • They'd say, my problem is my boyfriend.

  • And I really don't know what to do about it.

  • And I say, OK, well let's work on that.

  • And say, yeah, I know, but the problem is he moved out

  • and now I can't pay my rent.

  • And I say, oh, well, let's work on how to do the rent.

  • At which we start working on that and they say,

  • well, I'm killing myself anyway.

  • I don't think it makes any difference.

  • I say, all right, let's work on that.

  • So I realized that I had to be able to really move

  • with the client.

  • So I also realized at the time that I

  • had to get radical acceptance of the clients themselves.

  • Now why did I have to do that?

  • Let me tell you how I got these patients for my research.

  • I was very afraid that my treatment would not

  • be as good as treatment as usual in the community.

  • So I figured that I couldn't just do a regular study.

  • Because what if everybody got better on their own

  • and I couldn't show my treatment was better?

  • So I decided what I would do is try

  • to get the worst of the worst, the most

  • difficult of the difficult. This was so that I'd be able to show

  • that my treatment was better.

  • So I called all the hospitals in town

  • and I said, what are the worst patients you have

  • and the suicidal, the most difficult to treat,

  • and the ones you really don't want to treat?

  • Would you send those to me for my research?

  • I was this little nobody from nowhere.

  • They said, right.

  • We'll send them right to you.

  • And that's how I got them all.

  • Because they were very difficult to treat.

  • And the problem was I had no experience

  • before this of ever dealing with anybody like this.

  • I had dealt with people where you had sort of simple problems

  • and treatments worked and they all got better.

  • And all of a sudden I had these people

  • who had a very slow and episodic rate of progress

  • and a real high risk of suicide.

  • And I realized that I had to figure out how to accept that.

  • And then I came upon the knowledge

  • that I needed to also get humility.

  • Because it turned out that it was clear

  • the problems were transactional.

  • In other words, it wasn't that they were screwed up and I

  • wasn't.

  • I had my own part to play in the relationship.

  • And I started to realize that also.

  • And just to let you know what happened

  • with the treatment, that particular finding,

  • was that to get on a DBT program, to be a DBT therapist,

  • you have to sign things that you agree to, to get on a team.

  • Because you have to be on a team.

  • I'll talk about that later.

  • But to get on the team, you have a lot of things

  • that you have to agree to it.

  • And one of the things that all DBT therapists have

  • to agree to, this is the truth, you

  • have to agree that in reality most therapists are jerks.

  • And that most of the things that our clients say that we do,

  • we actually do.

  • This is true too.

  • So this was a good agreement.

  • So the solution was to apply change strategies

  • and acceptance strategies.

  • And I had learned those primarily

  • from many behavior therapy strategies for the change

  • strategies.

  • And then acceptance strategies I learned in many other places.

  • And I'll talk a little bit more about that.

  • But the main acceptance strategies are validation.

  • And the core of change strategies

  • are problem solving of one [? square ?] to the other.

  • The next problem was I discovered that my clients had

  • very low distress tolerance, frequent crisis, high arousal,

  • and it made sustained work on anything almost impossible.

  • You could tell that from the story I told you.

  • At the time of developing this, distress tolerance

  • was not a topic of research, unfortunately.

  • Because I would have just stolen all that research and used it.

  • So I realized that I had to figure out

  • a way to teach the clients radical acceptance of one

  • set of problems to work on another set.

  • Because you can't work on everything

  • at the exact same time.

  • So all of us have to tolerate something to do something else.

  • I treat patients who have the most unbelievably tragic pasts

  • that you could possibly imagine.

  • I'm not going to go into it, but believe me, it's tragic.

  • And the facts of the matter are we all have to accept our past,

  • mainly because you can't change it.

  • And we have to accept the present

  • because you can't do anything about that either,

  • because the present is now gone anyway.

  • So I had to teach them that.

  • But then we have to also recognize

  • that there are limitations on the future.

  • That all of us have some sort of limitations of what we can do.

  • And I had to help my clients with that.

  • So I had to figure out how to do that.

  • Then I realized that I had to teach them

  • distress tolerance, which is basically the ability

  • to tolerate distress without impulsively moving to suicide

  • or other destructive behaviors.

  • You'd be amazed how many suicides is actually impulsive.

  • There's a lot of research now showing

  • a large number of suicides where people thought about killing

  • themselves for five minutes beforehand

  • and that's the only thinking they never did.

  • And this is people who lived just by the grace of God.

  • In other words, who threw themselves

  • in front of a train who somehow managed to live.

  • So it's really interesting how impulsivity itself

  • is such a problem when it comes to suicidal behavior.

  • The other thing is, you may not know this,

  • but the average suicidal person also,

  • and particularly the ones I was treating,

  • often feel they're alone.

  • They feel lonely.

  • That's one of the major problems.

  • I might talk about that again later.

  • They feel unconnected, unrelated, not loved by anyone,

  • not acceptable.

  • They have extraordinary amounts of shame.

  • And so I realized that I had to teach them to experience

  • on their own their connection with others

  • and the universe and their essential goodness.

  • Those of you who know DBT know that we

  • say there's no good or bad.

  • But essential goodness means that you're not a bad person.

  • And I had to figure out a way to try

  • to teach them how to recognize that particular fact.

  • It's very difficult. And also their essential validity,

  • which means they too have a right to raise their hand

  • and ask a question.

  • They belong on this earth just like the rest of us do.

  • Now just me telling you that I had

  • to do all that tells you who I was dealing with.

  • Because none of the people that I was dealing with

  • believed any of this.

  • So that was one of my major problems.

  • So what I did, and I began, and I will talk later about it,

  • because it's so important to this treatment.

  • I don't have time to tell you the skills I had them on

  • and I took them off.

  • But the solution was to develop a dialectical approach

  • where I started teaching my clients change skills.

  • And DBT has a whole set of change skills.

  • Organize that we teach that our clients.

  • But we also have an entire set of acceptance skills

  • which primarily are skills that are now

  • viewed as mindfulness skills.

  • Mindfulness at the time, DBT was the first psychotherapy

  • to put mindfulness into the therapy.

  • And as probably most of you know,

  • it's absolutely everywhere now.

  • But this was the first one to put it in.

  • Jon Kabat-Zinn had before me put mindfulness

  • into medical treatment.

  • But this is the first psychotherapy.

  • And it was to teach clients all the practices of mindfulness

  • and acceptance of which there are many.

  • So we have a whole set of skills on that too.

  • So the next sets of problem I had

  • was the ever changing clinical presentation,

  • which you've probably gotten a little taste of already.

  • Frequent crises and new problems resulted in confused therapists

  • and a chaotic therapy.

  • Mainly it was, what are you supposed to pay attention

  • to when was the problem.

  • And these were not clients who have one or two problems.

  • They had a zillion problems.

  • And so I needed a way to tell therapists,

  • OK, this is the level of importance of what.

  • So what I did was I developed an individualized target

  • based agenda, which I'm going to show you in a minute.

  • So that meant that I made a list of these

  • are the level of importance of various things.

  • Keeping people alive, of course, being the top one.

  • And we also put in a set of protocol based agenda.

  • So an individualized target one is

  • that you pay attention to what's happened to the client

  • since you saw them last.

  • And protocol based agenda is you already

  • have a schedule for what you're teaching.

  • And you teach that independent of what's

  • going on with the client.

  • Mainly because you almost always are doing the protocol

  • based in groups in DBT.

  • So we needed multiple interventions and a host

  • of behavioral skills could easily

  • lead to memory overload and confusion

  • about what to do when.

  • So therapists had to do so many different things

  • at many different points that I needed a way

  • to get them so they could remember what they were doing.

  • So this is where I developed a hierarchical hierarchy

  • of what was important.

  • So the most important thing was behavioral dyscontrol.

  • You've got to get behavior under control.

  • And the top problem in behave dyscontrol

  • was life threatening behaviors.

  • So in general DBT therapy always started

  • with trying to figure out a way to get the person

  • not to kill themselves before you saw them again.

  • And the way we usually do that is,

  • you know, you'd be very surprised.

  • If you ask a person who wants to kill themselves

  • whether they think they're going to be better off dead,

  • almost every single patient will say yes.

  • They actually think they were going to be better off.

  • Now the facts of the matter are, and I always tell them this,

  • there's 0 data that that's true.

  • [LAUGHTER]

  • And in fact, there's some religious

  • that say that you're going to be worse off.

  • I'm not kidding.

  • One of the religions says that if you kill yourself,

  • you have to start your whole life over again and do it over.

  • And if anything we keep me from doing it, that would do it.

  • [LAUGHTER]

  • So I tried to help them see that they don't really

  • have the data they need to make a good decision about suicide.

  • So we have all sorts of things.

  • We go from behavioral dyscontrol to quiet desperation.

  • That's when you're still totally miserable,

  • but you're not acting out all the time.

  • Problems in living, or when they have just

  • what I call ordinary problems of living.

  • And then we have incompleteness.

  • I don't think I have time to tell you about that.

  • But ask me when you do questions, because we're

  • at my all-time best.

  • So don't forget when we get questions.

  • All right.

  • The next problem I had to deal with

  • was treating individuals at chronic high risk.

  • Often leads to treatment based on fear.

  • This is a major problem in this country in particular

  • where people can be sued.

  • And they can lose in suits.

  • And so the standard of care at the time and now,

  • just to let you know in case you didn't know, is 0 data for it.

  • And hospitalization has no data whatsoever

  • that it reduces suicide.

  • In fact, there's more data suggesting it may be iatrogenic

  • than there is anything else.

  • And if I were giving a talk on that topic,

  • we would spend all of our time on it.

  • It's my favorite topic, but I'm not going to.

  • But the facts of the matter are there's not

  • any data that shows that hospitalization has ever kept

  • anybody alive for five minutes.

  • And it predicts very high risk for suicide afterwards.

  • And if you ask me some question about that at the end,

  • I'll tell you the data on DBT.

  • Because DBT is a very almost never hospitalizes.

  • So you got to remember that suicide

  • is a problem solving for the client and a problem

  • for the therapist.

  • I've never had a client come in who said, listen my problem

  • is I want to kill myself and you want

  • to help me not to kill myself.

  • I've not even once in my whole career.

  • Most people say I want to kill myself, period.

  • So I had to develop a DBT risk assessment and management

  • protocol.

  • So I developed a protocol and also

  • a checklist that went with it.

  • And at the very end of the talk, you're going to see something.

  • If you're interested, you can actually

  • get a copy this for free by going onto my website.

  • It's on there.

  • And so at the end, you'll see how to get it.

  • So I didn't ignore standard of care

  • completely, because that would be, I think, irresponsible,

  • or I thought it was at the time irresponsible.

  • But I did develop a DBT risk assessment and management

  • protocol, which gives a lot of information to the therapist,

  • but also gives therapists a checklist.

  • And we know that people do checklists

  • can stay fidelity better.

  • But then therapist's emotion, disregulation

  • often lead to excessive fear, anger,

  • hostility resulting in attempts to control the patient.

  • Believe me, one of the biggest mistakes

  • you can make as a psychotherapist

  • with suicidal people is you start trying to control them.

  • It makes it worse almost always, never better.

  • But you definitely want to do it.

  • Because you get afraid and then the therapists

  • fall apart themselves.

  • They reject and have burnout.

  • And one of the biggest problems of the people we treat

  • is DBT doesn't allow people to be kicked out

  • of therapy for the behavior that brought them in.

  • But is that me?

  • My time's up?

  • No, it's a client calling me.

  • Well, I'll just have to let it go.

  • [LAUGHTER]

  • I've already talked to this client once about a half

  • an hour ago.

  • Sorry about that.

  • Not much I can do.

  • Let's hope that it stops ringing.

  • Thank you.

  • But then on the other side you have

  • people with excessive empathy that

  • often leads to falling into the pool of despair

  • with the client.

  • And you see this a lot.

  • These are the therapists who fall in the pool

  • and start reinforcing the very behavior they're

  • trying to get rid of by being more sweet

  • and all of that kind of stuff.

  • So I had to come up with a solution for that, of course.

  • So what we did, that's when I came up

  • with the idea of developing DBT as a team treatment.

  • Because the function of a team, among other things,

  • is that people meet at a team, they meet once a week minimum.

  • Not really minimum, but in general minimum.

  • And that function of the team is to keep

  • the therapist's infidelity.

  • And the other function of it is to support the therapist

  • and help the therapist, especially in high risk,

  • difficult times.

  • And in a general, team members form the backup therapists

  • when anyone's out of town or anything

  • else, mainly because they're the ones who know the client.

  • So I made up the therapy, so I got to make up the rules.

  • And you can't say you're a DBT therapist

  • if you're not on a team.

  • But the team can be one that you do by phone or other things.

  • So the other huge advantage of this

  • is that it lead to dissemination of the treatment

  • and to fidelity.

  • And so we can talk about that later if you have questions.

  • So then I had another problem, which

  • was I now had showed that my ideas have promise.

  • So now I wanted to get a real grant.

  • The problem was, this is not true now, but it was true then.

  • To get a grant, they told me I had to have a mental disorder.

  • Now remember I'm dealing with suicidal people.

  • So I didn't give them mental disorders.

  • But other people told me they thought they were Borderline,

  • but I'd never heard of Borderline Personality

  • Disorder.

  • So I didn't know that's what I was treating.

  • Borderline Personality Disorder, you're

  • going to hear a lot more about it from Martin,

  • who comes after me.

  • One of the reasons he's coming is he's the world expert on it.

  • I had never heard of it.

  • But then I started looking it, up once

  • they told me they thought that's what I was treating.

  • And So I had a choice of either Borderline Personality Disorder

  • or depression.

  • At that time nobody believed in Borderline Personality Disorder

  • who was a behavior therapist.

  • That was considered sort of weirdo stuff.

  • But they look like they met criteria to me.

  • So I decided to take patients who have Borderline Personality

  • Disorder.

  • NIMH told me I was making the biggest mistake of my life.

  • I did it anyway and it was probably

  • one of the best decisions I've made in a long time.

  • So the solution was to have a diagnosis

  • but also pay attention to problem behaviors.

  • But then I had to develop a model of the disorder.

  • I mean, you have to have a theory if you're

  • going to call it a disorder.

  • You have to have some sort of theory.

  • And I didn't find any theories of the disorder that

  • met any criteria I would want to meet.

  • So I needed one that was capable of guiding effective therapy,

  • had non pejorative and engendered compassion.

  • And I needed something compatible

  • with current research data.

  • Now, the good thing about me, my stuff's

  • always compatible with research.

  • Because the minute new research comes, I just change my theory.

  • [LAUGHTER]

  • So that's how I've kept up.

  • So my theory then was that borderline personality disorder

  • is a pervasive disorder of the emotion regulation system

  • and that the criterion behaviors of it, which

  • are problematic criteria behaviors,

  • those behaviors function to regulate

  • emotions or a natural consequence of emotion

  • dysregulation.

  • So this all came from just the people I was working with

  • and figured out these appear to be

  • what the key problems are here.

  • So the solution was to provide a biosocial, biological

  • regulation disorder.

  • So I saw the treatment as a biological regulation disorder.

  • I figure there's inheritance here somewhere.

  • Together with invalidating social environment.

  • And I got the research on invalidating social environment

  • and the biology, but Martin, I hope,

  • is going to talk about some of it.

  • The next thing that happened was I

  • had patient populations that differed due to differential

  • diagnosis problems, et cetera.

  • In other words, we started having

  • all sorts of other people wanting

  • to have this treatment, different cultures.

  • So we had to figure out what to do about that.

  • So the solution here was to start

  • stretching DBT without changing it to a non DBT.

  • So the idea was we've made a lot of modifications

  • to the treatment to fit different cultural groups

  • like Native Americans, Alaskan Natives, et cetera.

  • And a lot of my grad students are working on it now.

  • I've got grad students working on DBT for transgender people,

  • for example.

  • So you can see that there are a lot of modifications

  • have to be made.

  • But at the same time, we have to figure out

  • how to stay inside the treatment and keep everything

  • that you can.

  • So the idea is you don't change anything until you find out

  • that you need to change it.

  • Now, the next problem I had, this

  • was not a good problem to have because my wonderful treatment

  • here did not treat anxiety disorders anywhere near

  • as well as standard behavior therapy.

  • This is the first thing I found that wasn't as good

  • a standard treatment.

  • So this is a big problem.

  • So it's here.

  • And you'll see here, on substance dependence

  • DBT brings it down by 87% and major depression by 68%.

  • By the way, there's no other treatments that are better.

  • And eating disorders by 64%.

  • Now you get to panic disorder and other anxiety disorders

  • and PTSD.

  • And all of a sudden, we're not as good as very everybody else.

  • So what was the problem with our treatment?

  • Well, it turns out that the only way to treat anxiety

  • is going to be with prolonged exposure.

  • So you have to do an exposure treatment.

  • In other words, itself is a type of treatment all by itself.

  • And although I pulled in every other therapy

  • that I'd ever learned, I had not pulled in this.

  • And it turned out it was unbelievably important.

  • I was very lucky to have-- whoops.

  • I was very lucky to have Melanie Harned who's a research

  • scientist, in our center.

  • And she is an expert in prolonged exposure,

  • thank the Lord.

  • So she took on the task of figuring out

  • how to treat this group of people

  • with exposure when we had to also worry about the fact

  • that they might not be able to tolerate it.

  • This is probably the saddest thing

  • I've been through in this field largely was when I found out

  • that the strategy that she developed,

  • which worked like a charm, was this.

  • It was we told the patients that if you

  • will stop trying to kill yourself and stop

  • harming yourself, we will give you an effective treatment.

  • Now imagine that.

  • Imagine that no one else had offered them

  • an effective treatment before us.

  • And I found it so sad.

  • You find so many people with disorders

  • who get suicidal because no one helps them,

  • because no one offers an evidence based treatment

  • to them.

  • So this worked like a charm.

  • And we're still using, I wouldn't call it perfect,

  • but nothing's perfect.

  • The next problem was DBT was viewed

  • as a treatment for mental disorders

  • only and in particular for Borderline Personality

  • Disorder.

  • And there's all kinds of stigma.

  • I'm not kidding.

  • People would talk to me in the grocery store

  • because people would think they were Borderline Personality

  • Disorder.

  • I had people, particularly in the military, come see me

  • and they made me promise not to let the military find out

  • that they'd come to treatment with me

  • because they were worried about losing their insurance

  • and everything else.

  • So it is unbelievable the stigma of this particular disorder.

  • I mean, it's slightly understandable

  • but really unbelievable.

  • I tell my patients, I say, you go to the emergency room,

  • for God's sake's don't tell them you're Borderline Personality

  • Disorder or they may not treat you

  • or they start thinking that you really

  • don't have anything wrong although you're

  • having a heart attack.

  • They'll think it's all in your head.

  • So don't tell them.

  • So this is a major problem.

  • So I had to do something about that.

  • I decided let's find out if DBT only

  • works for Borderline Personality Disorder suicidal

  • people and people with really serious disorders.

  • So now we've been doing a bunch of research.

  • We continue with Borderline Personality Disorder,

  • but we've added all the other disorders that are around.

  • And we started developing DBT skills,

  • which is a major part of the treatment,

  • for friends, family, and schools.

  • And that has had a huge effect, particularly in schools.

  • Where in schools, the biggest effect this has

  • is to cut down suicidal behavior.

  • But almost anyone can learn from these skills.

  • And we've realized.

  • I use these skills all the time.

  • Everybody I know uses the skills all the time.

  • The rest of us of our clinic use the skills all the time.

  • So that was very important.

  • So where are we now?

  • Let's look at the data to see where to go.

  • So this is going to be fast on data

  • because I have other things I want to talk about.

  • Is DBT effective?

  • Yes.

  • [LAUGHTER]

  • I mean, the a are no one disagrees now.

  • I've been in a battle my whole career.

  • I've had almost all my studies have

  • been in response to criticisms.

  • Your treatment doesn't do this.

  • I say, OK, I'll study that.

  • Yes it did.

  • OK, next.

  • So there are 17 randomized control trials.

  • Internationally DBT is the only treatment viewed as effective

  • for Borderline Personality Disorder.

  • In other words, they have enough studies

  • done on it to say that this in fact is effective.

  • This is my very first set of research.

  • I was so excited when I did my first study.

  • And showing that the yellow is the control condition suicide

  • attempts.

  • And the blue is the DBT.

  • So you can see right away a big difference there.

  • Let me get out of here.

  • This is when people said, oh well, any expert

  • would be just as good as you.

  • And I said, OK, I'll do a study on experts.

  • So we called round, found out who are the best treatment

  • people were in Seattle.

  • Wrote them all and said you've been nominated as an expert

  • therapist.

  • Would you like to be a research therapist in my research?

  • Every single person agreed.

  • We brought them in and we compared them to DBT.

  • And what we found was suicide attends 50% lower in DBT.

  • Visits to emergency rooms 53% lower in DBT.

  • And inpatient hospitalization 73% lower than DBT.

  • Then we were accused of saying that all we treated

  • was symptoms.

  • Now, behaviors don't even have a construct

  • of symptoms in the first place.

  • That's a psychiatric term, not a behavior therapy term.

  • But nonetheless, they said that.

  • So I said, OK, give me a measure.

  • And if I can get a good finding on it, you will be quiet.

  • And so I spent about a year writing and saying,

  • come on, send me a measure.

  • Finally, they sent me a measure.

  • I actually told them they would shut up.

  • And they gave it to me and I have about six of these,

  • but I'm only showing you one.

  • And DBT by far was better than other treatments

  • at what was viewed by them as the key components of treatment

  • that's really primarily from the psychoanalyst.

  • So they stood up and cheered when I told them

  • I had found the data.

  • So I appreciated that was humility on their side.

  • Then we looked at we teach behavioral skills.

  • We have a lot of change skills, a lot of acceptance skills.

  • We have mindfulness skills, a lot of different mindfulness

  • skills.

  • So the question was, do people use the skills that we teach?

  • So we did research on that.

  • And this, what you're going to see this really,

  • really interesting.

  • Oh no.

  • She's calling again.

  • OK, when I get off I'll go talk.

  • Oh thank heavens.

  • So do clients the skills?

  • Now the red one here is the DBT.

  • So you see that the DBT clients use the skills all the way up

  • and also continue to use them after in the post treatment.

  • Now, what's really interesting is that control condition also

  • is using behaviors.

  • We had written up the skills so they

  • didn't sound like DBT skills, but they covered

  • the terrain of DBT skills.

  • And what you see that's the most interesting about this

  • is that the control conditions did

  • use the skills during treatment and then

  • they quit using them in follow up.

  • Of course, that's really important information to have.

  • So the question is, are skills important?

  • I would say of everything in our treatment,

  • the one thing you absolutely cannot get rid

  • of in our treatment actually is the skills.

  • So we did a lot of research looking at whether it mediated,

  • that is to say, was it the factor driving other things.

  • And DBT skills mediated increases

  • in emotional regulation, improving

  • interpersonal relationships, reduction

  • of suicidal behaviors, and about five or six other things.

  • It's probably the only thing that you

  • can't remove from the treatment and still

  • have the treatment working.

  • I'm not going over that research because it would take so long,

  • but we did a whole study looking at what would

  • happen if you took skills away.

  • And that's a bad idea.

  • So of course everyone complains this treatment

  • must be too expensive.

  • This treatment is not expensive.

  • It saves money.

  • It saves an unbelievable amount of money.

  • There's multi-site examinations of the efficiency and cost

  • of DBT in the United States and Great Britain

  • and many other places.

  • And it's at least 50% lower cost than any other treatment,

  • particularly within the United States.

  • It's true with the military.

  • And so the main reason the treatment

  • saves so much money is that DBT rarely hospitalizes patients.

  • It's an outpatient treatment where

  • we very rarely hospitalize.

  • We have a lot of data on that which

  • you could ask me at the end.

  • So where are we going?

  • I just want to tell you.

  • We need more effective dissemination of DBT.

  • We're developing computerized DBT.

  • We have a computerized DBT skills,

  • which turns out to be as good as in person DBT skills training.

  • We're really happy about that.

  • And the reason I'm happy is I had a mother call who

  • we didn't let in the study because her daughter was

  • psychotic.

  • Mother calls and cries and says, how can you do this?

  • My daughter can't go to groups and learn skills,

  • but she got to learn them.

  • I said, OK.

  • We got permission from [INAUDIBLE] subjects,

  • gave her the skills.

  • She called and told us how much it helped her daughter.

  • You immediately realize how important

  • it's going to be to computerize our treatments for so

  • many people who can't get to therapy

  • or can't tolerate therapy.

  • We want to computerize our entire treatment.

  • Right at the moment I have a graduate student

  • who just got funded.

  • We're doing research now.

  • She is doing research for high risk for suicide alcoholics.

  • And turns out that she also did the research

  • and found out that high risk for suicide alcoholics

  • don't want to come see a therapist.

  • But they're very willing to come to an online treatment.

  • So she's gotten funding from NIAAA to do that.

  • And that's exactly what we're doing.

  • So that's exciting.

  • What else is needed?

  • We need a more robust field of suicide researchers.

  • So many people willing to print books

  • on how to do a treatment that has no data whatsoever.

  • I mean, this is extremely common.

  • So I had a friend who was doing that.

  • And I happened to be eating lunch with him

  • and he told me he was publishing this book.

  • And I said, what are you talking about?

  • You can't do that.

  • He said, why not?

  • And I said, you don't have any data.

  • You can't do that.

  • You've got to do research first.

  • That's not right.

  • He said, well I don't know how to do research.

  • I said, OK, fine, come to Seattle.

  • I'll teach you how to do research.

  • So he did.

  • And we brought a whole group of people

  • in at the University of Washington

  • and we did a whole program on training them

  • on how to do research on suicide.

  • And I was just at a huge meeting for people

  • who are interested in suicidal behavior.

  • And I asked how many of the therapists

  • in this room who are researchers know

  • how to do research on suicide.

  • It was very few.

  • How many if I run a program and train you would you come?

  • And I'm not kidding, must have been

  • 200 people raised their hands.

  • So I'm hoping that I can put this together and put

  • another program together to help with that.

  • We also need just better research itself.

  • Not just learning research, but we need to do better research.

  • And so the University of Washington

  • started and formed a international DBT

  • strategic planning meeting.

  • Basically the bottom line is if you're a researcher in DBT,

  • you're invited.

  • You can bring your graduate students and your post-docs.

  • All you have to do is say that you do research

  • or you want to do research, then you can come to our meeting.

  • And the meeting addresses what research is needed now.

  • And Martin Bohus, who's going to be your next speaker,

  • is on the executive group of that

  • and has worked a lot with us.

  • But we have people all over Europe,

  • all over Canada, South America.

  • And it boils down to if you want to do research,

  • you come to see us.

  • And we will help you.

  • And we have all kinds of small groups with young people

  • to try to teach them how to do research.

  • There are rules though for coming.

  • I forgot that.

  • I should tell you.

  • So the rules are they have to sign

  • a pledge that, one, they will not

  • withhold any ideas they have.

  • Two, they will not take anybody else's ideas and use them.

  • Three, if anybody has really bad data,

  • they will not say bad things about them when they leave.

  • And four, I think we have more than that, but four,

  • the most important is they will do the dishes at my house.

  • [LAUGHTER]

  • And they do do the dishes.

  • Because everybody comes to my house to have dinner.

  • So we have, I don't know, we're up to 70 people I think

  • or something.

  • I mean, it's a big group.

  • But I'm telling all of you all in here, anybody in here

  • is a researcher, who wants to do research,

  • has graduate students doing research, wants them to do it,

  • this is the place to come.

  • You're here for the best of the best.

  • You just have to sign and agree to get in.

  • The next question is we have to answer

  • the question of sending highly suicidal people to hospitals,

  • is it iatrogenic.

  • NIMH now sends me every paper that suggests that it's true.

  • The data is unbelievably overwhelming.

  • Suicide's the number one cause of death

  • on psychiatric inpatient units.

  • The first day you're getting out is a very high suicide risk

  • day.

  • There is not one study that's ever shown that it's effective.

  • And yet people are so afraid of being

  • sued that they put people in hospitals for that very reason.

  • I'm fighting this like mad.

  • So we have to do the research though to prove it really well,

  • substantial, to make people secure.

  • I spend a lot of time helping people be secure

  • and keeping people out.

  • But we're going to have to have the data, much better data

  • than we've got now.

  • So we have to conduct that and we have

  • to talk NIHM into funding it.

  • Fortunately, I'm at the University of Washington.

  • It's probably one of the few universities

  • in the country that would actually let scientists

  • do that research.

  • I'm going to talk about that in a minute.

  • We have to stop fragilizing our graduate students.

  • Almost every graduate school I know of

  • will not let their students treat

  • suicidal patients, high risk for suicidal patients.

  • Now if we don't do that, who is going

  • to treat these people in the real world?

  • So we have very few people who know

  • how to treat suicidal who will do it

  • who will take serious people.

  • They're so afraid and that's how they end up in hospitals.

  • So University of Washington.

  • Now, we can do better.

  • Because I at the University of Washington

  • have a training program where I train

  • students for extremely high risk for suicidal patients.

  • We have an adolescent program where we

  • have adolescents at high risk.

  • My graduate students are treating them.

  • We have an adult program and my students are treating them.

  • They have done wonderfully.

  • This is not true that grad students can't do this.

  • We need to get the interns in psychiatry into this

  • and we need to get this.

  • What we have to do now is figure out

  • how to get this to other universities.

  • And I have a curriculum for it which is on my website.

  • People can download it for free.

  • But we need to figure out how to let everybody know it's there.

  • So this is that.

  • The next thing, we've got to address IRBs and the university

  • fears.

  • I am not kidding.

  • I am so unbelievably lucky to be at the University

  • of Washington.

  • Because I have never once been turned down

  • for anything at all.

  • And that is because human subjects here

  • has been really wonderful.

  • And they have not turned me.

  • I have not ever once been told I could do something.

  • I've had to rewrite things every single time.

  • That's true.

  • But they have worked with me.

  • You can't believe how rare this is.

  • I have a lot of friends who tell me their universities won't

  • let them do it at all.

  • I call people and say, OK, let's do

  • this where we would do a randomized trial

  • on hospitalization.

  • Our university would ever approve that.

  • So we're really lucky to have this university.

  • What I'm trying to figure out now

  • is how to get what this university is willing to do out

  • to these other universities.

  • And that's what's got to happen.

  • [APPLAUSE]

  • [MUSIC PLAYING]

[MUSIC PLAYING]

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