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Marsha Linehan finds the core principles of DBT in a Buddhist monastery, challenges the psychoanalytic establishment, and returns to the hospital where her journey started.
Publication Date: 01/11/2026
Duration: 21 minutes, 11 seconds
Transcript:
KELLIE NEWSOME: Warning: this episode is full of polarities, Adderall and Xanax, Kernberg and Linehan, Buddhism and Catholicism, doctor and patient. We'll tie most of them together in this final installment on borderline personality disorder. Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.
CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.
KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
CHRIS AIKEN: When we left Marsha Linehan last week, she was driving down the coast of Seattle to Shasta Abbey, a Buddhist monastery in the mountains of California. In this episode, you'll learn the core skills of DBT that she found there, how she challenged, and was challenged by the psychoanalytic establishment, and how Marsha Linehan ended up back where she started at the psychiatric hospital in Connecticut.
KELLIE NEWSOME: The regimented life at Shasta Abbey left Linehan tired, bored, and distracted, but that was all grist for the mill as she practiced meditation day in, day out. And from these two seeds, she formed the core skills of DBT: mindfulness from Buddhist meditation and radical acceptance from willingness. Both of these are hard to put into words. They are experiences more than they are ideas, but we'll do our best, borrowing from Linehan's own words:
CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of The Carlat Psychiatry Report.
KELLIE NEWSOME: And I'm Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.
CHRIS AIKEN: When we left Marsha Linehan last week, she was driving down the coast of Seattle to Shasta Abbey, a Buddhist monastery in the mountains of California. In this episode, you'll learn the core skills of DBT that she found there, how she challenged, and was challenged by the psychoanalytic establishment, and how Marsha Linehan ended up back where she started at the psychiatric hospital in Connecticut.
KELLIE NEWSOME: The regimented life at Shasta Abbey left Linehan tired, bored, and distracted, but that was all grist for the mill as she practiced meditation day in, day out. And from these two seeds, she formed the core skills of DBT: mindfulness from Buddhist meditation and radical acceptance from willingness. Both of these are hard to put into words. They are experiences more than they are ideas, but we'll do our best, borrowing from Linehan's own words:
"Mindfulness is the act of consciously focusing the mind in the present moment, without judgment and without attachment to the moment. It contrasts with automatic, habitual, or rote behavior. When we are mindful, we are alert and awake, like a sentry guarding a gate. It is the awareness of what is, at the level of direct and immediate experience, separate from concepts, category, and expectation. When we are mindful, we are open to the fluidity of each moment as it arises and falls away.” “Radical Acceptance is accepting all the way, with your mind, your heart, and your body—accepting something from the depths of your soul, opening yourself to fully experiencing reality as it is in this one moment.” This is difficult for patients to do. Their suffering is immense, and we are asking them to accept it. To accept something doesn't mean that we're judging it as good. We are accepting the knowledge of reality, what is, and deciding to tolerate the moment as it is. We let go of fighting reality because refusing to let go only creates more suffering. Or, as Linehan puts it, "Acceptance is the only way out of hell". Let's pause, breathe deep, and take in the first question from the CME quiz, which you can take for credit through the link in the show notes:
Which antidepressant has a high risk of causing suicidality, aggression, and paranoia when used in borderline personality disorder?
A. Mirtazapine.
B. Amitriptyline.
C. Bupropion.
D. Paroxetine.
A. Mirtazapine.
B. Amitriptyline.
C. Bupropion.
D. Paroxetine.
CHRIS AIKEN: By the early 1980s, Linehan had blended these disparate threads of Buddhism, behaviorism, Catholicism, and her own experience with mental illness into the piecemeal quilt of DBT. In doing so, she faced many critics. Psychoanalysts argued that she was treating the symptoms, not the cause. As one of my psychoanalytic attendings warned me in the 1990s, “Be careful about these DBT therapists. They treat the symptoms, not the cause, and by focusing so much on behavior change, they turn their patients into robots.” Others levied the same attacks that were heaped on Bill Wilson's 12-step movement. DBT was a cult, a religion, a Zen-infused, New Age pseudoscience. Linehan did not hide her Buddhist influences, but she did keep silent about her own mental illness. She wore elaborate bracelets to hide the scars on her arms. One person did take notice, and that was Otto Kernberg, the psychoanalyst who gave borderline personality its name in the 1960s and the one who developed one of the first therapies for borderline. Linehan was visiting Kernberg in 1991 when the Austrian psychoanalyst looked at her with concern and said, “Can I talk with you privately, Marsha?” They went into his office, and he said, in a caring voice, “Have you been in a mental institution, Marsha,?” “Yes, I have.” “I thought so,” said Kernberg, noting her scars. He advised her not to tell anyone. He wanted to protect her career. Marsha was about to publish her first papers on DBT, and Kernberg knew that she was going to be under attack just for the radicalness of her ideas. It was a kind gesture, for if Kernberg was a different kind of man, he might have felt threatened by her rising star, which was a challenge to his therapy. Kernberg and Linehan had different approaches to borderline personality disorder, some would say polar opposites. They didn't really mix. This wasn't like antidepressants and TMS that you can use together, or psychotherapy and physical exercise, where you can combine all these to get a better result. For Kernberg, the core problem in borderline was unmodulated aggression, born out of an inability to integrate the good and bad experiences that the patient had in their early years with their parents. Kernberg's approach was more confrontational and less validating. He focused on distortions in the therapeutic relationship, inner thoughts, and fantasies, not skill building and behavior change.
KELLIE NEWSOME: For Linehan, the core problem was emotional dysregulation, caused by an unfortunate pairing of a hypersensitive temperament and an invalidating family environment. She worked from the outside in, building skills to tolerate extreme distress and greasing the wheels of behavior change to help patients create a life worth living. As they sat in his office in 1991, 63-year-old Kernberg was at the top of his field. His name was synonymous with psychotherapy for borderline personality disorder, and he was the first psychiatrist to fully describe the disorder in a paper he wrote in 1967. DBT wasn't well known outside of Linehan's department in Seattle, but that was about to change. The Archives of General Psychiatry, now known as JAMA Psychiatry, was preparing to publish the first clinical trial of DBT. The journal had rejected this study twice before accepting it.
CHRIS AIKEN: Kernberg's therapy was built on psychoanalytic theory, but he had not tested it in a clinical trial. Actually, there were no randomized psychotherapy trials for borderline personality disorder in 1991, just a handful of medication trials, and those didn't look so good. Amitriptyline helped depression a little in borderline, but it made many borderlines suicidal, paranoid, and aggressive. Carbamazepine controlled their behavior but made some people with borderline depressed. Alprazolam made them disinhibited. Methylphenidate caused dysphoria, and amphetamine was the worst; half of the patients with borderline became psychotic on this stimulant. The reaction was so pronounced that some suggested using an amphetamine challenge test to diagnose borderline personality. Probably that would be unethical today, but it's a notion worth considering. Next time you see a patient with borderline personality disorder on, say, Adderall and Xanax, a common and troubling combination, Linehan's small randomized trial landed in this bleak landscape in December of 1991, the same month that the Soviet Union formally dissolved. She compared DBT to treatment as usual in 44 women with borderline personality disorder. It was a small sample, but she managed to show a significant difference. The DBT group had a sixfold reduction in self-harm and a fivefold reduction in days in the hospital. But the problem was there wasn't much change on the inside. These patients were not as destructive, but they were still depressed, hopeless, and felt little reason for living. It would take larger trials to find a difference in those symptoms. Those trials would come, but they were a long way off. In the meantime, psychoanalysts found a lot to criticize in DBT. The study was small, and it was compared to treatment as usual. That is not a hard bar to pass. Expressive dance therapy probably could have done just as well when compared to treatment as usual. All she showed in the trial was that DBT changed behavior, about what you'd expect from a behavior therapy. But, behavior therapy was supposed to be for simple problems. Personality is complex, and borderline even more so in the view at the time, there's no way that behavioral techniques could change the core inner dysfunction of borderline personality. And besides, Linehan was a charismatic therapist enthusiastic about her work. How do we know that DBT would work as well in the hands of another group? Well, we were about to find out.
KELLIE NEWSOME: Research on DBT was slow to pick up, but the therapy spread quickly as therapists from large health systems flocked to Seattle to train with Linehan. DBT struck at the right time. The baby boomers were stepping into leadership positions and bringing with them the values that Linehan epitomized: feminism, Zen Buddhism, empathy, and a more casual approach to work, chipping away at the formal barriers separating doctor from patient, high culture from low culture. DBT was also much easier to learn, and that mattered as the therapy workforce was rapidly expanding to meet the growing demand. And then there was the money problem. Managed care was taking over insurance plans, and they were no longer willing to pay for expensive treatments that didn't have any evidence, like the frequent psychoanalytic sessions and long-term hospital stays that Kernberg's therapy required. DBT may not restructure personality, but it did keep people out of the hospital, and that was enough for insurance to pay. But Kernberg didn't give up. He reworked his complex therapy into a manualized form, calling it transference-focused psychotherapy. In 2006, he published a randomized trial that tested this approach against DBT and supportive therapy. After a year of therapy, only those in the transference-focused treatment improved on the primary outcome, secure attachment. Sure, the outcome was biased toward Kernberg's view of the disorder, but he had shown something Linehan had not: his therapy brought about change on the inside, not just change in behavior.
CHRIS AIKEN: Linehan is the kind of person who thrives on a challenge. She titled the chapter in her book about involuntary hospitalization, “I Will Prove Them Wrong.” Now she wanted to prove that DBT brought about more than superficial change. So she asked the psychoanalytic community how they would measure internal change, and John Clarkin, a psychoanalyst who worked closely with Kernberg, suggested that she use the introject measure. It's a concept developed by Harry Stack Sullivan that measures a person's self-esteem, how they treat and relate to themselves. In 2015, Linehan tested this measure in a trial of 100 women with borderline personality disorder. Half got DBT, and half got eclectic or psychodynamic therapy by experts in the community. Over a year of treatment, this introject improved more with DBT. They had greater self-affirmation, self-love, self-protection, and less self-attack.
KELLIE NEWSOME: Today, DBT is supported by two dozen randomized controlled trials, including one that adapted the treatment in China, replacing some of the Buddhist concepts with a Confucian principle of the right way.
CHRIS AIKEN: At the heart of Linehan's theory is that we move closer to the truth by bringing together opposing contradictions. That's what the word dialectics in dialectical behavior therapy means. Borderline patients are caught between opposing forces on all sides, pulled apart by their reason versus their emotions, idealization and devaluation, the will to live and the desire to die. Linehan helps them turn this dilemma into a strength, and she did the same in her own career. She needed the critics, the doubters, the psychoanalysts to challenge her and sharpen her work, and Kernberg probably needed the same. I'm not sure that he would have gone to the trouble of manualizing his therapy and running a randomized trial in his late seventies if it weren't for the standard that Linehan set. Though opposed in theory, the two therapists had great respect for each other. Kernberg told Linehan that she was the only person he knew whose treatment matched the theory on which it is based, and Linehan called Kernberg "the kindest of human beings". I agree. I spent a year learning from Kernberg at Cornell, then changed residency programs and spent two years in supervision with someone from Linehan's group, Thomas Lynch. It was a difficult transition. I learned a lot from each group, but I think I learned more from the dialectic between them. I learned to treat therapy as a tool, not as the truth, and to stay grounded in reality, what the next patient, what the next clinical trial brings.
KELLIE NEWSOME: And that brings up another dialectic. Did Marsha Linehan really have borderline personality disorder? Does anyone have it? Do we even know what it is? Reading Linehan's autobiography, she checks a lot of the boxes: repeated self-injury, affective instability, and chronic feelings of emptiness. She went on to find not just stability, but success in her career, relationships, and identity. Not only is she a prominent therapist in 2012, she was ordained as a Zen master, and there are signs that if she did have borderline, she didn't have a typical case. She doesn't report a history of trauma, something that marks the childhoods of 70% of borderline patients. She was raised in a stable family and speaks of her parents with love and admiration. Were they invalidating? Yes, but only in the way a lot of upper-middle-class families were in the 1950s. They didn't see a place for women in intellectual pursuits and thought the best their daughter could do was stay thin and attract a good husband. In high school, she was productive and well-liked. Her siblings say she didn't have any signs of borderline until she went off to that psychiatric hospital, and you do get the feeling from the book that being stripped of dignity and self-control in that oppressive environment at the age of 18 only exacerbated, if not caused, her problems. Linehan surely was not alone in that. One of the patients she befriended in the hospital, Saburn Fisher, went on to become a prominent trauma therapist who helped bring DBT to Massachusetts. Susanna Kaysen describes a similarly oppressive experience at McLean Hospital in the 1960s in her memoir-turned-movie Girl, Interrupted.
CHRIS AIKEN: Judging from recent studies, Linehan's case is not so uncommon. 60% of patients with borderline personality disorder no longer meet the diagnostic criteria after five to ten years, and slightly less, around 50%, achieve functional recovery with gainful employment. Self-injury tends to improve first, followed by affective dysregulation and relationship problems. The best prognostic indicator is a lack of trauma history, as was true for Linehan.
KELLIE NEWSOME: Linehan herself is skeptical that borderline is a real diagnosis, not just for her, but for anyone. She wrote, “I have never been interested in borderline personality disorder as a "disorder" in itself. I've never targeted that. I target suicidal behavior, out-of-control behavior. I don't think of myself as treating a disorder. I treat a set of behaviors that gets turned into a disorder by others."
CHRIS AIKEN: In 2011, Linehan went back to Connecticut to face one more dialectic. She was to deliver a lecture at the same hospital where she had spent the last years of her adolescence, the Institute of Living. The building that once housed her now functioned as a DBT ward, and Linehan had called in advance requesting that the patients on that ward be let out to attend her lecture. As she stepped up to the podium, few knew that she had been a patient there herself.
KELLIE NEWSOME: “When I developed DBT, it was to fulfill a vow I had made when I was very young, and the place that I made that vow was at the Institute of Living because I was a patient here, always on that lowest unit, always on the locked unit. I was supposed to be here for just a few weeks, but I didn't get out for two years and one month. So I was locked up for a very long time. I was where you are now, and here's where I am now. You too can get out of hell. You can be where I am. I want to tell you this because I want you to realize how much hope there really is and how important it is not to give up.”
CHRIS AIKEN: Marsha Linehan retired in 2019. A year later, she published her autobiography, A Life Worth Living, from which much of the material in this podcast is based. A documentary based on the book is underway.
KELLIE NEWSOME: Dr. Aiken's new book, Difficult to Treat Depression, is now available in print or as an audiobook. Joseph Goldberg, deputy editor-in-chief of the Journal of Clinical Psychiatry, calls it a thoughtful, scholarly, and reader-friendly summary, a source of pragmatic insight and wisdom for any clinician who wrestles with the challenges of depressed patients who respond suboptimally to traditional antidepressant medications.
KELLIE NEWSOME: For Linehan, the core problem was emotional dysregulation, caused by an unfortunate pairing of a hypersensitive temperament and an invalidating family environment. She worked from the outside in, building skills to tolerate extreme distress and greasing the wheels of behavior change to help patients create a life worth living. As they sat in his office in 1991, 63-year-old Kernberg was at the top of his field. His name was synonymous with psychotherapy for borderline personality disorder, and he was the first psychiatrist to fully describe the disorder in a paper he wrote in 1967. DBT wasn't well known outside of Linehan's department in Seattle, but that was about to change. The Archives of General Psychiatry, now known as JAMA Psychiatry, was preparing to publish the first clinical trial of DBT. The journal had rejected this study twice before accepting it.
CHRIS AIKEN: Kernberg's therapy was built on psychoanalytic theory, but he had not tested it in a clinical trial. Actually, there were no randomized psychotherapy trials for borderline personality disorder in 1991, just a handful of medication trials, and those didn't look so good. Amitriptyline helped depression a little in borderline, but it made many borderlines suicidal, paranoid, and aggressive. Carbamazepine controlled their behavior but made some people with borderline depressed. Alprazolam made them disinhibited. Methylphenidate caused dysphoria, and amphetamine was the worst; half of the patients with borderline became psychotic on this stimulant. The reaction was so pronounced that some suggested using an amphetamine challenge test to diagnose borderline personality. Probably that would be unethical today, but it's a notion worth considering. Next time you see a patient with borderline personality disorder on, say, Adderall and Xanax, a common and troubling combination, Linehan's small randomized trial landed in this bleak landscape in December of 1991, the same month that the Soviet Union formally dissolved. She compared DBT to treatment as usual in 44 women with borderline personality disorder. It was a small sample, but she managed to show a significant difference. The DBT group had a sixfold reduction in self-harm and a fivefold reduction in days in the hospital. But the problem was there wasn't much change on the inside. These patients were not as destructive, but they were still depressed, hopeless, and felt little reason for living. It would take larger trials to find a difference in those symptoms. Those trials would come, but they were a long way off. In the meantime, psychoanalysts found a lot to criticize in DBT. The study was small, and it was compared to treatment as usual. That is not a hard bar to pass. Expressive dance therapy probably could have done just as well when compared to treatment as usual. All she showed in the trial was that DBT changed behavior, about what you'd expect from a behavior therapy. But, behavior therapy was supposed to be for simple problems. Personality is complex, and borderline even more so in the view at the time, there's no way that behavioral techniques could change the core inner dysfunction of borderline personality. And besides, Linehan was a charismatic therapist enthusiastic about her work. How do we know that DBT would work as well in the hands of another group? Well, we were about to find out.
KELLIE NEWSOME: Research on DBT was slow to pick up, but the therapy spread quickly as therapists from large health systems flocked to Seattle to train with Linehan. DBT struck at the right time. The baby boomers were stepping into leadership positions and bringing with them the values that Linehan epitomized: feminism, Zen Buddhism, empathy, and a more casual approach to work, chipping away at the formal barriers separating doctor from patient, high culture from low culture. DBT was also much easier to learn, and that mattered as the therapy workforce was rapidly expanding to meet the growing demand. And then there was the money problem. Managed care was taking over insurance plans, and they were no longer willing to pay for expensive treatments that didn't have any evidence, like the frequent psychoanalytic sessions and long-term hospital stays that Kernberg's therapy required. DBT may not restructure personality, but it did keep people out of the hospital, and that was enough for insurance to pay. But Kernberg didn't give up. He reworked his complex therapy into a manualized form, calling it transference-focused psychotherapy. In 2006, he published a randomized trial that tested this approach against DBT and supportive therapy. After a year of therapy, only those in the transference-focused treatment improved on the primary outcome, secure attachment. Sure, the outcome was biased toward Kernberg's view of the disorder, but he had shown something Linehan had not: his therapy brought about change on the inside, not just change in behavior.
CHRIS AIKEN: Linehan is the kind of person who thrives on a challenge. She titled the chapter in her book about involuntary hospitalization, “I Will Prove Them Wrong.” Now she wanted to prove that DBT brought about more than superficial change. So she asked the psychoanalytic community how they would measure internal change, and John Clarkin, a psychoanalyst who worked closely with Kernberg, suggested that she use the introject measure. It's a concept developed by Harry Stack Sullivan that measures a person's self-esteem, how they treat and relate to themselves. In 2015, Linehan tested this measure in a trial of 100 women with borderline personality disorder. Half got DBT, and half got eclectic or psychodynamic therapy by experts in the community. Over a year of treatment, this introject improved more with DBT. They had greater self-affirmation, self-love, self-protection, and less self-attack.
KELLIE NEWSOME: Today, DBT is supported by two dozen randomized controlled trials, including one that adapted the treatment in China, replacing some of the Buddhist concepts with a Confucian principle of the right way.
CHRIS AIKEN: At the heart of Linehan's theory is that we move closer to the truth by bringing together opposing contradictions. That's what the word dialectics in dialectical behavior therapy means. Borderline patients are caught between opposing forces on all sides, pulled apart by their reason versus their emotions, idealization and devaluation, the will to live and the desire to die. Linehan helps them turn this dilemma into a strength, and she did the same in her own career. She needed the critics, the doubters, the psychoanalysts to challenge her and sharpen her work, and Kernberg probably needed the same. I'm not sure that he would have gone to the trouble of manualizing his therapy and running a randomized trial in his late seventies if it weren't for the standard that Linehan set. Though opposed in theory, the two therapists had great respect for each other. Kernberg told Linehan that she was the only person he knew whose treatment matched the theory on which it is based, and Linehan called Kernberg "the kindest of human beings". I agree. I spent a year learning from Kernberg at Cornell, then changed residency programs and spent two years in supervision with someone from Linehan's group, Thomas Lynch. It was a difficult transition. I learned a lot from each group, but I think I learned more from the dialectic between them. I learned to treat therapy as a tool, not as the truth, and to stay grounded in reality, what the next patient, what the next clinical trial brings.
KELLIE NEWSOME: And that brings up another dialectic. Did Marsha Linehan really have borderline personality disorder? Does anyone have it? Do we even know what it is? Reading Linehan's autobiography, she checks a lot of the boxes: repeated self-injury, affective instability, and chronic feelings of emptiness. She went on to find not just stability, but success in her career, relationships, and identity. Not only is she a prominent therapist in 2012, she was ordained as a Zen master, and there are signs that if she did have borderline, she didn't have a typical case. She doesn't report a history of trauma, something that marks the childhoods of 70% of borderline patients. She was raised in a stable family and speaks of her parents with love and admiration. Were they invalidating? Yes, but only in the way a lot of upper-middle-class families were in the 1950s. They didn't see a place for women in intellectual pursuits and thought the best their daughter could do was stay thin and attract a good husband. In high school, she was productive and well-liked. Her siblings say she didn't have any signs of borderline until she went off to that psychiatric hospital, and you do get the feeling from the book that being stripped of dignity and self-control in that oppressive environment at the age of 18 only exacerbated, if not caused, her problems. Linehan surely was not alone in that. One of the patients she befriended in the hospital, Saburn Fisher, went on to become a prominent trauma therapist who helped bring DBT to Massachusetts. Susanna Kaysen describes a similarly oppressive experience at McLean Hospital in the 1960s in her memoir-turned-movie Girl, Interrupted.
CHRIS AIKEN: Judging from recent studies, Linehan's case is not so uncommon. 60% of patients with borderline personality disorder no longer meet the diagnostic criteria after five to ten years, and slightly less, around 50%, achieve functional recovery with gainful employment. Self-injury tends to improve first, followed by affective dysregulation and relationship problems. The best prognostic indicator is a lack of trauma history, as was true for Linehan.
KELLIE NEWSOME: Linehan herself is skeptical that borderline is a real diagnosis, not just for her, but for anyone. She wrote, “I have never been interested in borderline personality disorder as a "disorder" in itself. I've never targeted that. I target suicidal behavior, out-of-control behavior. I don't think of myself as treating a disorder. I treat a set of behaviors that gets turned into a disorder by others."
CHRIS AIKEN: In 2011, Linehan went back to Connecticut to face one more dialectic. She was to deliver a lecture at the same hospital where she had spent the last years of her adolescence, the Institute of Living. The building that once housed her now functioned as a DBT ward, and Linehan had called in advance requesting that the patients on that ward be let out to attend her lecture. As she stepped up to the podium, few knew that she had been a patient there herself.
KELLIE NEWSOME: “When I developed DBT, it was to fulfill a vow I had made when I was very young, and the place that I made that vow was at the Institute of Living because I was a patient here, always on that lowest unit, always on the locked unit. I was supposed to be here for just a few weeks, but I didn't get out for two years and one month. So I was locked up for a very long time. I was where you are now, and here's where I am now. You too can get out of hell. You can be where I am. I want to tell you this because I want you to realize how much hope there really is and how important it is not to give up.”
CHRIS AIKEN: Marsha Linehan retired in 2019. A year later, she published her autobiography, A Life Worth Living, from which much of the material in this podcast is based. A documentary based on the book is underway.
KELLIE NEWSOME: Dr. Aiken's new book, Difficult to Treat Depression, is now available in print or as an audiobook. Joseph Goldberg, deputy editor-in-chief of the Journal of Clinical Psychiatry, calls it a thoughtful, scholarly, and reader-friendly summary, a source of pragmatic insight and wisdom for any clinician who wrestles with the challenges of depressed patients who respond suboptimally to traditional antidepressant medications.
