The Woman Who Stops Patients From Killing Themselves
By ROBERT LANGRETH
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(Part III in a series on Medicine’s Suicide Problem. Part I is HERE, and part II is HERE.)
Few psychotherapists want to take on patients who kick in walls, play Russian roulette with a loaded gun, slice up their arms with a knife, or end up in the intensive care unit twice in one month from suicide attempts. University of Washington psychologist Marsha Linehan specializes in them.
The mental health industry has ignored suicidal patients so much that suicide isn’t even in the index of the 900-page bible of psychiatric disorders, Diagnostic and Statistical Manual of Mental Disorders IV. Doctors pessimistically have figured there isn’t much that can be done beyond standard drugs and psychotherapy.
Linehan deserves much of the credit for demonstrating that suicidal patients can be successfully treated. Now 67, she almost became a nun but realized she was too nonconformist. She got into the therapy business in the 1970s after deciding there was too little evidence backing psychiatry. “She started decades ago and has paved the way for others to treat high-risk patients,” says psychologist David Rudd, dean of the University of Utah’s college of social and behavioral science.
After getting a doctorate in psychology from Loyola University in 1971, Linehan wanted to devote her career to helping the most miserable people in the world. She got hands-on experience as an intern at a suicide crisis center in Buffalo, learned behavior therapy at SUNY Stony Brook and eventually landed at the University of Washington. “I called up all the hospitals and said, ‘Give me your worst.’ They were only too happy to send them,” she recalls. Her patients had suffered horrifying past traumas and were prone to crises at all hours. She had to convince the university human subjects board that it was possible to treat suicidal patients outside of the hospital. Her argument: “There’s no evidence hospitalization has kept anyone alive five minutes.”
Reading the literature, she realized that many patients suffered something called borderline personality disorder, in which people lack any ability to control everyday emotions. Their feelings spiral out of control at the slightest push, like a car parked on a steep hill without an emergency brake. It has a 10% lifetime suicide rate. “My fundamental theory is that highly suicidal people don’t have the skills to regulate their behavior and emotions. … You have to teach those skills,” Linehan says.
She spent years coming up with a combination of techniques to help. Her DBT is an offshoot of cognitive behavioral therapy, which focuses on correcting distorted thought patterns that can make people depressed. Her treatment, while keeping CBT’s pragmatic, problem-solving approach, drops the emphasis on directly changing thoughts and focuses more on a variety of behavioral techniques that Linehan found helpful.
Among other things, she added Zen acceptance techniques she learned from living one summer in a Buddhist monastery in California and from a Zen master in Germany. DBT teaches patients to tolerate the stresses of the moment, accept that imperfect lives are worth living and gain the skills to cope with raging emotions.
The therapy often starts with crisis control. Over the years her group has had a doctor who played Russian roulette with a loaded gun, patients who kicked in walls and one who threatened to kill the President. Some patients come in using so many psychiatric meds they can barely stay awake. Linehan tapers them down to the essential ones. Sometimes she practices tough love. When one patient had her stomach pumped in the er after an attempted antidepressant overdose, Linehan told her parents not to come, and had her take a cab home and report for work the next day. “That was the best thing that ever happened to me,” says the woman, who recovered, got married and is raising a 2-year-old boy.
The woman entered treatment because she had been cutting herself on the arm with a Swiss army knife. She was depressed over her job and her weight, but otherwise can’t explain why. (She does not want to be identified because her new friends don’t know about her past.) Linehan’s DBT taught her meditation techniques, slow breathing, and other methods to shut down bad emotions before they spiraled out of control. “I think the person I am today because of Marsha,” she says. “After working with her I just snapped out of it.”
Linehan’s first small study (1991) showing that DBT reduced suicide attempts was criticized because the patients got intensive treatment by experts like her, which might have accounted for the improvement. But in 2006 Linehan assigned 111 suicidal patients to receive either DBT or intensive treatment using other techniques. Patients on DBT had half the rate of attempted suicides over the next two years and were hospitalized less often for suicidal thoughts, according to the results in the Archives of General Psychiatry.
DBT usually requires six months or a year of twice-weekly sessions, but shorter courses of therapy can also help. University of Pennsylvania researchers found that ten weeks of cognitive behavioral therapy reduced the rate of repeat suicide attempts by half in patients who reported to the emergency room after an attempt. One key was logistics: A huge effort had to be made in tracking the patients and making sure they came to the sessions, says University of Pennsylvania psychologist Gregory Brown.
For frontline docs, Brown and Columbia University’s Barbara Stanley are testing a safety plan that patients write out with a clinician and keep with them at all times. Essentially a list of distracting things to do and people to call when suicidal urges arise, “it is the equivalent of ’stop, drop, and roll,’” says Stanley. One patient, she says, “went to a bridge, reached into his pocket, realized the safety plan was thereand didn’t do it.”
(Come back tomorrow for Part IV in our series on Medicine’s Suicide Problem: Why Drug Companies Won’t Study Suicidal Patients. Read the full story in the September 13 issue of Forbes on newsstands now. Former Forbes staff writer Rebecca Ruiz is co-author of this series.)