Linehan’s Theory of Suicidal Behavior: Theory, Research, and Dialectical Behavior Therapy

Linehan’s biosocial theory (1981, 1988, 1993a) states that suicidal behavior is a learned method for coping with acute emotional suffering. Suicidal behavior is viewed as a skill deficit; i.e., people are thought to seek death as the solution for their intense suffering because they can think of no other effective options. The theory has roots in social-behaviorism (Staats, 1975) and radical behaviorism (Skinner, 1957) and has been further shaped by emerging research. Linehan’s work through the years has focused prominently (though not exclusively) on borderline personality disorder (BPD). Suicidal ideation and behavior are often chronic in individuals with BPD, including recurrent suicide attempts and various forms of self-injury. Although Linehan’s theory was originally developed to explain chronic suicidal behavior, it is also useful for understanding other dysfunctional behaviors in borderline personality disorder (BPD), including nonsuicidal self-injury (e.g., Linehan, 1993a). However, unique aspects of BPD and nonsuicidal self-injury will not be reviewed here; the reader is referred to other sources that cover these topics more thoroughly (Brown, Linehan, & Comtois, 2002; Brown, 2003; Linehan, 1993a). This chapter begins with a detailed description of Linehan’s theory of suicide and discusses research relevant to the theory. Next, treatment strategies used in Dialectical Behavior Therapy (DBT), which developed out of Linehan’s theory of suicidal behavior, are discussed. The Causes of Suicidal Behavior According to behavioral theory, there are numerous causal pathways to dysfunctional behaviors. A behavioral analysis (i.e., functional analysis) is required to discover the specific controlling variables for specific suicidal acts for specific individuals. In this analysis, the causal variables to be considered include: cognition, emotions, environmental factors, and overt behaviors. In some cases, cognition is a primary cause of suicidal behavior, and at other times it has a minimal role. Situational factors are seen as having a prominent role in most cases even when cognitions and emotions are identified as important. It is not sufficient to explain dysfunctional behaviors simply in terms of internal experiences, because the origin of these experiences also must be explained (Baum & Heath, 1992). An exclusive focus on dysfunction inside the person risks ignoring a wide range of potentially important contextual factors in the onset and maintenance of suicidality. Cognition is symbolic activity that regulates behavior, not in an absolute way, but only in certain contexts. Therefore, it is crucial to understand the context in which thinking leads to problematic emotions and overt behaviors (Wilson, Hayes, & Gifford, 1996). Important environmental cues often trigger problematic cognitions, emotions, and behaviors. Like all other forms of human activity, cognitions are “not initiating causes," though they participate in overall causal relations. From a dialectical framework, events, including private and overt behaviors, can both be the cause and outcome of multiple complex events (Linehan, 1993a).