When Marsha M. Linehan was 18, she went from prom queen nominee to suicidal mental hospital patient in a matter of months.
She cut herself, fought with staff, and smashed her head onto the concrete floor. Pretty quickly, her parents and therapists gave up hope of her getting better.
Fast forward 10 years after being committed and Marsha was well on her way to developing Dialectal Behavioral Therapy (DBT), which became the gold standard therapy to help patients suffering from her same illness — borderline personality disorder –actually get better.
This book tells the story of that incredible rise from the ashes.
The Epiphany
What drove her to such a dark place at age 18 is not that interesting. She isn’t really sure herself, other than that she suffered from low self esteem and her mother was invalidating. The best parts of the book are about how she battled her way out of a truly grim situation, so that’s what I’ll focus on.
Mental hospitals in Tulsa, OK in the 1960s were about as grisly as you would imagine. Marsha was forced to get multiple rounds of shock therapy, she was pumped full of drugs, and suffered various other indignities that would not fly nowadays.
Between the drugs, the intentionally smashing her head into hard surfaces, and the electric brain shocks, Marsha lost most of her memories of this period. She remembers breaking windows to get shards of glass to cut herself with, being placed in solitary confinement for months at a time, and callous nurses. She almost constantly wanted to die.
Her attitude started to change not because of a breakthrough therapy session, but because of an experience by herself at a piano.
Part of losing her memory was forgetting how to play the piano, an activity she used to be really good at. She liked to hang out at the piano anyway.
One afternoon, she sat at the piano and felt compelled to make a promise to god that she would get better. She promised she would help others like herself get better, too.
Here’s how Marsha describes it:
“The day when I was sitting in the piano room by myself, a lonely soul in the midst of other lonely souls on the unit, I can’t be sure what made me do what I did next. There and then I made a vow to god that I would get myself out of hell and that, once I did, I would go back into hell and get others out. That vow has guided and controlled most of my life since then.”
She blows right past how this breakthrough happened! Maybe she assumes the reader will understand that people who are raised religious tend to make unbreakable vows to god when at low point.
I wanted her to say so much more. That’s a massive decision and a big shift with little precipitating cause. At least from the reader’s perspective.
This was the same person who asked nurses to strap her to a bed while wrapping her up like a burrito in wet, cold, bed sheets. That was supposed to be punishment. Martha would request it because it would stop her from trying to hurt herself.
Then, bam, “I guess I’ll sit at the piano and decide to devote my life to getting better and to helping people.” And she actually does it, as opposed to most people, who can’t even commit to going to the gym after buying a membership.
Did she have other times she made promises but just not keep them that she left out? Was this kind of her schtick? We don’t know.
Her compact with god didn’t lead to instant healing, but there was clearly a shift that left her open to changing her predicament in ways that didn’t involve killing herself.
She says she finally realized that she actually didn’t want to kill herself when her doctor told her he stopped caring whether she died or not. He gratuitously added in that he would not go to her funeral. This feels harsh, but it fired Marsha up.
Her theory is that everyone worrying about her suicide attempts was encouraging her to do them more, for attention.
“When Dr. O’Brien made his stand that day, I came to realize for the first time that I did not want to die. That was the turning point. I realized that killing myself was incompatible with my vow to get myself out of hell. I had to find a way to stop wanting to kill myself, and I did.”
That’s hardcore! Hey, whatever works.
She soon gets another important motivational boost when she learns that if she didn’t get better her parents would put her in a state hospital instead of a the private facility she was in. If her facility was good in the grand scheme of things it would be real depressing to know what was bad. We have to imagine Marsha had an idea of how much worse it could get, because this threat scared her straight.
“When I heard that the hospital was giving up on me, and that my parents might really put me in a state hospital, I decided that I would prove them all wrong if it was the last thing I did on earth.”
I guess they should have threatened that sooner!
Her writing makes it seem like each event is an isolated catalyst and I wish she’d dug more into how they all built on each other and culminated in her breakthrough. It went something like → see God at piano → have doctor give up on her → have parents give up → feel righteous anger burning like a thousands suns → get act together. Not the order of events I would have guessed.
I am most struck by the original piano epiphany. Can that happen to the average person? Do you have to hit rock bottom? How do you cultivate what’s needed to get to that point when you are, again, spending much of your day literally hitting your head against a wall and being physically re-strained in freezing cold sheets?
I would have loved her to explore this more and cut out some of the fluff around her meditation retreats later on. I bet she’d say something about “finding your why” and this book made me want to take that a lot more seriously in case I find myself in a situation where my “why” is the only thing that keeps me going.
Setbacks, Getting Her Act Together, Facing New Challenges
Marsha starts living on her own at a YMCA and takes a secretarial job at her dad’s company. She struggles, and even tries to commit suicide multiple times by swallowing pills. The pact with god only got her so far.
She keeps chugging along, and eventually starts going to night school, meets someone, and falls in love. But it turns out he had a wife on the side. This crushes her but surprisingly does not send her into a suicidal tailspin, which is kind of remarkable considering her recent history.
She just sort of, got through it. How? Again, she’s just kinda unsure. Which is as remarkable as it is unhelpful to those trying to draw lessons.
She writes:
“Within a year of leaving the institute of living [her mental hospital] and going back to Tulsa, I experienced a significant shift. It is hard to explain, but it was as if a new and happier me emerged from the cocoon of the anguished old me. And, remarkably, the metamorphosis just happened, unprompted by anything I said or did.”
I don’t buy that self analysis. It seems to me that it very much was prompted by things she said or did. She decided that she was going to devote her life to getting out of hell and helping others do the same.
She slipped up on this with her suicide attempts, but the decision and motivation still clearly meant something to her. And she also proved she can step out from under the shadow of her invalidating, emotionally unsupportive parents by earning some income and going back to school. And a huge part of what made her depressed at 18 was that she felt boys didn’t like her, so learning a boy could devote so much time to her must have been a boost to her ego, even if he ended up being pretty shitty.
Also, she was really drugged up at the institute, so maybe, ironically, it was a matter of getting off the antipsychotics that helped her improve.
I feel like clearing the drugs out of her system, plus the self esteem boost from love, earning a wage, and progress towards getting a degree was enough to push her into a state where she felt there was something to live for.
I find more hope in that story than just “one day I woke up and felt good, no idea why.”
It is hopeful that a change of scenery and a few lifestyle tweaks can blossom into very positive outcomes, even if you can’t pinpoint exactly what combination of changes made the difference.
On the Right Path , God Helps Out Again
She goes to Chicago, she works hard, she goes to school, her rich uncle agrees to pay for college. All looking mostly good! Marsha on the up and up!
Yet again, the most intriguing part to me was an unexplainable moment that shifted Marsha internally and set her on a different path.
As she worked toward a degree in night school, she was in a place where she did not want to kill herself. But she still felt despair, she still go depressed, and she still had low self esteem.
Then this happened one day when she was feeling particulary bad:
“I went into the chapel, knelt at a pew, and gazed at the cross behind the altar. I don’t recall what I was saying to God at the time, if anything, but as I gazed at the large crucifix, all of a sudden the whole of the chapel became suffused with a bright golden light, shimmering all over. And I immediately, joyfully knew with complete certain that God loved me. That I was not alone.“
She ran back to her room proclaiming how much she loved herself, and spends a page talking about how she felt like before that experience she was “split” and after she was healed and had become her true self in a way.
“I said out loud ‘I love myself.’ The minute the word ‘myself’ came out, I knew I had been transformed. If anyone had asked me up to that point, ‘Do you love yourself’ I might have answered ‘I love her.’
After I descended into hell in the institute, I had always though or spoken of myself in the third person, as if there were two of me, split somehow. I hadn’t been split like this before I went into the institute, but during that experience, until this moment in the chapel, I had been somehow split.”
Wild! Out of nowhere spiritual healing experiences for the win. I guess if you pray enough this just might happen? I’ve had profound experiences meditating where I see all sorts of cool stuff, but nothing which healed something deep within me quite like Marsha’s experience.
I like how Marsha is very spiritual and not ashamed about it. Her vibe reminds me of how more scientists in the past used to be open about their delightfully weird spiritual beliefs. Isaac Newton spent a ton of time identifying hidden messages in the Bible, for instance. Erwin Schrodinger, of quantum mechanics fame, said that, “In the presentation of a scientific problem, the other player is the good Lord.” I think Marsha would agree.
Post church epiphany, Marsha’s up and down journey continues. She falls in and out of love, gets different jobs, tries new research methods, and starts to develop what will ultimately become Dialectal Behavioral Therapy (DBT).
She still struggles with wanting to die, which she differentiates from wanting to kill herself. She gets a good therapist and calls him at all hours of the night and is a bit of a wreck. She gets through it and does what Marsha does, which is to plow forward and work her ass off.
A couple other interesting tidbits from this period:
- She became keen on taking troubled people into her house to live. One time she had someone on parole for murder mingling with her students during a study session. Her students were not woke enough to handle this and asked her to stop brining murderers around.
- She quit smoking using the following strategy → She knew she needed a habit to replace getting cigs from her purse. She chose to grab a dime and transfer it from one jar to another, and to convince herself this is what she actually wanted to do. She stuck with this until it worked. Maybe borderline people are much better at convincing themselves of things? Or maybe I overestimate how hard it would be to convince myself of something. But this is bananas to me.
Living the Zen Life, Creating DBT
Spiritual experiences continue to influence Marsha’s life as she develops large chunks of DBT therapy while at a zen monastery.
She decides to go to a monastery on a whim and ends up loving it so much that she rearranges her schedule in order to stay longer. She has spiritual awakenings there, as one does when they spend 14 hours a day meditating. She cries at the feet of a Zen master named Willigus for a long time and then emerges back into society with a newfound ability to use what she calls “wise mind.” She eventually becomes one of the first therapists to bring mindfulness into western therapy practices, and her patients get a lot out of it.
I ended this section thinking academic tenure sounds pretty sweet, taking casual 4 month sojourns to zen monasteries for “work purposes” and whatnot.
I also think it’s cool that she didn’t read a book about Zen and then decide to start using it in therapy. She wasn’t doing this stuff based on theory alone. If Marsha was going to incorporate mindfulness and radical acceptance into her approach it’s because she went to a remote mountain and radically accepted herself for 4 months to see how it felt first hand.
Similarly, if she’s teaching that it’s important to say off the cuff, slightly ridiculous things during sessions even when tensions are high, it’s because she’s had success doing just that. She once had a patient say “A friend will take care of my dog if I killed myself and Marsha said, “No they won’t, because I’ll tell them not to.”
If she’s teaching patients to convince themselves they like something more healthy than their destructive habit it’s because she made herself want to move dimes from one jar to another instead of smoking cigarettes. Still can’t believe that one worked.
Through trial and error, intentional collection of feedback, and trips to monasteries, the standard version of DBT therapy started to take shape. As she was building the practice of DBT, Marsha focused above all else on finding something, anything, that actually helped people.
It’s worth stopping for a second to point out that those with borderline personality disorder are notoriously hard to treat. BPD is “characterized by emotion dysregulation, impulsivity, self-injurious behavior, and suicidal behavior all of which contribute to the highest emergency and inpatient service utilization of any psychiatric disorder.” There are also no effective drug treatments as of 2021.
That’s a tough situation to step into. As she was developing DBT, Marsha would to sit with patients while others watched her through a one way mirror. She’d try everything she could think, then everyone would review and say what went well and what didn’t. Then they’d iterate. It reminds me of comedians preparing their set by doing open mics. You bomb a lot, but you learn, and you build on the bits of laughter you did get. It’s kind of amazing this wasn’t standard practice with how to develop therapies before, or maybe it is and I just need to do more research.
I was less interested in what DBT actually is than in how it came to be, but here’s a brief summary: DBT is the practice of accepting bad things as they are while also understanding that you can learn skills that will improve your life. It involves group therapy, phone coaching, mindfulness, and emotional regulation skills.
The therapist tries to strike a balance between accepting the patient fully, validating their problems, and making them feel heard while also encouraging them to change and teaching them how they can do that (hence the “dialectical” part of the name, which means striking a balance between two contrasting poles)
And all therapists practice in groups because the patients can be insanely taxing and the therapists need support, too.
Marsha admits DBT therapist turnover is very high and she kind of describes it like the investment banking of the therapy world. It’s an intense process where you learn a lot and work a lot but burn out quick. It’s like the investment banking of the therapy world, minus the high pay and the Adderall plus they actually help people.
This approach was a sea change in how people dealt with Borderline people previously. In the bad old days, all patients went through endless psychotherapy aimed at uncovering the source of their issues. This can help some patients, but suicidal people with borderline personality disorder had poor outcomes with traditional therapy.
Marsha was having none of that Freudian bullshit. She wanted to change behaviors and get people healthy, to hell with the source of their issues. She built a system based first and foremost on changing behaviors.
I’d be remiss if I didn’t mention one last, and, according to Marsha, crucial part of the DBT therapist toolkit — dance circles.
Marsha makes up her own moves and says patients love them and that everyone always cries tears of joy during the dances . I had a hard time believing this. I looked it up, and it’s real, but I can’t confirm tears of joy or transformational dance inspired breakthroughs. I just love that DBT is like “We use advanced techniques to help the hardest to treat patients and part of that is doing the horah, so what?”
The establishment was annoyed as hell by Marsha’s shenanigans, as it tends to go with establishments.
They’d be like “Wah, but how are you even helping these people, you’re just putting a band-aid on the problem.” And Marsha was like “well all your basic-ass talk therpay mumbo jumbo leaves a lot more dead bodies in its wake, so I’m going to keep doing me.”
I am totally on team Marsha with this one. The controversy reminded me of an anecdote from psychiatrist Scott Alexander about an effective treatment for a peculiar patient that had some docs applauding while others pulled their hair out:
The Hair Dryer Incident was probably the biggest dispute I’ve seen in the mental hospital where I work. Most of the time all the psychiatrists get along and have pretty much the same opinion about important things, but people were at each other’s throats about the Hair Dryer Incident.
Basically, this one obsessive compulsive woman would drive to work every morning and worry she had left the hair dryer on and it was going to burn down her house. So she’d drive back home to check that the hair dryer was off, then drive back to work, then worry that maybe she hadn’t really checked well enough, then drive back, and so on ten or twenty times a day.
It’s a pretty typical case of obsessive-compulsive disorder, but it was really interfering with her life. She worked some high-powered job – I think a lawyer – and she was constantly late to everything because of this driving back and forth, to the point where her career was in a downspin and she thought she would have to quit and go on disability. She wasn’t able to go out with friends, she wasn’t even able to go to restaurants because she would keep fretting she left the hair dryer on at home and have to rush back. She’d seen countless psychiatrists, psychologists, and counselors, she’d done all sorts of therapy, she’d taken every medication in the book, and none of them had helped.
So she came to my hospital and was seen by a colleague of mine, who told her “Hey, have you thought about just bringing the hair dryer with you?”
And it worked.
For good measure, Marsha conducted a lot of studies showing how people actually do improve their self esteem when going through DBT therapy, they don’t just paper over their issues. Other studies have replicated these findings, and DBT is firmly cemented as the best treatment for borderline personality disorder these days.
No Excuses
Her writing style can be dry at times, but the content makes it a good read anyway. Everyone loves a good comeback story, and this is one for the ages. We all talk about proving the haters wrong. Few rise up from the depths of a wicked mental illness and actually do so.
At the end of the book, Marsha revisits the mental hospital where she spent her most hellish years. She gives a moving speech where she reveals to the pubic her struggle for the first time. That’s so baller! It’s like the ultimate version of going back to your high school reunion and being better looking and richer than all the bullies. “Yeah, I used headbutt a concrete wall right over there just to feel something, but look at me now!
You can see how that would inspire so many people facing dark situations. If Marsha can climb out of mental hospital hell and become a world class therapist / dance choreographer, the rest of us have no excuses when it comes to overcoming hardships and following our dreams.
My thoughts on everything 