By Greg Simon, MD, MPH, senior investigator, Kaiser Permanente Washington Health Research Institute and psychiatrist, Washington Permanente Medical Group
If the Mental Health Research Network had a book club, we’d start with Marsha Linehan’s memoir, Building a Life Worth Living.
Marsha is the creator of Dialectical Behavior Therapy or DBT, a treatment approach once seen as heretical that’s now the standard of care for people at risk of self-harm or suicide. Her memoir is much more than an academic autobiography, describing her groundbreaking research at the University of Washington. It is her personal story of recovery and spiritual evolution. The history of DBT doesn’t begin with a post-doctoral fellowship or a research grant for a pilot study. Instead, it begins with Marsha’s descent into severe depression and relentless suicidal ideation, leading to a two-year inpatient psychiatric stay as “one of the most disturbed patients in the hospital.”
Marsha’s remarkable story pushed me to think about all sorts of questions regarding mental health research and mental health treatment: Why does our clinical research often focus on reconfirming the modest benefits of treatments that are so disappointing? How could the scientific peer review system welcome true innovation rather than comfortable confirmation? Do mental health clinicians’ traditional “boundaries” really serve to protect patients from harm—or more to protect clinicians from upset or inconvenience? How central are spirituality and religion to recovery from mental illness? And where would we be today if Marsha Linehan had chosen a traditional religious order over psychology graduate school?
For me, the book’s most valuable lesson was understanding the dialectical center of DBT. Dialectical thinking—holding two seemingly opposite ideas at the same time—is central to Marsha’s treatment approach and her life story. Following the first rule of good writing (“Show, don’t tell”), Marsha generously describes her own intellectual and spiritual journey to dialectically embracing the tension between radical acceptance and hunger for change. Her message to her clients is “I accept you as you are; how you feel and what you do make perfect sense.” And her message is also “There is a more effective way to be who you are and feel what you feel. Wouldn’t you like to learn about it?” Both are completely true, at the very same time. The tension between acceptance and change is not a problem to be solved but a creative space to inhabit—or even dance inside of. Marsha also has some important things to say about dancing!
Marsha reveals her dialectical approach most clearly in describing her own mental health treatment. She endured over-medication, forcible restraint, and weeks spent in a seclusion room. Her descriptions of those traumas are vivid, but they include not the slightest tinge of blame or resentment. Instead, she gracefully expresses gratitude and compassion for her caregivers, knowing they were doing the best they could with the knowledge and skills they had at the time. That is truly radical acceptance. At the same time, Marsha was passionate for change. She vowed that “I would get myself out of hell—and that once I did, I would find a way to get others out of hell, too.” It seems that the mental health care system is Marsha’s last client. And I think she is practicing a little DBT on mental health clinicians like me—compassionately accepting all of our failings and flailings while showing us a better way.
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