Building a Life Worth Living: A Memoir
It’s rare that I’ll read a biography, autobiography, or memoir. However, Marsha Linehan’s legacy in suicide prevention warranted a deeper understanding of her, and Building a Life Worth Living: A Memoir is certainly that. She lays out her life and how she came to develop dialectical behavior therapy (DBT). (See Cognitive Behavioral Treatment of Borderline Personality Disorder, and DBT Explained for more about the therapeutic approach.)
The Descent into Hell
Central to the amazing work that Linehan did was her own struggle and commitment to the Institute of Living – a psychiatric institution – for two years and one month. Her experience there is a horrifying story of electroconvulsive therapy (ECT) and its abuse, which left gaping holes in her memory, and the solitary confinement that wouldn’t be allowed today – and wasn’t normal then. What’s amazing is that, out of this, she became determined to do better by others.
Her work was motivated to increase the success of others – including their happiness. She explains that you can’t describe hell – you can only feel it, experience it. She didn’t want others to have this experience.
Beauty
A particularly poignant quote from her mother is, “Beauty is worth the effort it takes.” While it was used in the context of making a home beautiful, it felt as if, somehow, it was the same with people. Working your way out of hell takes work – an incredible amount of work. However, the results are so remarkable that it feels like it’s worth the effort. This is the response I get from the amazing people I meet who have been through hell and have chosen to climb out – and to help others either avoid the descent or climb back out.
In the Presence
Linehan describes how her father couldn’t tolerate her misery. It’s, unfortunately, an all-too-common challenge that the time people need others most is when they find themselves abandoned. It’s not just mental illness. It’s seen in substance abuse. Even families bereaved by loss – especially suicide loss – experience their friends, associates, and colleagues pulling back for a variety of reasons that are all rooted in discomfort.
Perhaps the discomfort they are feeling is that they’re concerned it will spread. Maybe they’re uncomfortable because they believe they should have somehow, magically, prevented it. No matter what the cause, it’s hard to develop the strength of character to be present when we are uncomfortable – and do nothing to solve it.
Doing nothing to solve it is important, because sometimes it isn’t “solvable” in the traditional sense. Sometimes, we don’t have the agency to accomplish the change. Sometimes, the answers on what to do to solve the problem aren’t clear. Other times, we must rely on others and their expertise to help us through. For problem solvers, like me, it’s hard to just be in the presence of a problem knowing we can’t solve it – yet it’s perhaps equally important that we learn how to.
The Institutional Paradox
When a clinician is confronted with an actively suicidal person, they have a few approaches. Those who are trained can start a research-supported therapy like DBT, BCBT-SP, or CAMS. (See Cognitive Behavioral Treatment of Borderline Personality Disorder for DBT, Brief Cognitive-Behavioral Therapy for Suicide Prevention for BCBT-SP, and Managing Suicidal Risk for CAMS.) For those who are untrained, it’s often unclear where they should refer to, so they default to the emergency room – which often leads to institutionalization.
Most states have laws that allow for the detention of people when they pose a risk to themselves or others. Someone with active suicidal ideation is often considered a risk to themselves. Therefore, they can be deprived of their freedom and forced into an institution, where they can be forced to take psychoactive medications.
There are serious problems with this approach. First, there are some people for which this strategy is appropriate. However, there’s no research to support how many people this might be appropriate for – because there’s literally no research on the efficacy of institutionalization. There is, however, research that demonstrates the highest risk of suicidal behavior is immediately following discharge from an institution. (Typically, the first 30 days.) There’s even some research that says that not all this risk is a result of the population. It’s caused by the institutionalization process. (See Myth: Inpatient Hospitalization Is Best for People with Suicidal Ideation.)
The problem is that untrained clinicians – which is most clinicians – don’t have much of a choice. If they don’t refer the patient, they may get sued by the family. (See The Suicide Lawyers for more.) Referring the patient to the ER or to inpatient hospitalization may make things worse. This drives clinician anxiety higher – and makes the referral even more likely.
It’s believed that part of the problem is that institutionalization takes away freedom, thereby decreasing hope. If you’ve been institutionalized once, you know it can happen again. (It tends to be easier for someone to be committed to an institution after it happens once.) Many people who are struggling to believe that their life is worth living feel as if the world is being inflicted upon them and they have no control. Removing what little control they do have is dangerous.
Valued as You Are
It was Linehan’s Aunt Julia who was the consistent voice saying, “We love you as you are and for who you are. You do not have to change to be valued.” These words would reverberate inside Linehan and ultimately break free as an awareness that clients needed to be validated for who they are, what they feel, and what they’re doing. This isn’t to say that the change aspects of therapy could be ignored. Rather, they had to be integrated. This integration is at the heart of DBT. Instead of trying to eliminate the tension by ignoring an aspect of the problem, it is necessary to find a way to hold two opposing ideas at the same time.
On the one hand, people are inherently valuable as they are. They have the right to stay as they are. On the other hand, when they are suffering, we’re pulled towards helping them to make the changes that will result in less suffering, more happiness, and thriving.
It starts with accepting the person. It’s the foundation of therapeutic alliance. (See The Heart and Soul of Change.) You can only help those who are in a relationship with you – and that relationship is based on acceptance. Change comes after acceptance.
Tenacity
Where did the tenacity it takes to persist through challenges come from? How did Linehan survive the rejections, snubs, and barriers that presented themselves as she tried to find better ways for treatment? Her answer is, “You just wait and see. I’ll show you.” People would tell her something was impossible that she knew to be possible – but perhaps difficult. She’d determine that she was going to show them.
Sometimes, this tenacity required taking different directions. For instance, her focus on borderline personality disorder was because it was a recognized mental illness for which there was funding. Inside that space, she could work on suicide and get funding. It’s a tangential approach that allowed her to accomplish her life mission while accepting the current funding conditions.
Not Fitting In
Of the things that I identified with in the book, the most important one is, “But not fitting in was something of a fact of life for me.” I live in a state between worlds. (See Straddling Multiple Worlds.) This existence in multiple worlds means that I don’t fit into any one world completely. While Linehan’s feeling of not belonging is different than the kinds that I experience, it resonates.
Getting the Help They Need
Sometimes clinicians, exhausted from their workload, complain that they don’t like their patients. The reasons they provide are directly related to the reason the patient is seeing them. It’s not fair or right to be frustrated with a client for the very reason they came to see you in the first place – but it is an all-too-common occurrence.
The truth is that people who are suicidal see suicide as a solution. It’s a solution to some problem they perceive cannot be solved in another way. In my review of The Cry for Help, I explained that suicidal thinking, ideation, and even attempts can be a cry for help. It can be a warranted cry for help signaling that they need better solutions to their problems than the ones they believe are possible.
We can either approach people who struggle with suicidality as manipulative and trying to control others, or we can wonder what is it that they believe suicide is a solution to. That perspective change makes all the difference when it comes to how we interact with others who struggle with suicidality.
Distress Tolerance
Life is suffering. Buddhist teachings aren’t subtle on the point that we must suffer in this life. (See The Trauma of Everyday Life.) Christian beliefs are aligned with this as well. They believe that Christ suffered to save us – that even he must suffer in this life. Despite the relative consistency in the belief that life means suffering, we’re not always appropriately equipped and skilled to deal with the distress that is presented to us.
One of Linehan’s observations is that everyone has distress and the patients with suicidality appear to be limited in their ability to tolerate distress. Part of DBT is teaching a set of skills that allow people to better accept the distress that is in their life. It isn’t always easy to resolve the source of the distress, but it is possible to improve our ability to respond to it.
Consider the gradual building of skills that is advocated for in Nassim Taleb’s Antifragile or the amazing results that are possible through conscious practice as explained by Anders Ericsson in Peak. In both cases, it isn’t that there isn’t distress, but rather there’s a goal at the end to become more capable of weathering the storms of distress as they come.
I’m careful here, because there’s a fair amount of discussion about resilience. Technically, resilience is a return to a prior state after a stressor – and most people acknowledge that Heracles was right when he said, “No man steps into the same river twice. He’s not the same man and it’s not the same river.” Our goal shouldn’t be resilience but rather growth. See Resilient and The Resilience Factor for more on resilience and Transformed by Trauma for growth.
What Nietzche said rings true: “He who has a why to live can bear almost any how.” We can learn distress tolerance indirectly by learning why we’re living. We can engender hope that our distress will pass if we’re willing to stay focused on why we’re still here.
A Life Based on Hope
Linehan says, “You can live a life based on hope.” I’m reminded of the story of Pandora’s box. Often, it’s seen as a story about how curiosity can end badly. Pandora released all the evils of the world that were once contained in the box. However, what is often missed is that there was one thing in the box with these evils. That was hope. Sure, hope didn’t emerge triumphant from the box and instead showed the strain of the sustained conflict with the evil in the box – but hope survived. Hope was able to hold its own against all the evils of the world. That’s impressive.
The challenge with hope, for some, is that it feels as if it’s some mystical substance that you either have or don’t have. However, as Rick Snyder points out in The Psychology of Hope, hope is a cognitive process. It’s an evaluation of both willpower and waypower. Willpower is generally well understood, and Roy Baumeister’s book, Willpower, provides a more thorough explanation. Waypower, however, is less commonly used and most closely resembles “know how.” It’s the sense that you know there is a way for something to happen. It can come in the form of blind faith in humanity or in a rough vision of what would need to happen. Snyder asserts that when both of these are present, you’ll feel hope.
I’d like to extend and clarify that while Snyder doesn’t speak about whether the components need to be internal to the person or external from the environment, I believe that both are options. It’s possible to believe that “God will provide” and thus have hope. Conversely, you have the perspective of “I’ve been through worse before and survived,” which relies solely on internal tenacity and the sense of problem-solving skills. In truth, it’s not probably ever one or the other but rather the relative degree to which one has faith in eternal sources and themselves.
She Said “Yes”
Linehan comments that she suggested that her tombstone should have the words “She said ‘yes’” inscribed on it and shares, “Meaning that I lived my life willingly, doing what God wanted me to do for the betterment of people’s lives and the world.” In short, when the call came to do something, she didn’t turn away.
Brene Brown’s work in The Gifts of Imperfection focuses on the concept of wholeheartedness. Conceptually, this is the same – fully engaging with life. Brown’s work is built on the work of Harriet Learner, particularly from The Dance of Connection. There are people who, under the pressures of life, cave in. They crumble or retreat. In Transformed by Trauma, Rich Tedeschi shares stories of those who have grown through their trauma – like Linehan.
Calling a Spade a Spade
There is something to be said for ritual and ceremony. For instance, Arnold van Gennep in The Rites of Passage describes not just the kinds of rituals (rites) but also their importance for individuals and society. In more modern terms, Raising a Modern-Day Knight shares that ceremonies can instill important values. Even bureaucracy can have its place. It can help to generate needed consistency. However, there is also the need to be true.
The folktale, “The Emperor’s New Clothes,” provides this powerful lesson from the eyes of a child who could tell the truth without fear of being criticized for being stupid. In over 30 years of consulting, I’ve seen plenty of ideas destined to fail with teams diligently working. They’d fallen into “groupthink,” the word that Irving Janis popularized for when everyone fails to see the obvious, because they’re too wrapped up in the need for coherence to question what they’re doing in a truly honest way.
Linehan describes herself as naturally irreverent. Perhaps that’s why she could maintain the courage to challenge the status quo and move us all forward.
Evidence of Pain in Death
Linehan explains that she would say to clients, “There is absolutely no evidence that you will feel better when you are dead. Why take the risk?” The mind-bending response challenges the inherent assumption that exists in the mind of the suicidal person. The assumption is that death will mean an end to their pain. Of course, no one can know what death will feel like, and therefore there cannot be evidence about what, if anything, people feel in death.
This kind of irreverence, and questioning the “unquestionable” assumptions, can be the very thing that people need to escape the cognitive constriction endemic of suicidal thinking. (See The Suicidal Mind for more on cognitive constriction.)
Not a Zen Master
There’s a bit of paradox in becoming a Zen master. On the one hand, you’re supposed to embody the Zen Buddhist who is detached. Buddhists know that life is suffering and temporary. It’s through detachment and acceptance that one can reach Nirvana – or, short of that, be a master. However, there is a certain air of importance that comes with being a Zen master. After all, it’s something that a candidate has been striving for. That’s why a Zen master could offer sage wisdom while speaking to Linehan: “Marsha, you are the best teacher here. Because you are the only one who does not care if you become a Zen master or not.”
Pausing for a moment, there’s a great compliment. However, more importantly, the master identified the core factor that was leading to the results being complimented. Because she didn’t care if she was a Zen master or not, it freed her to be more honest, open, transparent, and real. She wasn’t attending so that she could achieve another accolade. She was hoping to learn so that she could share that learning with others. That is both amazing and at the heart of Buddhism.
Knowing to Accept
The other aspect of Buddhism is acceptance. It’s learning to accept the world as it is – rather than insisting in beliefs that are inconsistent with reality. Linehan states, “It is very difficult to accept reality with our eyes closed. If we want to accept what is happening to us, we have to know what is happening to us.” It’s true, but it takes more than our eyes. We must be open to experiences and accepting them for what they really are – whether we like them or not. It’s not until we have a firm understanding of a solid foundation that we can begin the process of Building a Life Worth Living.