Marsha Linehan and Building a Profession Worth Practicing

Marsha Linehan died on November 10, 2026. She was 83. I reviewed her memoir, Building a Life Worth Living, for Psychiatric Times in February 2020. This is a heavily revised and updated version of that review.

“Building a Life Worth Living: A Memoir” by Marsha M. Linehan; New York: Random House, 2020. 384 pages

Marsha Linehan—the legendary creator of dialectical behavior therapy (DBT)—needs little introduction. During my residency training, residents in our program were organized into “societies” to facilitate socialization and mentorship for junior trainees, and these societies were named after prominent figures in our field such as Kraepelin and Freud. Linehan was among them. Such is her status among psychiatrists and psychotherapists of my generation: a towering figure who found a way to help some of the most difficult-to-treat patients in psychiatry. She is a mythical figure, but she was also human, with all the imperfection and fallibility that entails. To read Linehan’s memoir, Building a Life Worth Living, is to realize that she underwent a crucifixion and resurrection of her own, and the Pontius Pilate in her story may have been the psychiatric profession itself.

Before Linehan’s DBT took mental health professions by the storm, Otto Kernberg’s psychoanalytic account was the dominant model of borderline personality disorder in psychiatry, at least to the extent that any practicing psychiatrist had a model. In Linehan’s telling, anger was at the core of that. Psychiatrists trained by Kernberg, she writes, were primed to look for expressions of anger in their patients, and resultantly that was all that they ever saw, often in a self-fulfilling prophecy:

“It seemed that with the Kernberg model, if you tell a patient she is displaying aggression and she denies it, you then tell her that’s just because she isn’t aware of it, and pretty soon that patient really is going to get angry. Then you sit back and say, ‘See what I mean!’” (p300)

This is one side of a long theoretical rivalry, and when I first read the book, I was ignorant and impressionable, and I accepted it rather uncritically. Kernberg’s model does give importance to aggression, but it is also concerned with the broader organization of personality that includes identity diffusion, splitting, and the instability of a person’s internal picture of self and others. Reducing it to “anger at the core” is about as fair as reducing DBT to DEAR MAN. Nor did history hand Linehan a clean victory in this rivalry. Transference-focused psychotherapy, the treatment derived from Kernberg’s model, does about as well as DBT on most outcomes in randomized comparison. Mentalization-based treatment and structured general psychiatric management also do about as well as DBT. Contrary to popular understanding, DBT is not uniquely superior among the current menu of options. While DBT is often the only thing available to patients—and that too, diluted beyond recognition, a homeopathic caricature of the real thing—the field knows that no one school is right. Coherent, structured, well-delivered, extended treatments help; DBT is among them, and I am thankful it exists, but it is no panacea.

Any clinical approach that can absorb every denial as further confirmation of the hypothesis risks becoming self-fulfilling. This hazard applies to any framework that becomes overconfident, DBT included. To indulge in pure hearsay, a psychoanalyst shared with me that he once attended a session where a senior and famous psychoanalyst conducted a live clinical interview with a patient (as an educational demonstration for mental health professionals), and my acquaintance was shocked to see the senior therapist coax the patient into a state of irritability with his questioning and then interpret that anger as transference. Linehan’s dialectical sensibility, an insistence on holding opposing truths at once, is one antidote to this, and it is meant for everyone, DBT’s enthusiasts among them.

A reader might expect a memoir of such treatment to be angry at the mental health professions. It is not, not really. She approaches her history of mental health treatment and interactions with psychiatrists with her usual Zen-like acceptance. This is described very well by Greg Simon in his review of the book:

“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 . . . 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.”

In 1961 at the age of 18, Marsha Linehan was admitted to the Institute of Living as a psychiatric patient, where she ended up staying for 26 months, and was considered to be among the worst patients in the hospital. The exact nature of her psychiatric condition remains somewhat unclear. Linehan herself doesn’t seem to provide a conclusive answer in the book, but she displayed many features typically associated with borderline personality disorder. When she first spoke publicly about her history, in a 2011 New York Times profile, she said she had chosen to treat people with the diagnosis she would have given her younger self, borderline personality disorder. She came to see her younger self through the lens of the condition she spent her career treating, while remaining somewhat wary of the diagnostic label.

The way Linehan was treated as a psychiatric patient at the Institute of Living appears to have been of little benefit and may in fact have worsened her condition. She describes being over-medicated and feeling like a “zombie,” as well as receiving electroconvulsive therapy (ECT) and experiencing loss of biographical memories. It is not clear from the book whether the ECT was administered against her will. While these days there are legal safeguards against involuntary administration, I suspect in early 1960s on a long-term inpatient psychiatric unit, the line between voluntary and involuntary administration was blurry. She underwent repeated seclusions and restraints which she believes only reinforced her behaviors. Although Linehan describes the disciplinarian behavior of the nurses in a non-judgmental way, they sound more like prison guards than individuals from a place of healing.

Looking back, I read these descriptions now with a grain of salt. While I do not dismiss them, and have no reason to, I find myself curious about what may be missing from this retelling. It is difficult, I have realized, for any of us, to undergo an intense experience like this and come out with an entirely accurate assessment of what really helped and what didn’t.

The Institute of Living was not her only psychiatric confinement though. Subsequently in her life, she was admitted involuntarily to Cook County Insane Asylum, which she describes as a “Kafkaesque nightmare.” She was deprived of her rights, treated horribly, and the more she tried to demonstrate to the staff that she was safe and stable enough to be discharged, the more they were convinced that she was unwell. She received a diagnosis of schizophrenia. When her family tried to get her out, there were so many bureaucratic hurdles that her brother began to despair, “Can we ever get her out of here?”

I read these episodes of Linehan’s life with shame and emotional turmoil. It is hard to confront the checkered legacy of one’s profession. While some of the practices she describes are now extinct, many others remain part and parcel of current inpatient psychiatric treatment.

When Linehan’s memoir was published, there was frequent talk of a suicide “epidemic” in the US, especially in the youth, given that the suicide rate had climbed about 35% two decades from 1999. It seems to have peaked around 2018-2022 and has since been going down but still remains a matter of concern. The dominant response to this crisis was a clinical screen-and-refer model. It relied on risk assessments, that have turned out to be largely worthless at the individual level, and involuntary hospitalizations, whose impact is still unclear beyond safety through physical confinement. The ambitious “Zero Suicide” was widely adopted and met with hope as well as chagrin. The National Suicide Hotline (988) gained a new prominence. “Rapid-acting antidepressants”—ketamine being the flagship intervention—dominated the new hope narrative. Esketamine was approved by the FDA in 2020 for depression with suicidal ideation as the indication, with little actual evidence that it reduces suicidal behaviors beyond placebo. Structured therapies, including DBT, were widely promoted, particularly in the form of therapy groups. Some of this, in some combination, has worked to some degree. It has not all been a waste, but we have focused on safety and control at the expense of dignity and autonomy to a point where even psychiatrists have begun to protest that hospitals feel more like prisons.

Suicide is complex, and there are no easy answers here. Most clinicians are doing the best they can in a system that does not make it easy to be compassionate or empathetic. However, as Linehan proved through her own life and career, we can and must do better, not only as individual clinicians but also collectively as a society. In 2020, it was common in progressive discussions to invoke social determinants of health and the need to listen to the voices of the consumer/survivor movement. These are still necessary, of course, but invoking them as solutions to the grand problem of suicide rings hollow to me now. Every day in the clinic, I sit with people who are in various states of suicidality, and I am reminded of how little we know and how limited our tools are. DBT and DBT-based programs have helped a lot of people, I agree, but if I had to generally talk about what I think works in the clinic for the chronically suicidal, when something works, it would be some combination of radical attention, human presence that serves as a container for emotions the patient cannot yet hold, a stubborn belief that we are all deserving of grace and salvation, a space for acting out plus repair and relational relearning, collaborative medication-treatment attuned to patient concerns, a relationship where patients can see through their own bullshit on their own terms, and patience and time, lots of patience and time.

Not surprisingly, subsequently in her professional career as a DBT therapist, Linehan saw little of therapeutic value in admitting suicidal patients to inpatient psychiatric units as the default management of suicidality. She writes:

“I often found myself tangling with psychiatrists, who made my life difficult. When I went out of town for the weekend and one of my clients had some kind of suicide crisis, the first response of psychiatrists was to admit them to a hospital. There are no data that show that hospitalization saves lives or is useful in any way with suicidal people. I believed then, and still do, that in the majority of cases, suicidal clients do just fine in outpatient treatment.” (p188)

Linehan doesn’t seem to make a distinction between involuntary and voluntary hospitalization (perhaps for good reason, the distinction can be fuzzy in the US system), and while I remain uncertain about what involuntary hospitalization does, other than extreme situations in where an imminent suicide needs to be prevented, I do recognize that there is a huge difference between someone suicidal who is held against their will and someone suicidal who genuinely wants to be in the hospital and believes they need to be in the hospital and welcomes the care, data be damned.

Inpatient psychiatric care has an appropriate role in the management of suicidality, and while I’m not sure how much Linehan truly appreciated that, her views on the matter still force us to consider whether this appropriate role is more limited than we currently believe it to be. I am increasingly of the view that the inpatient vs outpatient isn’t really that productive; what matters is what care is being offered and under what conditions, and there is nothing stopping us from making inpatient units place of genuine psychological care.

Linehan is reluctant to utilize the label “disorder.” She writes,

“I have never been interested in borderline personality disorder as a ‘disorder’ in itself. I have never targeted that. I target suicidal behavior, out-of-control behavior. I don’t think of myself as treating a disorder. I treat a set of behaviors that gets turned into a disorder by others.” (p304)

When I first read this passage, I read it as a comment on pathologization, but when I read it now, it seems to me to be bundling three different sorts of assertions. There is an assertion about clinical targets, a behaviorist’s transdiagnostic commitment to prioritize what can be observed (”suicidal behavior, out-of-control behavior”) regardless of what the specific diagnosis may be. The second is an assertion about reification (“A set of behaviors that gets turned into a disorder by others”) and whether a cluster of clinical features should be treated as a “thing.” In effect, she’s saying, “I’m treating these behaviors, I am not saying this is a disorder entity.” And third is a possible claim about whether features associated with borderline personality meet some definition of “disorder.” She is often read as making the third claim; the younger version of me thought so as well. But if you look at what DBT implies about BPD—people lack capacities for emotion regulation, distress tolerance and interpersonal effectiveness that others have—this is a dysfunction claim in all but name. Her working notion of disorder was probably something like “problems in living rooted in skill deficits and harmful transactions.” That is pathology-adjacent, not disease-like, but not one where it makes sense to me to insist that “disorder” doesn’t apply, unless one was working with a very reductive concept of “disorder.”

The irony is that DBT, built by Linehan in a collaborative and liberatory spirit, became for many clinics the standard treatment for mood disorders and personality disorders, and for some of the people who went through it, DBT’s rules and contingencies felt less like therapeutic validation and more like another regime of control. Many voices in the survivor movement are hostile to DBT. As I scroll through Twitter looking at tweets about Linehan’s death, I see some psychiatric survivor accounts cheering the death of an “abuser” and expressing “good riddance.” Part of this is an occupational hazard, Linehan taking up a role and working with a population where one will be hated by some, no matter what. Part of this is an implementation nightmare. A treatment with a radical potential was stripped down and offered to patients in the most rigid and ridiculous way possible. Death by a thousand asinine therapy groups. But part of the story is that a genuine reassessment is warranted, one that takes Linehan’s own skepticism directed at Kernberg, etc., seriously and turns it on her legacy. Who will look at the decaying flesh of DBT, at what happens in Linehan’s name across the world, and weep, “Look how they massacred my boy”?

She describes the skepticism with which DBT was received by the psychiatric community:

The psychiatrists thought they had stumped me when they started to claim that suicide is a biological disorder . . . [and] you have to treat it with a drug, electroconvulsive therapy, or something like that—not with behavior therapy . . . I relished these encounters. I’d stand up and say, “I see how suicide must be biological. I have a biological intervention, and I can tell you that right now. It’s DBT, of course. It changes the biology. If it’s a biological problem, and I can change it, then how could I be doing that except by changing the biology?” (p305)

Linehan’s retort is a clever reductio; it’s not really a concession that DBT is a “biological treatment.” What it shows is that the predicate “biological,” used in this indiscriminate way, has stopped doing any meaningful explanatory work. If every mental event is realized in the brain, then we gain nothing, learn nothing by saying suicide is biological. The characterization cannot adjudicate between psychotherapy and ECT. When the psychiatrists talking to Linehan insisted that suicide is a biological disorder, they meant something stronger, that the neural level is where suicidality and suicide are properly explained and treated. But that confuses the level at which a phenomenon is realized and at which it is most intelligible. Suicidality can be a state but suicide is an act; it has intentions and reasons, and psychological difference-makers (a sense of being trapped; a lack of meaning and purpose; inability to bear one’s own distress;…) are genuine causes in psychological terms, not placeholders for neural ones. DBT works by intervening on some of these. To treat the brain as the only locus of “real” causation is a philosophical error. It also has clinical consequences, because it directs attention away from the reasons for which people seek to die.

Linehan lived an immensely spiritual life, and the development of DBT was as much a spiritual undertaking as it was scientific. In 1967, a few years after leaving the Institute of Living and still struggling, she was praying in the chapel of the Cenacle retreat center in Chicago when, as she later described it, the room seemed to turn gold and she found herself saying, for the first time, that she loved herself. The euphoria faded, but something stayed: she could weather her emotional storms without harming herself. Years later she gave that change a name, radical acceptance, and built it into a treatment. She was a lifelong Catholic who also trained deeply in Zen and became a Zen teacher, and DBT’s central dialectic, accepting life as it is while working to change it, carries both traditions. This aspect of her life and work was highly instructive for me. It is also a reminder that effective ideas in modern psychotherapy can come from many sources.

Linehan was not typically seen as a critic of reductionistic, biomedical psychiatry, but as her memoir makes evident, she should be. She belongs among those insiders such as Allen Frances who have pushed the field toward reform from within, and in Linehan’s case, she did so by trying to building something better. Reading Marsha Linehan’s memoir is a reminder that a different kind of psychiatry is possible, that we can approach individuals in psychiatric distress in innovative ways that are humanistic and effective at the same time. She once made a vow, from inside a seclusion room, that when she got out she would come back and get others out. She kept the vow, and passed on the baton to us, but I think we fumbled it and lost sight of the spirit of her message. Maybe every generation gets the DBT it deserves.