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Mental Illness: When A Therapist 'Comes Out'

As therapists we can't offer patients the shining moment in a Chicago chapel that started Marsha Linehan on the road out of hell. But we can recognize and embrace the central insight she had, which she later came to call "radical acceptance."
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It's a remarkable and riveting story -- a teenager spirals, inexplicably, into severe emotional distress that leads her to attack herself brutally by slashing and burning her body. Confined to a locked "safe room" at a psychiatric hospital, she uses the only weapon available to keep hurting herself, banging her head against the wall or even the floor.

"I was in hell," she says many years later. "And I made a vow: when I get out, I'm going to come back and get others out of here."

And she does.

That deeply-troubled teenager, Marsha Linehan, became Dr. Marsha Linehan, a therapist and researcher at the University of Washington who used her own experience to develop a groundbreaking behavioral therapy.

She did that in part because nothing offered at the time she was in agony -- the late 1960s -- helped her get better. Not the Thorazine and Libruim, not the Freudian analysis, not the electric shock treatments. What did begin her journey to recovery was a religious experience, a vision that allowed her to accept who she was. This was a transformative moment for Linehan, then in her 20s, alleviating the despair that drove her self-destructive furor. As The New York Times writer Benedict Carey put it in a story about Linehan, "She had tried to kill herself so many times because the gulf between the person she wanted to be and the person she was left her desperate, hopeless, deeply homesick for a life she would never know."

As therapists we can't offer patients the shining moment in a Chicago chapel that started Linehan on the road out of hell. But we can recognize and embrace the central insight she had, which she later came to call "radical acceptance." It's the basis for the treatment she pioneered -- dialectical behavioral therapy (DBT) -- which enables patients to channel or change the emotions that are driving suicidal urges. But acceptance is also the beginning of many other effective therapies, for everything from substance abuse to obsessive-compulsive disorders.

And acceptance by a broader public of the reality of psychiatric illness is the key to effective treatment for many, many people who are struggling without diagnosis and treatment. That's why it's so important that Dr. Lineman decided, after decades, to go public about her own story, an unusual enough step for a clinician that one of my colleagues at the Child Mind Institute called it "coming out."

Clinicians are trained not to inject their own reality into the therapeutic relationship, but Linehan saw she had an opportunity to give hope to others in the same kind of hell she knew. Hope may not sound like much of a cure-all, but it's absolutely critical to recovery, which is not a passive but an active pursuit.

And as Linehan's struggle with what was eventually diagnosed as borderline personality disorder shows so poignantly, confronting a debilitating mental illness takes enormous personal courage. "So many people have begged me to come forward," she said in the New York Times article, "and I just thought well, I have to do this. I owe it to them. I cannot die a coward."

Of course she was anything but a coward. After getting her Ph.D. in psychology, Linehan chose to work with the most desperate patients, those she calls "supersuicidal," because she felt she understood them.

"I figured these are the most miserable people in the world -- they think they're evil, that they're bad, bad, bad -- and I understood that they weren't," she said to the New York Times. She worked by acknowledging the feelings that drive the suicidal behavior, in a sense accepting the logic of that behavior. Patients can then begin to accept that emotional reality of who they are, that they feel great pain that others just don't feel. That leads to a commitment from the patient to try to change the behavior. As Linehan notes without hyperbole, "Therapy does not work for people who are dead."

Linehan's courage was matched by her compassion and the discipline to translate her personal approach into rigorous protocols to enable it to reach the wider population. Dialectical behavioral therapy continues to be one of the best evidence-based treatments for borderline personality disorder as well as other conditions, including eating disorders and substance abuse.

DBT is one of a host of behavioral therapies that have become extremely powerful tools for defusing psychiatric illnesses, from anxiety disorders to depression to disruptive behavior disorders. Not as well known as the medications in the psychiatrist's arsenal, they are especially important for children and adolescents, whose personalities, and, indeed, brains are still developing. I can't overstate the importance of treating a child with OCD before he becomes a seriously-disabled adult, of treating a teenager who cuts herself before it becomes a lifelong habit. The longer a teenager or young adult has anorexia, the poorer the prognosis.

Dr. Linehan pioneered behavioral tools used in many kinds of psychotherapy, including opposite action -- in which patients experiencing a problematic emotion try to act in the opposite way --and mindfulness -- in which people focus on their breathing and experience their emotions without acting on them. Many of these tools can be customized for children as young as 3 or 4 years old. Accepting the reality of a child or adolescent who is suffering is the first step in giving her the tools to become the person she wants to be.

Harold S. Koplewicz, M.D. is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more on mood disorders and the evidence-based therapies that can help, go to our website, which offers parenting advice and a wealth of information on childhood psychiatric and learning disorders.