In myths the world over, heroes must first descend into the underworld, where they are faced with a series of epic challenges to be overcome before they can prevail in their heroic life journey. Once they succeed, they return to their country bearing some special new secret of life.

Two things make DBT unique. The first is the dynamic balance between acceptance of oneself and one’s situation in life, on the one hand, and embracing change toward a better life, on the other. (That is what “dialectics” means—the balance of opposites and the coming to a synthesis.)

This balance between pursuing change strategies and pursuing acceptance strategies is a basis of DBT, and unique to DBT. This emphasis on acceptance as a counterbalance to change flows directly from the integration of Eastern (Zen) practice, as I experienced it, and Western psychological practice.

In psychodynamic therapy, which is a form of in-depth therapy that seeks to open a window on a person’s unconscious mind, therapists never tell a client what to do. I tell clients what to do all the time. This is another way in which DBT is different.

My stance toward each client is this: “You know what you need in your life, but you don’t know how to get what you need. Your problem is you might have good motives, but you don’t have good skills. I will teach you good skills.”

And from a medical point of view, we now know that when a person cuts themselves like this, endorphins, which can be thought of as natural opiates, are often released in the blood, and their effect is to reduce stress and induce a sense of well-being.

When the bar owner discovered what I had done, he called the police. They came quickly and patched me up with bandages. “Please don’t take me back,” I begged one of the cops, but I knew they were going to, no matter what I said. He said, “Well, do you want to take the direct route back or do you want to take the scenic route?” I said, “I want to take the scenic route.” They drove me around for quite a while before they took me back. It was the sweetest thing, a simple, kindly act for a desperate girl who seemed so crazy. It touches me still when I think about it.

Dear Dr. O’Brien, I feel I can’t express how I feel to you (or anyone else), but let me tell you one thing—I don’t belong in this unit. If I do, I am as crazy as they are. I am depressed, dejected, deflated, and unhappy & I wish I had never been born. I hate this place so much. You could never realize how miserable I am. I wish I were dead, dead, dead, dead. I feel so lonely & that row boat just won’t move. I am so alone. Even the idea of seeing Aline doesn’t cheer me up. Why can’t you help me? At home I could just cover all these feelings by staying on the go but here there is nothing to cover them with. They are coming into the open. It scares me. Sincerely, Marsha

I welcomed the feeling of being safe while in seclusion. In my clinical notes, there is mention of the fact that the more they tried to control me, the worse I got. Putting me in seclusion didn’t discourage my problem behavior; it did the opposite.

Later, working as a therapist, I fell into the same trap. When you become afraid that a client might commit suicide, you become anxious, and as your anxiety increases, your urge to control the client increases, too. So for a while, my experience with clients was the same one the institute had with me. I eventually learned that trying to control a suicidal person often makes them worse, not better. Instead of reducing dysfunctional behavior, trying to control it can reinforce—or promote—the behavior. This insight became important in my work as a therapist.

Dear Dr. O’Brien, What am I afraid of? I am afraid of never getting married, so I stay in here to give me a good reason. I’m afraid of being a social oddity, so I break windows to give me a good reason for being one. I am afraid being thin wouldn’t solve my problems so I stay fat to avoid finding out. I’m afraid that Aline would still be more popular than me even if I were thin, so again I just stay fat. I’m afraid that mother wouldn’t love me even if I were thin, so that again I stay fat.

(Today I have many clients whose suicidal behaviors have been reinforced by going to hospitals, because of the attention and care they got there—a similar unconscious link.)

“apparent competence.” I’ll elaborate on this below, but in short, it is when an individual appears to be in control of her life while inside she is in complete emotional turmoil and pain.

“My father should know,” she told me. “He knows how unhappy I am.” But he didn’t know, because she had never made it clear to him. And sure enough, when she told him, her dad changed his behavior. He had had no idea of the impact he’d been having. I had been like that client, nursing great emotional turmoil and unhappiness without making it obvious to others. I looked as if I was in control, but I wasn’t.

“I know the compassion of others is a relief at first. I don’t despise it. But it can’t quench pain, it slips through your soul as through a sieve.”

“It is not enough to be compassionate. You must act.”

Dr. O’Brien’s emotional withdrawal had a big impact on me. I had been in an environment where no one could effectively help me, so the only thing I could do was try to get them to try harder. Trying to kill myself, or obsessively dwelling on it as I did, had the effect of getting people to help me more. It wasn’t a conscious strategy on my part. (And I don’t think it is a conscious strategy in most people who repeatedly threaten suicide.) But I now suspect that my suicidal behavior was likely being reinforced by increased efforts to help me. (This is such an important insight into patient–clinician interaction that it bears repeating several times, as I have.)

The idea of proving everyone wrong kept me going. Much later, when I was in college at Loyola University in Chicago, one of my professors told me that this kind of anger could be very helpful in keeping a person from giving up.

Saint Isaac Jogues, who had his nails pulled off because he wouldn’t give up his faith in Jesus, and was later killed.

My all-time favorite martyrdom story, though, was of Saint Agatha of Sicily. She decided at a young age to devote her life and her body to God. Senator Quintianus proclaimed his passion for her, but when Agatha rebuffed him, he had her confined to a brothel for a month, hoping this would change her mind. It did not, and she refused him again. This time Quintianus had her thrown into prison, there to be subject to various cruel tortures, the most barbaric of which was having her breasts cut off. (Paintings of Saint Agatha typically show her holding a tray, upon which rest her two severed breasts.)

Having a love affair with God can sound pretty weird. I myself thought it was weird for many years. That changed when I read a book by Bruno Borchert called Mysticism: Its History and Challenge. He says that mystical experiences, which can be found in every religion, perhaps can be understood as the state of being in love. When I read that, I stopped thinking I was weird or crazy. It fit perfectly. I practically screamed hallelujah.

This tulip/rose conflict eventually became part of the way I talk to my clients in DBT. This is what I tell them: If you’re a tulip, don’t try to be a rose. Go find a tulip garden.

This constant disapproval, this constant pressure to be someone else—this is an example of a concept I came up with as I developed DBT: an invalidating environment and, in the extreme, a traumatic invalidating environment.

When hope of ever living a life experienced as worth living fades away, and no alternative can be found, thoughts of suicide can begin. The very thought of committing suicide can fill the mind with the belief that death can soon end pain. This belief can be so soothing that suicide becomes the only solution. (Of course, I tell clients that there is no evidence whatsoever that suicide will end their suffering.)

The combination of the biological predisposition and a toxic home environment proves to be a psychologically deadly mix. Had I grown up in a different family environment, one where I was accepted for who I was and what I valued (an environment such as Aunt Julia’s, for example), my life might have been different.

So I decided to come up with a rule that I kept all the way until I was forty: No drinking alcohol when alone. First Steps to Building a Life Experienced as Worth Living Imposing this rule on myself, to prevent destructive behavior and stay in a place that was at least tolerable, is an example of what I later termed “building a life experienced as worth living.” This is the overall goal of DBT. Even if you can’t create an ideal life for yourself, you have sufficient control to live a life that has enough positive elements to it that it is indeed worth living.

I had refused to allow my parents to subsidize me financially, because I was not going to let them have any credit for my getting out of hell.

merry-go-round.

Believe, Whether You Believe or Not

This dynamic became something of a pattern in my life: people telling me what I couldn’t do, and me thinking, “You just wait and see. I’ll show you.” And eventually it became a good message for me, and also for my clients and their families: Believe, whether you believe or not. I tell them that it may be difficult to believe, but believe you must. You can do it.

There was another woman who was schizophrenic. She was totally delusional, and probably about seventy-five. She thought her father was going to come pick her up and take her home. I tried to keep her calm by playing games with her, because the nurses kept threatening to put her into seclusion if she didn’t shut up. She would leap up and yell, “Wait a minute, my father’s coming, my father’s coming!” As she was dragged off to seclusion, one of the aides said to her, in a voice dripping with sarcasm, “Aw, honey, your father’s six feet under. He’s not coming.”

This sleight of mind, convincing yourself that something is true when in fact it is not, turned out to be a very helpful skill. It ultimately became an important DBT skill, particularly for people with addictions, a skill I named adaptive denial. Like many ideas in DBT, it is based on acceptance: accepting things as they are. In a later chapter I will tell you in detail how I used adaptive denial to help me stop smoking.

Anselm gave me my all-time best advice about prayer. “Marsha,” he told me very early on, “when you pray, don’t say anything.” I was completely surprised, and probably protested, “How can I possibly pray without saying anything?” Anselm refused to explain. He merely said, “Marsha, just try it.” I was shocked by the experience. If you talk when you pray, it is a dialogue with someone separate from you. But if you don’t talk, there is nothing separate from you. You are as one with God. If you keep it up, there is every chance that you will ultimately experience that oneness. It is hard to articulate what I mean, just as with love it is hard to articulate what we really, deeply mean. In this case, it means I am in the middle of God.

He had a schizophrenic brother, so there was a point of empathy. But it was much more profound than that. He loved me, in the purest sense, and I loved him. This is how Ted kept me alive.

Although Ted was fully and freely giving me what I needed, which was unconditional love and support, I was unable to say “Thank you.” I could say it later, but not as I was wrestling with such despair and loneliness. So, if you also are helping someone who is in hell, holding them physically and emotionally, don’t interpret their absence of thanks as a sign that you are not giving them what they desperately need. You very probably are. That’s the first lesson.

One of the worst moments is walking down the hall after a meeting or a session, and now you won’t see the person who is helping you for a whole week and you’re unbelievably alone.

The second lesson is about what it is like to have to say goodbye to someone when you are still in hell.

If you are with someone who is in hell, keep loving them, because in the end it will be transformative. They are like someone walking in a mist. They don’t see the mist, and you may not see it, either. They don’t see that they are getting wet. But if they have a pail for water, you put it out in the mist. Each moment of love adds to the mist, adds to the water in the pail. By itself, each moment of love may not be enough. But ultimately the pail fills and the person who has been in hell will be able to drink that water of love and be transformed. I know. I have been there. I have drunk from that pail.

I almost always got depressed when left alone. One way to alleviate the depression, which I continued to experience for many years, was to get involved doing volunteer work.

I love the organization’s motto: “Flowers before bread.” People need the special pleasures in life, in addition to the necessities. “Love, dignity and beauty in life are as essential to life as physical needs,” they assert. If I learned anything from my mother, I learned the value of beauty, and that the effort to bring beauty into any setting is worth the work it entails.

Mother Teresa had a beautiful phrase that captures some of this: “Kind words can be short and easy to speak, but their echoes are truly endless.”

Sister Thérèse had a vision, which she described in a letter in 1866: “I saw as in letters of gold this word Goodness, which I repeated for a long while with an indescribable sweetness. I saw it, I say, written on all creatures, animate and inanimate, rational or not, all bore this name of goodness.”

“When Marsha said ‘I love myself,’ it was a recognition and acceptance of her own goodness. A miracle of grace!

In graduate school, I asked other students to let me practice free association tests on them. I had a great time with this. I would sit down one-on-one with a student and say, “I am going to do a free association experiment with you. I will say a word and you say immediately what word comes to your mind. For instance, I might say ‘Dark,’ and you might say ‘Night.’ ” We would do this several times, a classic Freudian procedure. At the end of the test, I would tell the person something about himself or herself, and typically the person would say something like “You are so right! You are good. How do you do that?” It was a riot.

A behaviorist outlook is based on social learning theory, which is what its name implies: that much of an individual’s behavior is learned, through observing and mimicking others, rather than being driven by elusive inner forces or as mechanical responses to punishments or rewards.

The outcome was exactly what Bandura had predicted. The children who had witnessed an adult being aggressive toward the Bobo doll were themselves aggressive toward it, both in ways they had seen the adult behave and in inventive new ways, such as using the gun on the doll. Children in groups two and three were much less aggressive. Unlike the children in the first group, those in groups two and three had not witnessed any aggressive behavior toward the Bobo doll by the adults; they hadn’t learned that aggression was an expected and accepted behavior. Instead, they had seen the adults behave in a peaceful or neutral manner, and this is how the children subsequently behaved. This is the essence of social learning theory.

One of my heroes, the psychologist Carl Rogers, reportedly described the T-group as “the most significant social invention of the century.”

It’s something I try to inculcate in my clients: Never give up. It doesn’t matter how many times you fall; what’s important is that you always get up and try again.

If someone is threatening to kill themselves, you go talk with them and find a way for them to see that perhaps they don’t want to die after all. The lesson from that day was very simple but powerful: Never give up when you are trying to help your client. Never give up. I tell this story to my students to this day. It’s my mantra.

The behaviorist approach is yet another approach, also very different from psychiatry and psychoanalysis. It focuses on behavior, on what people do. And rather than change a disturbed person’s biology (psychiatry) or change his thoughts (psychoanalysis), the behavior therapist seeks to directly change what the person does, their behavior. In graduate school, as I’ve noted, I had fully embraced the ideas of Walter Mischel and Albert Bandura on social learning theory. Their idea is that much of behavior is learned from observation of other people’s behavior. This implies that behavior can be changed. (If behavior were innate, it would be much more difficult to change.) The work of behavior therapists, then, is to figure out which behaviors are causing problems in their clients’ lives, and then work to change them. Behavior therapy is therefore a form of psychotherapy that is based on a behaviorist approach.

Behavior therapy is the behaviorist’s tool to help people extinguish unwanted behaviors and ignite wanted behaviors.

There’s that old saying, “We study what pains us.”

Do not believe that he who seeks to comfort you lives untroubled among the simple and quiet words that sometimes do you good. His life has much difficulty and sadness….Were it otherwise he would never have been able to find those words.

I had a model that understood suicide as a cry for help—that suicidal people can’t get the help they need.

DEAR MAN stands for “describe, express, assert, reinforce, (stay) mindful, appear confident, negotiate.”

At Stony Brook, I readily absorbed the notion that people’s behaviors are quite heavily influenced by their cognition, their thinking. This implies that people’s problems might be in their thinking rather than in their behaviors. At Catholic, I came across the work of Arthur Staats, specifically his social behaviorism theory, which argues that cognition is just another form of behavior. Everything is behavior, and if you change one thing, you change everything—thinking, acting, everything. Everything is connected to everything else. Everything is one, which is very Zen-like, really. It had a big influence on me.

Staats’s theory says: Change your behavior and you will change your emotions. (Fear is an emotion.) When the facts say that what you are afraid of is not actually dangerous, the trick is to do just the opposite of your fear. Parents walk their child into the room; we get up our courage and assert ourselves with a person who is likely to respond well; you get back on the horse that is unlikely to throw you again. Sit in the room with the corpse to absorb the information that dead people don’t spontaneously rise up and your fear will go down.

(Opposite action is a change skill.) In opposite action, you force yourself to do the very thing you don’t want to do. Saying to yourself, “People do like me” or “I’m not fat” doesn’t really change how you feel. You have to act. I had a client whose problems mostly involved hating her own body. Telling her that her body was just fine didn’t help. I had to get her to act differently, to act as if she had a beautiful body. When she did, she carried herself in public with assumed poise and confidence, and she felt beautiful. It worked. It is like that mantra “Fake it till you make it.” It is also the equivalent of Aristotle’s notion that acting virtuous will make you virtuous.

Maybe you are afraid to go to parties because you think people will disapprove of you or even be hostile to you. So you don’t go. With opposite action, you force yourself to go to the party and be as present as you can. You don’t skulk in the corner and look no one in the eye or talk with no one. Nor do you have to try to be the heart and soul of the party. You do what you can. There is usually someone at a party who is happy to have small talk with you.

You can’t think yourself into new ways of acting; you can only act yourself into new ways of thinking.

chaplain in 1968. “The anti-war movement,

By now I was firmly in what psychologists call an intermittent reinforcement schedule, like a fish on a hook. It is the same psychological force that keeps people sitting in front of slot machines for hours on end, essentially addicted. If the machines paid out little reasonable sums of money fairly regularly, players would quickly get bored, but the possibility of a jackpot at any given moment keeps them hooked. It is also why people often stay in abusive relationships. “Maybe it will be different this time.” And it is why I relented with Ed and said, “Okay, come down.” Maybe it would be different this time. Maybe I’d hit the jackpot.

Earl hugged me, calmed me down until I stopped crying. Then he said something to me that I have never forgotten—so wise, and so soothing. He looked intently at me and said, “Marsha, you are really lucky, because you know that you are capable of loving someone else. You know you are capable of great love. And many people don’t know that about themselves.” That was so profound that I was able to let go of the agony that had gripped me.

And then I started a mantra to myself, one that I would likely give to a patient if one were in my boat: “Marsha, you must grieve, you must not avoid this, do not suppress this. You must cry. Do not stop it.” I was talking to myself as though there was me, who was grieving, and at the same time I was the therapist talking to me. “Don’t worry about this. Just cry as much as you need to—you will be okay,” and on and on.

This is what a behavior therapist does: to look at dysfunctional behaviors and look at functional behaviors, to reduce one and increase the other.”

At the core of DBT is the dynamic balance between opposing therapeutic goals: acceptance of oneself and one’s situation in life, on the one hand, and embracing change toward a better life, on the other. That is what “dialectics” means: the balance of opposites and the coming to a synthesis of two opposites.

DBT is a behavioral treatment program, not so much an individual psychotherapy approach.

The role of DBT skills is to give clients practical ways of, first, accepting the problems they have and then, second, solving the problems they have.

If you want to get out of hell, you have to get through the fire to the other side. It’s like you are in a house, and it’s on fire. There are flames all around, especially at the front of the house, surrounding the door that is the only way out. Your impulse is to retreat into the house, try to find someplace safe. But, of course, you will just die there. You’ve got to find the courage to go through the flames at the front of the house, the flames around the door. Then you can get to the other side. You have to go through your anger, open up to your therapist, keep going through the pain. It isn’t overnight that you are going to feel better. But you will.

Here are a few things Sister Florence says about silence: Only silence is deep enough to hold everything. Silence is the language of God. Listen.

“The first time you practice contemplation, you’ll only experience a darkness, like a cloud of unknowing,” writes the anonymous author of the book by that name, The Cloud of Unknowing. The book was published in the latter half of the fourteenth century, as a spiritual guide to contemplative prayer. It was a how-to book: how to unite your soul with God. This is the path. Saint John of the Cross, the sixteenth-century Spanish mystic and poet, talks about it, too, in Dark Night of the Soul. It is going into the path and not experiencing anything, but not worrying, because this is the spiritual path.

In The Cloud of Unknowing, the author writes, “We can’t think our way to God….He can be loved, but not thought.” It is all about being, not saying. That’s where I was, casting myself upon the oceans in a boat without a rudder, being willing to go wherever I would be taken. “Beat on that thick cloud of unknowing with the sharp arrow of longing and never stop loving, no matter what comes your way,” the author writes. That’s exactly it. It’s all about love. Life is all about love. Loving and being loved.

My recognition that living alone was bad for me had been very slow in coming. But when it did come, my active decision never to live alone again encapsulates another eventual DBT skill: namely, living an anti-depressant life. This simply means taking steps to include things in your life that make you smile, make you feel happy, and also taking steps to avoid, where possible, those things that cause you unhappiness and depression. I see it working with clients all the time.

It’s a useful exercise for anyone—make a mental list of those things that make you happy and those things that make you sad or depressed. Then act on it. I urge you to try it.

It is not denying that the addictive urge is upon you. Instead it is about adamantly convincing yourself that you want something other than the addictive behavior you are trying to quit. A dime instead of a cigarette. Do something that is a similar action. Convince yourself that you want something other than the urge you are experiencing. Adaptive denial is appropriate for any addiction—eating too much chocolate, for instance, or overdoing alcoholic drinks; I’m sure you can think of more examples. It can be very effective, as long as you don’t give up.

So what I am really afraid of is that the roof is going to come down, and a piece of metal is going to go through my wrist, pinning me down. No one will know I’m there. There will be a fire, and I am going to die. When I told this story to my clients, I asked them, “What skill am I going to turn to now?” They all got it: acceptance. So in my mind I start going into the tunnel, practicing being buried in pain, dying. And it worked—SUDS down to zero.

The “cope ahead” skill, then, involves figuring out which situations are likely to cause you trouble, cause you anxiety, and then planning ahead how to cope with the expected difficulties—but also imagining being in the situation and coping effectively.

I believe that I do not have a moral right to suicide. I am too well known, and too many people would be hurt if I did kill myself. I also believe that adults with the capacity to think clearly have a right to suicide. This excludes individuals who are in psychotic episodes. I believe I have a right to do everything I can, short of taking away someone’s freedom, to keep a person from suicide. This includes pounding on their door, calling their relatives, telling them I will tell others to not take care of their cats if they commit suicide, and so on.

“Love may have kept me alive, but it didn’t treat my suffering.”

It is beautifully outlined in The Cloud of Unknowing, which I mentioned earlier. One of my favorite pieces of advice from the book is this: “Go into the cloud of unknowing with a cloud of forgetting at your feet.” I also love the direction to “pick a word of one syllable and fasten this word to your heart so that it never goes away from you. This word will be your shield and your spear. With this word, beat on this cloud and this darkness and strike down all thought under the cloud of forgetting.”*1 Being truly present and spiritually open requires both perseverance and letting go.

In Zen they say, “Act compassionate and you will find that you’ve always been compassionate. Act enlightened and you will find that you’ve always been enlightened.”

Willingness is about opening yourself to what is. It is about becoming one with the universe, participating in it, doing what is needed in the moment. It is doing the dishes when needed, helping someone up who has fallen, letting go of battles you will never win and even some you could win. It is letting go of being right, even when you are right. It is when you do things you might not want to do, but you do them because they are needed. With willingness, you accept with grace what is happening. You could say it is throwing yourself into the will of God, or into acceptance of the causal factors of the universe. It is giving up tantrums. “Willingness,” says Gerald May, “is saying yes to the mystery of being alive in each moment.”

The opposite of willingness is willfulness. With willfulness, the focus is on controlling reality, it is “my way or the highway,” it is about being right. It is a battle with reality, and that consumes emotional energy and gets you nowhere. Willfulness is doing the opposite of what is needed.

After it was all over, I had to figure out why opposite action had not worked. I realized that you can’t treat willfulness with willfulness (commanding it to get down like a dog, my saying, “Down, willfulness! Down, willfulness!”). Then I thought, “What am I afraid of here?” It was that they could take away my academic freedom, and that is my highest value. The minute I realized that, I thought, “Oh, no, they can’t take that away from me. They can take space away from me, but they can’t take academic freedom away from me, because I have tenure.” I calmed down. It worked out.

In other words, your feelings sculpt your overall posture. That is the power of mind over body. Research shows that the reverse is also true—that if you adopt the posture of anger or happiness, you have a tendency to experience that same feeling. The power of body over mind.

I tell my clients that half-smiling is a way of accepting reality with your body. For instance, if you half-smile when you are thinking about someone you dislike, it helps you feel more accepting of that person, more understanding. Sounds hard to believe, but it is true.

There is the domain of experience, and there is the domain of articulation. Science is the domain of articulating with words. Spirituality is the domain of experiencing.

Proceed Mindfully: Ask yourself, “What do I want from this situation? What are my goals? What choice might make this situation better or worse?”

When you feel that your emotions are about to take control, stop! Don’t react. Don’t move a muscle! Just freeze! It can help prevent you from doing what your emotion wants you to do—to act without thinking. Stay in control. Remember: you are the boss of your emotions. Or at least you can become the boss.

Throughout the development of DBT, I had to be prepared to go where my clients wanted to go. At other times, I had to guide them where I wanted them to go. It required a spaciousness of mind, dancing with what I call “movement, speed, and flow.” Both the client and the therapist are moving forward into a new place, smoothly and quickly. It became a mantra for us. Knowing when to push. Knowing when to support. Going back and forth, an organic and loosely scripted flow. It’s not easy to explain this process.

The therapist needs to be compassionate without getting drawn into the horrors of her client’s current crisis. In addition, clients are free to call their therapist at any time of day or night. Again, the therapist has to be compassionate, but completely focused on directing the client to the DBT skills that are relevant to the current crisis. DBT practitioners have to be willing to reveal themselves to some degree. It’s not surprising, then, that there is a high burnout rate among DBT practitioners. Many therapists have to move on to other avenues of work after three years or so.

Being irreverent is saying the unexpected. Research shows that unexpected information is processed more deeply than expected information.

Most people are very serious when they talk about suicide. It is a serious matter, of course. But being serious all the time is not the answer. The occasional irreverent statement, spoken with humor, warmth, and support, can be an effective tool.

Dialectics is the process of seeking the truth in the moment, drawing on a synthesis of opposites.

Many of us tend to see reality in polarized categories of “either/or” rather than “all” or “this and that.” We are often stuck in either the thesis or the antithesis, unable to move toward synthesis. An inability to believe in both of these propositions: “I want to be with you, and I want time alone.” Or, “You forgot to pick me up at the ferry, and you still love me.” Or, “I want to finish this chapter before I go home, and I want to go home and stop working right now.” All of us face this. It is the inability to ask, “What am I leaving out here?” and “Where am I being extreme?” that gets us into trouble.

The therapist must help find the syntheses of opposites, to look for what is being left out. I have spent many a session saying to myself, “Look for the synthesis. What am I missing?” A patient wants to go to the hospital. I don’t want him in the hospital. A battle ensues. What is the dialectic? The patient thinks he is likely to commit suicide if he doesn’t get in the hospital (a point I completely fail to understand); I believe he is likely to commit suicide if he goes into the hospital (a point the client completely disagrees with). What is the synthesis? We have to find a way for him to be safe either way. We have a problem to solve.

“If we can find a way to get your life to be experienced as worth living, would you be willing to work on finding that?”

“If we could find a way to solve the same problems that are upsetting you without self-injury, would you be willing to make the switch?”

“You are miserable and want to die; I can understand how you feel, how painful your life is at times and how hard it is to stay alive. On the other hand, I can also imagine the tragedy of your dying by suicide. I know you often think no one cares, but I am pretty sure you know that I care, that your cat cares, and, if you really think about it, that your parent cares. I totally believe that you can build a life that you will view as worth living. Even in your tears, you have to believe whether you believe or not, letting go of disbelief, holding on to hope.”

In the 1980s, psychoanalysts insisted that it was vital for the patient’s psychological well-being to keep therapy very stable. The room had to be the same for every session, everything in the same place. I said, “Absolutely not. We will not do this.” Our task is to help clients feel comfortable in all environments. We all need to learn to live with change. Switching the room up was one small way to help.

(I eventually learned that when it comes to spirituality, the more you actively want it, the less likely it is to happen. You have to throw yourself into your life as it is, and be open to whatever might be. That is acceptance

“If you go down a road once, and it is the wrong road, you cannot go down that same road again, because it will still be the wrong road”—was an example of radical acceptance, which, until that point, I had failed to follow. The same thing happens when you’ve mislaid your keys and you go looking for them. You look in all the obvious places. You don’t find them. You start looking in less obvious places. You still don’t find them. Then you check the obvious places again. No luck. You have to accept the fact that once you’ve checked the obvious places and not found your keys, looking again in those places is a waste of time, because they still won’t be there. We’ve all been guilty of this one, I should think.

Acceptance is acknowledging or recognizing facts that are true, and letting go of fighting your reality (and of throwing tantrums). Radical acceptance is accepting all the way, with your mind, your heart, and your body—accepting something from the depths of your soul, opening yourself to fully experiencing reality as it is in this one moment.

You have to accept reality in order to change it. Reality is what it is. If you don’t like it, you can change it. The following are the six key pointers about radical acceptance: Freedom from suffering requires acceptance from deep within of what is. Let yourself go completely with what is. Let go of fighting reality. Acceptance is the only way out of hell. Pain creates suffering only when you refuse to accept the pain. Deciding to tolerate the moment is acceptance. Acceptance is knowledge of what is. To accept something is not the same as judging it as being good.

If you’re a tulip, don’t try to be a rose. Go find a tulip garden.

The music we use is “Nada Te Turbe,” a beautiful, soulful, meaningful piece that translates to “Let Nothing Disturb You.” Later, in Chapter 36, you will learn about its meaning. When I have groups of therapists together, I get them to dance, too. For this one we use “The Shepherd’s Song,” which has a strong beat and is easy to dance to. Everyone calls it “the DBT dance.”

I was ruminating all the time, the way depressed people do, ruminating, worrying, feeling guilty, feeling bad, being self-critical. All of a sudden I felt, “Wait a minute. I don’t have to turn this damn soap opera on. This whole thing is meaningless.” I had such a sense of freedom. At this time, I was still searching for the experience I’d had in the Cenacle chapel. But I realized I had to let go. I knew I had to let go of that, let go of God.

I had no idea what I was crying about, because I didn’t connect it at all to my mother. I am still not sure it was about my mother. Willigis just looked at me and said, “Keep going,” and rang his bell, and out I went. His position was “It didn’t have to have meaning. You didn’t have to think about it. You didn’t have to do something about it. Everything is what it is.”

Alas, I missed this particular point a lot of the time. When I did, Willigis would say to me, “Marsha, it’s just this,” and then he would make a gesture as if he were holding and playing a violin, and say, “It’s just this, nothing else, just this.”

I said, “Pat, you are a Zen master. Aren’t you joyful all the time?” He responded, “Marsha, wouldn’t you rather have the freedom to not have to have what you want, whatever it is? Wouldn’t you feel better if you were free not to have to have all the things you think you want?” Pat was right. We are better off accepting what life has to offer, rather than living under the tyranny of having to have things we don’t yet have. This is not to say that we are to be completely passive—not at all. It means that we should strive for important goals, but we must radically accept that we might not obtain them. It is letting go of having to have. And accepting what is.

Psychologists have long recognized that each of us possesses two opposing states of mind: “reasonable mind” and “emotion mind.”

The opposite of dysfunctional behavior is not wisdom; it is functional behavior.

To be beautiful means to be yourself. You don’t need to be accepted by others. You need to accept yourself.

Saying to the therapist “Be mindful” is saying, “Be aware, lock into the session, focus on your client, don’t be planning dinner or thinking about the last session you had.”

For the client, the idea is that we often don’t experience the moment we are in, because we are focusing on something different from the moment. Teaching clients mindfulness skills will lead to other behavior changes that help clients function more effectively in the world. Teaching clients to be effective is the goal of much of DBT.

The other part of my theory is that one of the toughest challenges borderline individuals face is regulating their emotions. They are quick to become very emotional in response to some trigger in their environment, and slow to come back down. Emotion dysregulation is known to have a strong biological component, probably including a genetic one. I came to the conclusion that borderline individuals have biologically based emotion dysregulation, and have been and often still are exposed to an invalidating environment. People who have a tendency toward emotion dysregulation will have problems in an invalidating environment but will fare quite well in a validating environment. I call that the biosocial theory of borderline personality disorder.

Do not believe that he who seeks to comfort you lives untroubled among the simple and quiet words that sometimes do you good. His life has much difficulty and sadness….Were it otherwise he would never have been able to find those words.

Let nothing disturb you, Let nothing frighten you, All things pass away: God never changes. Patience obtains all things. He who has God Finds he lacks nothing; God alone suffices.

That’s how I ended the gathering with the former DBT clients, that morning at the institute. All of us in a circle, one step to the left, two to the right, moving slowly, bodies swaying slightly, tears falling down many cheeks. Including mine.

REASONS FOR LIVING INVENTORY BY SUBSCALE* SURVIVAL AND COPING BELIEFS I care enough about myself to live. I believe I can find other solutions to solve my problems. I still have many things left to do. I have hope that things will improve and the future will be happier. I have the courage to face life. I want to experience all that life has to offer and there are many experiences I haven’t had yet which I want to have. I believe everything has a way of working out for the best. I believe I can find a purpose in life, a reason to live. I have a love of life. No matter how badly I feel, I know that it will not last. Life is too beautiful and precious to end it. I am happy and content with my life. I am curious about what will happen in the future. I see no reason to hurry death along. I believe I can learn to adjust or cope with my problems. I believe that killing myself would not really accomplish or solve anything. I have a desire to live. I am too stable to kill myself. I have future plans I am looking forward to carrying out. I do not believe that things get miserable or hopeless enough that I would rather be dead. I do not want to die. Life is all we have and is better than nothing. I believe I have control over my life and destiny. RESPONSIBILITY TO FAMILY It would hurt my family too much. I would not want my family to feel guilty afterwards. I would not want my family to think I was selfish or a coward. My family depends on me and needs me. I love and enjoy my family too much and could not leave them. My family might believe I did not love them. I have a responsibility and commitment to my family. CHILD-RELATED CONCERNS The effect on my children would be harmful. It would not be fair to leave the children for others to take care of. I want to watch the children as they grow. FEAR OF SUICIDE I am afraid of the actual “act” of killing myself (the pain, blood, violence). I am a coward and do not have the guts to do it. I am so inept that my method would not work. I am afraid that my method of killing myself would fail. I am afraid of the unknown. I am afraid of death. I could not decide where, when, and how to do it. FEAR OF SOCIAL DISAPPROVAL Other people would think I am weak and selfish. I would not want people to think that I did not have control over my life. I am concerned about what others would think of me. MORAL OBJECTIONS My religious beliefs forbid it. I believe only God has the right to end life. I consider it morally wrong. I am afraid of going to hell.