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Linehan, who grew up in Tulsa, Okla., and spent several years as a nun before becoming a psychologist, embodies several dialectical contradictions: a nun who has never lived in a convent; a careful scientist whose most engaging feature is her wry irreverence; a 65-year-old who has a maternal steeliness but was never a mother. It doesn't pay to underestimate Marsha Linehan. In Cognitive-Behavioral Therapy for Borderline Personality Disorder, she writes, "If the patient says, 'I am going to kill myself,' the therapist might reply, 'I thought you agreed not to drop out of therapy.' "
In one intense session a few years ago, a patient told Linehan that her work stress was going to lead her to suicide. The patient said Linehan could never understand this stress because she was a successful psychologist. Suicidal borderline patients often confront and alienate therapists in this fashion; for many years, this kind of confrontation was seen as a defining characteristic of the disorder. Linehan believes that borderlines are hurting, not manipulating, but that doesn't mean she indulges them. In this particular confrontation, Linehan responded, "I do understand. I live with a similar amount of stress ... You can just imagine how stressful it is for me to have a patient constantly threatening to kill herself. Both of us have to worry about being fired!"
Such in-your-face tactics were highly controversial when Linehan started out. Other mental-health professionals accused her in public meetings of being heartless, even unethical. But her therapy has saved so many lives and worked so well in randomized trials that few criticize her today. For Lily, who calls Linehan's therapy "Zen philosophy meets tough love," Linehan was the first therapist to understand that managing Lily's illness would require Lily to take a new kind of responsibility — a willingness to grow the emotional skin she never had.
In the beginning, Lily resisted Linehan's assistance. She felt no one could truly understand the depths of her pain. But Linehan was the first therapist who responded to Lily with more than just endless psychoanalysis and pills. Instead, Linehan taught her practical methods of getting by day-to-day. Once, just after she started with Linehan, Lily locked herself in her parents' bathroom and swallowed six or seven antidepressants in a half-hearted suicide attempt. Her father broke the door down; her mother called the police. Lily never lost consciousness, but the cops said she had to go to the hospital anyway. Linehan advised Lily's parents not to accompany her. She also told them they needed to get Lily to work the next day. Lily learned that she wouldn't be cosseted.
Linehan also taught Lily various skills to regulate her emotions. Among the most important is one Linehan calls the "wise mind" — a kind of calm, Zen state that Linehan insists even the most debilitated patients can achieve. "Generally," she writes, "I have patients follow their breath ... and try to let their focus settle into their physical center, at the bottom of their inhalation. That very centered point is wise mind." Lily remembers this sensation clearly; she came to feel that her dark moods had a physical location in her body — her solar plexus — and when she focused on it, she could deactivate a destructive emotion.