When Marsha Linehan was seventeen, she developed terrible headaches. The family doctor didn’t seem to know what was causing them, so Linehan saw a psychiatrist, who recommended a two-week inpatient “diagnostic evaluation” at the Institute of Living, a private mental hospital in Hartford, Connecticut. A few days later she was cutting herself with the smashed lenses of her glasses. The staff psychiatrists moved her to a ward for “the most disturbed patients” where nurses stripped her naked, wrapped her in frozen wet sheets, and strapped her to a bed for hours. She had been class council secretary, and a committed member of the Young Christian Students society. Now, in between sessions of nonconsensual electroconvulsive therapy, she was diving off her bed to try to smash her skull.
The story, remarkably, has a happy ending. In 1963, two years after being committed, Linehan was discharged from the Institute of Living. She went to college and got a PhD in clinical psychology, and, in 1993, she published the blueprint for a new therapeutic modality she called dialectical behavior therapy (DBT), designed with her younger self in mind. Linehan kept her adolescent experience secret until 2011, by which point it was a newsworthy revelation in therapy-world. “I suppose it’s true that I developed a therapy that provides the things I needed for so many years and never got,” Linehan told The New York Times that year.
Linehan largely does not remember her crisis, but she has come to understand it as the result of what she eventually termed a “skills deficit” — she hadn’t learned how to survive life. “More than sessions with a compassionate psychiatrist, I needed skills,” she wrote in her 2020 memoir, Building a Life Worth Living. Linehan felt that psychoanalysis, then the most influential theoretical framework in clinical psychology, was unscientific: processing her past with the Institute’s psychoanalysts had not helped her change her present behavior and, in concert with a copious drug regimen, “may have made me worse, too.”
Today, DBT is considered the “gold standard for treatment” of clients at especially high risk of suicide. (DBT avoids the word “patient.”) A 2019 meta-analysis of eighteen empirical studies suggested that, when compared to control treatments, DBT offers a small to moderate decrease in the frequency of self-directed violence and use of psychiatric crisis services. If there were a war on mental illness, DBT therapists would be the Navy SEALs. They confront clients’ distress with the heavy artillery, utilizing a carefully calibrated tactical protocol designed to rescue people from suicidal ideation and deliver them to a “life worth living,” as Linehan titled her memoir. In the classical formulation of DBT, practitioners deploy the combined forces of one-on-one therapy, round-the-clock availability, and weekly skills groups in which clients complete six-month syllabi of worksheets and activities, often several times over.
In recent years, DBT has left the therapist’s office. A team of psychologists introduced a program in 2016 for “expanding DBT Skills delivery from clinical to school-based settings.” Their manual, intended for middle- and high-school-aged students regardless of whether they’ve been diagnosed with psychological problems, has since sold over 39,000 copies. Over the past five years, social workers and education researchers have combated workplace burnout in nurses and teachers with DBT-informed interventions involving hour-long weekly trainings in mindfulness. In 2023, the state of Connecticut spent millions on prison mental health programs with a particular emphasis on DBT. Popular culture has caught on: both Lady Gaga and Selena Gomez have publicly expressed gratitude for their time in DBT; longevity guru Peter Attia did a podcast episode on DBT skills; neuroscientist Andrew Huberman has shared viral “protocols” for emotional wellbeing. Inspired directly or indirectly by DBT’s collection of “Emotional Regulation Skills,” wellness influencers, self-help media, public-facing therapists, and even Jordan Peterson have offered their own toolkits for correcting “dysregulation” — as if we manage our feelings in the same way our bodies regulate heat. Today, you can hone these abilities with a deck of DBT cards featuring “52 Practices to Balance Your Emotions Every Day” or on apps like Ahead, which boasts the tagline “Duolingo, but for anger.”
DBT is therapy for a world that makes the false promise to give way if you’re just good enough at living. These days, it seems commonly accepted that feeling good is in large part a matter of being good at life. Your happiness is determined by your ability to handle your circumstances skillfully. But when Linehan invented DBT, the idea of directly teaching emotional regulation skills was a novelty in therapy. In the first part of the twentieth century, “skills” left the workshop and factory and moved into the C-suite and boardroom, where the ability to manage others’ emotions became known as “leadership skills.” In the ’90s, DBT brought skills out of the workplace and into the most high-risk regions of mental health, developing formulas that have come to define popular conceptions of wellbeing. If you are a skilled manager of your own mind, your feelings will not go on strike.
In the wake of World War I, early management scientists associated with the “human relations” movement at Harvard Business School began to apply the language of “skills” to interpersonal encounters. As Elton Mayo, a key figure in the team, saw it, workers were blaming their employers for workplace discontent. In his view, their real antagonist was the loneliness of life in the industrialized modern city, which exacerbated the alienation they felt at work. If management cultivated community feeling in the workplace, the logic went, workers would stop demanding power. Soon, manipulating workers — and preventing collective action — began to be seen as a matter of skill. “Management should introduce in its organization an explicit skill of diagnosing human situations,” advised Fritz Roethlisberger and William J. Dickson in their 1939 volume Management and the Worker. Executives gained a way to describe their own social abilities as profitable commodities. Businessmen weren’t merely flaunting social graces or providing care — what their wives did at home — but demonstrating serious expertise.
While “skill” once primarily denoted technical ability in a particular craft, the word took on an increasingly abstract meaning as the U.S. deindustrialized in the 1970s. By the 1980s, the category had “expanded almost exponentially to include a veritable galaxy of ‘soft,’ ‘generic,’ ‘transferable,’ ‘social’ and ‘interactional’ skills, frequently indistinguishable from personal characteristics,” as employment studies researcher Jonathan Payne put it. The language of “skill” could be slapped onto any capacity an organization considered necessary. As labor became more flexible and jobs less secure, workers had to become their own managers, eking out a living from serial opportunities. As sociologists Luc Boltanski and Eve Chiapello write, the concept of skills allowed workers to “equip themselves with a stock of qualifications” that could be developed like a “portfolio.” These vacuous new skills (leadership, communication, attention to detail) offered an illusion of security: employees could make themselves into Swiss Army knives, with the tools to adapt to any new task or role.
Psychotherapy soon fell under the sway of the imperative to be a skilled manager of oneself, regardless of whether one was a manager at work. As the psychiatry professor Aaron Beck had come to see it in the 1960s, depression was a result of misapprehending reality — feeling bad came from thinking bad thoughts. The cure was logic; the therapist was there to help you revise your bad thoughts into better thoughts. In this model, which became cognitive behavioral therapy (CBT), depression was a finite problem in need of rational solution. With the right oversight, sorrow could be managed away.
Today CBT is often described as the dominant paradigm of therapy. It holds that “mental disorders are thinking disorders; how we think shapes our moods,” writes historian Rachael Rosner. “Teach patients to evaluate and restructure their thinking and their moods will improve.” Behavioral therapies like CBT and DBT contrast sharply with more traditional therapies informed by Freud’s theories. Those older “psychodynamic” methods focus on interpreting clients’ pasts in order to understand the unconscious patterns that structure their emotions, thoughts, and desires. The aim of psychodynamic therapy is to understand what cannot be directly perceived or controlled so as to find a little psychic wiggle room within these invisible scripts, to make the mind feel like a space of possibility. Behavioral therapies instead emphasize measurable outcomes and aim to modify clients’ observable conduct directly. In CBT, the client completes worksheets that prompt answers to questions like “What could happen if I changed my thinking?” and “How much do I believe the thought(s)?” Clients might assign percentages to their anxiety levels on an “exposure monitor,” or list and label each bad thought as one of a dozen or so types of cognitive distortion: “Tunnel Vision,” or seeing only what’s wrong; “Mind Reading,” believing you know what others are thinking; “Mental Filter,” missing the forest for the trees; and so on. At different points in treatment, you fill out an inventory ranking the quality of your sleep, your appetite, and your mood on a scale from zero to three.
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