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.

While psychodynamic therapy requires costly hours of expert attention, CBT is a “mostly self-guided therapeutic regime in which the patient is responsible for their own psychological growth,” as Hannah Zeavin put it — it is flexible and ripe for automation. By contrast, DBT is extremely time-intensive and involves pods of practitioners willing to take clients’ calls after hours; because insurance does not usually pay DBT therapists enough to cover all this labor, many providers don’t take insurance. Most DBT that is covered by insurance is not certified by the Linehan Board of Certification, meaning that it does not strictly adhere to Linehan’s standard protocols.

While early CBT sought to help clients develop abstract capacities such as “problem solving,” DBT transformed those generic abilities into highly specific skills for handling emotions. DBT offers a menagerie of cute mnemonic devices, putting acronyms under strain to package its life advice. “TIP” skills calm your body down by using, in turn, Temperature, Intense exercise, Paced breathing, and Paired muscle relaxation (a secret bonus “P”). “ABC PLEASE” skills encourage general day-to-day physical wellbeing (Accumulate positive emotions, Build mastery, Cope ahead; treat PhysicaL illness, balance Eating, avoid mood-Altering substances, balance Sleep, get Exercise). “STOP” skills (Stop, Take a step back, Observe, Proceed mindfully) slow you down when you’re feeling impulsive. To tolerate acute distress, “ACCEPTS” skills (Activities, Contributing, Comparisons, Emotions, Postponing, Thoughts, and Sensations) will help you distract yourself. Alternatively, you might “IMPROVE the Moment,” making use of Imagery, Meaning, Prayer, Relaxing actions, One thing in the moment, Vacation, and Encouragement.

Whether at work or in the therapist’s office, behind skills-based thinking lies a fantasy of autonomy. In 1994, the guru Ram Dass gave a dharma talk in which he discussed his approach to facing social turmoil and global chaos. “You and I are in training to find a place in ourselves and in the way we live our lives where we are not so dependent on the forms of existence that we freak when it changes, that we freak in the presence even of increasing chaos,” he told his followers. For Dass, those who could stay calm in a crisis would be best equipped to help the world heal. Adapting and twisting this attitude of acceptance into apolitical, everyday “effectiveness,” DBT skills promise to help you unplug from the world when things get unbearable. I will be fine if I lose my job; I will survive if the people I need leave me. My emotional regulation skills will insulate me from economic precarity, climate crisis, illness, war. Skills are the psychic equivalent of a parachute — or an apocalypse bunker.

Though she began her career as a CBT practitioner, Linehan encountered a problem. If you pushed clients to change too aggressively, she found, they lashed out. If you affirmed your clients’ feelings, however, they stayed just as miserable. You had to somehow convince clients they were good, relatable people who nonetheless needed to fix their behavior immediately. Struggling to articulate this contradiction, Linehan learned the term “dialectic” from an assistant whose husband was a Marxist philosopher. She remembers that she “called the philosophy department and said, ‘Can you send someone over here to teach me and my students about dialectics?’” A dialectic, she was excited to discover, is a dynamic relation between two ideas that seemingly cannot both be true — antithetical positions that offer some flash of insight when you hold them together. DBT literature rarely mentions the concept’s association with Marx, let alone with Hegel, from whom Marx adapted it. But, in the spirit of dialectics, DBT’s vocabulary is subtly designed to hold together the contradiction between the need for self-acceptance and the need for change. 

By teaching “skills,” you aren’t modifying people’s personalities, but rather equipping them to change their “behavior.” Linehan writes, “the focus of the treatment is to help clients replace negative behaviors, such as anger and aggression toward others, with positive behaviors, including acceptance and the understanding that there is no good or bad.” The vocabulary implies that people are not intrinsically flawed — they just haven’t been given the right tools. “You don’t have good skills,” she wrote, apostrophizing a hypothetical client. “I will teach you good skills.”

The dialectic between acceptance and change shapes every element of DBT. The therapist learns to dance between offering “validation” (for acceptance) and deploying “irreverence” (for change). In one transcript published by Linehan, the therapist outright tells the client, “That is bullshit,” after the client refuses to say the words “I’m angry!” While berating people who are hurting seems counterproductive, if you do it right, the sense of irreverence is meant to keep the client slightly “off balance”; it reminds them that they will have to “do the work.” As Linehan explains, “It is, literally, a program of self-improvement.” The dialectic, in the German philosophical tradition, is ultimately a theory of historical change: a contradiction between two historical conditions mutates into a new condition. DBT’s unstated premise is that people change in the same way the world changes: an internal tension propels a person into a new mode of life.

Individual therapy in DBT largely consists of a protocol called “chain analysis,” in which a therapist coolly marches a client through the precise sequence of thoughts and feelings that led up to an incident of negative behavior. Chain analysis aims to teach the client to recognize such patterns in the future and use new skills to stop them. The process can feel humiliating and therefore act, in the words of one 2006 journal article, “as a punisher for engaging in target behaviors.” In between chain analyses, the therapist provisions warmth and understanding in a thoughtful choreography of carrots and sticks.

While psychoanalysis had focused on making sense of the relationship between a patient’s present experience and life history, behavioral therapies like CBT and DBT eliminated “unobservable” concepts like the Oedipus complex, the death drive, and the id itself — going Marie Kondo on the unconscious in the name of empiricism. In DBT, everything besides present behavior just gets in the way. Linehan’s manual emphasizes the influence of trauma on clients, but even so, practitioners are trained to respond to biography as if it’s a distraction. “When the patient responds to anxiety-provoking topics by diverging into (and persisting in) discussion of another irrelevant trauma or ‘soap opera,’” Linehan writes, “the therapist may say, ‘Do you want help with your real problems or not?’ or ‘Oh, no! Another soap opera.’” A life history is a comfort object that, from this perspective, tends to become a crutch: you build a conception of yourself as a person whose problems can be explained with the recitation of several memorized lines about your childhood. Linehan believes people grip stories about their pasts too tightly and become so attached to narratives about their suffering that they cannot deviate from these plots. They wield their biographies like talismans to ward off blame, offloading responsibility onto others for a skill deficiency that behavioral therapy can fix.

Linehan sees interpretation as an impractical strategy in an acute crisis. She accuses psychoanalysis of putting the cart before the horse. It’s a chicken-and-egg debate: according to Freud, you need to interpret your emotions in order to regulate them; Linehan says you need to regulate your emotions before you can interpret them. “It’s like you are in a house, and it’s on fire,” she writes. Trying to understand why you are in a burning building is not the right approach to being in a burning building. Later, when the fire is out, you can ask why the infrastructure is fire-prone. But when someone says “Get me out,” you need a good hose.

To devise the set of skills that became the focus of DBT, Linehan pored over sources ranging from behavioral therapy manuals to the writings of Buddhist monk Thích Nhất Hạnh, broke down scientific findings and belief systems into principles, and repackaged those principles as instructions. In her eyes, Zen and mindfulness could prop up the “acceptance” side of DBT’s dialectic better than any product of Western science, but spiritual practices needed to be “translated” into “several discrete behavioral skills.” The emphasis is always “on being effective in one’s life.” Becoming effective makes life more than merely bearable: DBT, which ideally lasts around a year, culminates in a final stage of therapy “designed to increase a sense of completeness, to find joy, and/or achieve transcendence.” Acronyms start to feel somewhat insufficient for these aims. Linehan admits that “insight-oriented psychotherapy,” “spiritual traditions,” and “life experiences” may be of help here.

At face value, the skills are patronizing — the psychic equivalent of cutting up someone’s food for them. Even so, for many the skill set is a life raft, “something to hold on to,” as one former client put it to me. I feel the acronyms’ appeal: they make you believe you can get outside your personality, hold it at arm’s length, and fix it. Having a catchphrase ready to hand can make you feel less alone in the face of a bad habit, less reliant on your meager reserves of willpower. The same former client told me the skills help them “veer away from the obsessive, ruminating patterns that so often lead to sadness and a kind of torment.”

Unfortunately the acronyms don’t always work, as a case study from the early days of DBT shows. Linehan and her colleague, Elizabeth Dexter-Mazza, refer to the client as Cindy. At 27, she was a high-functioning medical student; by thirty, she had been hospitalized for psychiatric reasons on ten separate occasions. After Cindy spent several months in therapy, her husband, fed up with her continued crises, left her. Following another three-month hospitalization, Cindy returned to DBT with Linehan, determined to get him back. The treatment seemed to help, for a time: her symptoms subsided, and she restarted medical school. Fourteen months into therapy, Cindy learned her ex-husband was dating someone else. Unable to imagine a future for herself, she died by suicide.

“In this case, DBT failed,” Linehan and her colleagues wrote. They blamed human error: the individual therapist, who happened to be Linehan herself, had not noticed that “each previous near-lethal attempt was a result of the client’s believing that the relationship with her husband had irrevocably ended.” They stopped short of admitting that the method itself had a flaw: DBT could not help Cindy to rework her self-understanding in the face of her husband’s departure. It could not appreciate the irreplaceable psychic significance of particular relationships in clients’ lives, and so it could not help her disentangle her self-image from his care for her.

Most people I spend time with — leftists prone to anxiety and depression — are skeptical of “self-improvement.” Many of us, following the critic Mark Fisher, think that depression reflects an encounter with the harshness of reality, rather than a merely pathological distortion. We definitely want to feel better, but we don’t want to be hijacked by acronyms or worksheets or positive thinking in the process. We try to attribute suffering to crappy world systems rather than personal deficiencies. We find ways to trust that our negative emotions signify something other than our own inadequacy — that they contain a deeply rational response to the world’s irrational injustice. If we can uncover that deeper nugget of rationality, we believe, it might even reveal strategic weaknesses in the slick machinery of capitalism. Left uninterpreted, our feelings grease its gears: as the theorist Paolo Virno suggests, anxiety and insecurity ensure people keep striving to get ahead.

Another scholar, Mikkel Krause Frantzen, writes, “Before we can throw bricks through windows, we need to be able to get out of bed.” If you cannot get out of bed, DBT has clear advantages as a stopgap measure. It makes sense that therapists encourage clients at a certain threshold of desperation to stop trying to make sense of their pasts, stop dwelling on the broken world, and develop the skills to hold it at bay so that they might feel better. If I were unable to get out of bed, I would want DBT, despite it all. 

At the same time, I hope DBT wouldn’t condition me to disentangle my emotional wellbeing from the fates of others, helping me to ACCEPT the world as it is. To be fair, I don’t think any therapy is effective enough to make a person lose their politics: DBT’s good fire safety protocols are meager consolation if the flames are spread by wildfires on a planet wrecked by the cult of economic growth. Even so, in the face of ecological breakdown, it is easy to get hooked on the dream of needing only your own mental resources.

According to Rebecca Donaldson, a PhD student in psychology and former DBT client, the treatment’s mindfulness skills are “sugarcoating” that hides a heavily engineered process of behavioral modification. In 2021, after leaving DBT early in treatment, Donaldson founded a Facebook group called “Stop Dialectical Behavior Therapy.” The group’s 1,300 members are highly active and heavily moderated; they share grievances, claiming DBT added fresh trauma to the old trauma it failed to heal. A few users constantly post screenshots of peer-reviewed articles, particularly Linehan’s papers from the early ’90s, where she describes, in scientific prose, tactics for “punishing” noncompliant clients by withdrawing warmth. Members say skills training reduces therapy to mere procedure, that it can feel manipulative, uncompassionate, and infantilizing. They allege that DBT actively remolds outward behavior while failing to address clients’ internal states, thereby encouraging clients to lie. If you have a history of being committed against your will, the logic goes, you tell therapists whatever you think they want to hear — you behave like a mediocre middle manager of your own unconscious, assuring higher-ups that your employees are under control while they’re all quiet quitting due to terrible work conditions.

As the analogies suggest, DBT and workplace management are symbiotic. Though she doesn’t seem to know it, Linehan’s adoption of skills is a side effect of changing labor practices; in turn, by reskilling burnt-out clients, DBT readies them for the strain of flexibilized, gigified labor. Behavioral therapy is often accused of making discontents into docile workers — in the DBT homework sharebacks, as in the CBT worksheets, critics detect the hint of a cold imperative to get a grip, to stop suffering so you can get back to work. The implication is that if you are hurting, it is your fault for not managing your feelings properly. Of course, DBT practitioners are the first to say that changing yourself is hell, acronyms or no acronyms. Therapists should “never believe that a person chooses to be miserable,” writes Linehan.

Nonetheless, a few Facebook group members narrate refusing to change as a form of resistance. In brutally unfair circumstances, the weight of personal responsibility can be so hard to bear that it becomes easier to claim you are choosing your suffering than to admit you are unable to fix it. People often share a manifesto called the “Emotional Distress Bill of Rights” (subtitled “#RightToBeSuffering”). “I should not be held so personally responsible to take actions to be better,” it says. “Others (and systems) should be held far more accountable for better treatment of me.” There’s a grain of truth here: in an ideal world, someone else should take care of me when I can’t take care of myself, and vice versa. The trouble is that everyone else is living in an inadequate world, too. You are probably not equipped to alleviate my distress, especially when those inadequate “systems,” which are probably a key cause of my distress, are not supporting you either.

In teaching us to be better managers of ourselves, DBT joins the tradition of therapies that deliver the logic of workplace exploitation to every nook and cranny of human experience. As DBT becomes adaptable intellectual property, filtering into schools and prisons and workplaces in the form of skills, that logic seeps into the groundwater. The skills in DBT can feel remedial, like things we should have learned in some nonexistent orientation to being human. In the past, learning how to gracefully deal with feelings has only really been addressed when someone fails spectacularly at it. One worries that if DBT spreads out through the culture, more people will be equipped with the skills to feel better, but they may also learn to see themselves as operators of the faulty emotion processor we call the mind, and to believe that wellbeing is a matter of personal competence rather than collective care.

When the illusion of control falls short, DBT’s ethic of present-tense thinking and skilled self-reliance is met with an equal and opposite reaction: a culture fixated on the trauma plot, where people hold tightly to their stories as evidence that their lives aren’t their fault. Now that a logic of skillful self-management has become synonymous with mental health, people are left with two bad options: externalize the problem, molding it into a carefully crafted story about other people’s misbehavior so people will stop yelling at you to get a grip; or internalize it and commit to ceaseless skill acquisition in the hopes of someday needing nothing. DBT and its critics represent opposite sides within an often contradictory mainstream mental wellness culture ensnared in yet another dialectic — one that holds that you are defined by your trauma, yet accountable for your woes.

We can add this dialectic to our list: your pain is your responsibility; your pain is not your fault. You are good; you need to change. Fight the terms of capitalism and ableism; capitulate to them when you need to. DBT is a palliative that makes people into docile workers and uses a corporate vocabulary to remodel their behavior; DBT is one way to make the world survivable.