In January 2012, two weeks after my discharge from a psychiatric hospital in Connecticut, I made a plan to die. My week in an acute care unit that had me on a suicide watch had not diminished my pain.
Back in New York, I stormed out of my therapist’s office and declared I wouldn’t return to the treatment I’d dutifully followed for three decades. Nothing was working, so what was the point?
I fit the demographic profile of the American suicide — white, male and entering middle age with a history of depression. Suicide runs in families, research tells us, and it ran in mine. My father killed himself at age 49 in April 1990. A generation before, an aunt of his took her life; before her, there were others.
Shame runs in families, too, and no one in mine talked much about mental illness.
The first time I was hospitalized for wanting to kill myself, as a teenager, my dad visited me a few days in. I made an effort to greet him with a firm handshake; he shared a few jokes with me. Dad was visibly concerned and told me he loved me. Only after his suicide a few years later did I learn that he, too, had been hospitalized, for depression, when he was in his early 20s.
Setting out to start my own life after college, I felt that suicide was a clear and present opportunity, one that glowed more brightly during my depressive episodes.
But I had an ambitious plan to beat it. I’d be a performer: work hard, keep my goals in the line of sight at all times, and make as much money as I could. Professional success would be my first line of defense to keep hopelessness at bay. In parallel, I’d find excellent doctors and be a compliant patient, take my meds and show up for talk therapy.
And for a long time, through my 20s and 30s, that plan worked.
Then, in 2008, a business deal fell through, and I couldn’t shake my disappointment.
I slipped into a low mood, unfamiliar in both its persistence and depth. The doctors tried different drugs, different combinations of drugs. There were re-evaluations and second opinions. A course of electroconvulsive therapy was ineffective. My diagnosis shifted from depression to treatment-resistant depression.
Three and a half years later, I was done. I’d stopped sleeping through the night; I’d go to the office before dawn to avoid being alone with my thoughts. If not for daily business lunches, a custom in the publishing industry, and the brownies and whole wheat biscuits my partner baked in loving desperation, I would’ve lost far more than the 30 pounds I’d dropped just in a few months.
I diligently planned my death, contacting a lawyer to finish my will and updating my health care proxy. In case I botched the job, I wanted to leave clear instructions that nothing be done to try to revive me or to prolong my life. I intended to hang myself in the garage of my upstate house.
When I told my brother in an email that I was giving him power of attorney over my affairs, he replied immediately: You must not leave us! He reminded me of our father’s dark legacy, and what it had felt like when he’d left us behind. I remembered that agony, didn’t I?
His message confused me. I wanted to die, but I did not want to inflict suffering on the people I loved the most.
I became willing to consider long-term hospitalization, something I hadn’t yet tried because of its great expense. After a frantic search for an open bed at a treatment facility and the funds to pay for it, I left New York for the Menninger Clinic in Houston.
A few weeks after I arrived, I was enrolled in a dialectical behavior therapy skills group.
D.B.T. is a therapy that was developed in the 1980s by the psychologist Marsha M. Linehan as she worked with suicidal patients suffering from borderline personality disorder. In spite of my 30 years as an avid, often desperate medical consumer, I’d never heard of it.
Dr. Linehan had struggled with mental illness as a young woman. When she started seeing patients, substantial research showed that cognitive behavioral therapy — which focuses on helping patients identify and change negative, often erroneous thoughts (e.g., “I am stupid”) that underpin negative feelings and behaviors — could help many depressed people. But Dr. Linehan found that C.B.T. didn’t always work for her suicidal patients. Some found its emphasis on changing their own thinking tantamount to the belittling notion that their pain was “all in their head.” Many of them had experienced very real trauma, and many had tried fruitlessly to change many times before. C.B.T.’s implication that their emotion was “wrong” — merely a consequence of inaccurate thoughts — made the therapist seem unsupportive, and reinforced their sense of isolation and hopelessness.
Drawing on her own experiences and further study of both psychology and Zen practices, she began to create a form of C.B.T. that spoke to the particular vulnerabilities of her patients. Before her patients could or would change, she saw, they needed to accept themselves, and to be accepted, exactly as they were in the present. This dialectic tension between acceptance and change is the root concept of dialectical behavior therapy.
Dr. Linehan also recognized that people who struggled with the urge to commit suicide were often people who might be biologically vulnerable to being emotionally overwhelmed. It’s not that we have the “wrong feelings”; it’s that our feelings flood and overwhelm us, in ways they might not overwhelm someone with different genes, and that it takes longer for those feelings to ebb and subside. In response, she began articulating strategies, or “skills,” for people with these vulnerabilities.
It is in the pivotal moment between experiencing a feeling and acting on it, the theory goes, that I have a chance to “act opposite”: to behave differently from how I have historically, and often destructively, managed distress.
There were behaviors I wanted to change. When I was depressed, the self-possession I presented to the world belied just how out of control I felt inside. In my search for relief from anxiety, anger or sadness, I’d act impulsively — spending money when I couldn’t afford it, isolating myself from friends, lashing out at those people closest to me, even hurting myself physically. Afterward, I was kept low by regret. My urges to act out may have been satisfied, but now I had a set of new problems: debt, broken relationships, a hangover. Unable to forgive myself for my mistakes, the anger returned.
That cycle was killing me. D.B.T. provided me with a rubric for figuring out what was causing my anxiety, anger or sadness — and new options for how to behave in light of it. Classical D.B.T. treatment originally involved multiple components and required the participation of a team of specially trained professionals, keeping its price tag high. But in recent years, research has confirmed that a more streamlined, more affordable form of D.B.T. — D.B.T. skills training — is also remarkably effective.
Over the last decade or so, clinicians have adapted D.B.T. to help people with treatment-resistant depression, attention deficit disorder, post-traumatic stress disorder and eating disorders. New research published in March 2015 in JAMA Psychiatry highlighted the effectiveness of including the skills-training component in D.B.T.
The study’s finding wasn’t news to me. Once a week for the last two and a half years I’ve attended a D.B.T. group and learned a set of skills that have been nothing short of transformative. I pay $80 for each 90-minute session, which I pay for out-of-pocket, though it’s covered by some insurance companies.
Learning D.B.T. is like learning a new language. Organized in four modules, each one taught in rounds lasting four to seven weeks, it offers its own vocabulary, idioms, even mnemonics. I was no longer suicidal, but I wasn’t sure that would last. Since my 20s, I’d managed anxiety with aggressive use of benzodiazepines like Xanax and Klonopin, which had grown into an unhealthy dependence. I returned home without them after a tough detox at Menninger.
I was now subject to the full sensory assault of New York. Riding the subway to work, walking the dog, even tying my tie in the morning could provoke panic attacks. Frightened by the power of these feelings, I scrambled to apply the skills from the first D.B.T. module I’d learned, distress tolerance.
I followed the strategy of distracting myself with highly specific tasks just long enough — usually for two or three minutes — to lower the intensity of the fear before it overwhelmed me. Depending on where I was — at home, at work or on the street or train — I’d reach for a situationally appropriate activity. And because I can’t rely on my memory when anxiety swells, I’d carry lists on an index card or on my phone: pull out a piece of paper and write down all 50 states and their capitals — in my non-dominant hand; grab ice cubes from the fridge and hold them on the back of my neck; snap the rubber band on my wrist. At the office or in a meeting, I learned to make subtle changes to my posture like bunching my toes, half-smiling to activate facial muscles, even slowing my breathing.
And as imperfect as my D.B.T. practice was early on, I found that just taking anxiety down a degree or two gave me a measure of control over my decision making in the presence of intense emotion. The lesson was profound. I couldn’t eliminate anxiety from my life, but I could learn how to tolerate it, and cope without making the situation worse.
As I made slow, sometimes unsteady progress, I became curious about Dr. Linehan’s other D.B.T. modules. Mindfulness challenges me to accept emotions and situations as they are, not as I want them to be. I’ve learned how to “observe and describe”: to state the nature of a problem with facts, not judgments, so I can determine how best to solve it.
The interpersonal effectiveness training helps me ask for what I need in relationships and to manage conflict positively, and to do both while preserving my self-respect.
Prepping in advance for tough conversations and avoiding over-apologizing are key skills.
Emotion regulation teaches me how to identify and understand the functions of my emotions, and how to decrease my historic vulnerability to extreme moods. If I’m aware of how I feel physically when I’m sad, or how my speech pattern changes when I’m angry, I can recognize where I am and change course before the intensity of the emotion gets too high.
The time needed to learn D.B.T. can feel impossibly huge, especially for those of us who despair that change can’t come fast enough to save our lives. Yet, by empowering me to make the next minute or hour better than the one before it, in even the slightest, most incremental way, this therapy kindles hope. Better hours become better days, and several years on I’ve discovered my own resilience.
Now I am able and willing to fully participate in life, ready to experience its joy and pain equally as I reach for my long-term goals.
D.B.T. is a relatively young therapy. There is much more research to be done. Still, there is already compelling evidence of its effectiveness in its modified, less expensive formats. Mental health professionals and patients need to consider it directly alongside the usual programs and not as a treatment of last resort.
Suicide rates in the United States are at a shocking 25-year high. They spike in the spring, for reasons not entirely clear. But depression is treatable, and suicide is preventable. Don’t lose hope. You are not alone. I, too, once firmly believed that I was broken beyond repair — but I was wrong.
Will Lippincott works in publishing and lives in New York.