DBT Linehan en Barlow 2008

CHAPTER 9
Dialectical Behavior Therapy

for Borderline Personality Disorder
MARSHA M. LINEHAN
ELIZABETH T. DEXTER-MAZZA
This chapter presents one of the more remarkable developments in all of psychotherapy.
Few therapists are willing to undertake the overwhelmingly difficult and wrenching task of
treating individuals with “borderline” characteristics, yet these people are among the
neediest encountered in any therapeutic setting. They also impose an enormous burden
on the health care system. Over the past two decades, Linehan and her colleagues have
developed a psychological treatment for individuals with borderline personality disorder
(BPD). Importantly, data indicate that this treatment is effective when compared to alterna-
tive interventions. If results from the initial trials continue to hold up in future clinical trials,
then this treatment will constitute one of the most substantial contributions to the arma-
mentarium of the psychotherapist in recent times. What is even more interesting is that
this approach blends emotion regulation, interpersonal systems, and cognitive-behavioral
approaches into a coherent whole. To this mix Linehan adds her personal experience with
Eastern philosophies and religions. Among the more intriguing strategies incorporated
into this approach are “entering the paradox” and “extending,” borrowed from aikido, a Jap-
anese form of self-defense. Yet the authors remain true to the empirical foundations of
their approach. The fascinating case study presented in this chapter illustrates Linehan’s
therapeutic expertise and strategic timing in a way that will be invaluable to all therapists
who deal with personality disorders. The surprising and tragic outcome illustrates the
enormous burden of clinical responsibility inherent in any treatment setting, as well as the
practical issues that arise when treatment ultimately fails.—D. H. B.
Clinicians generally agree that clients with a attempts, with an average of 3.4 attempts per
diagnosis of borderline personality disorder individual (Soloff, Lis, Kelly, Cornelius, &
(BPD) are challenging and difficult to treat. As Ulrich, 1994). Suicide threats and crises are fre-
a result, BPD has become a stigmatized disor- quent, even among those who never engage
der resulting in negative attitudes, trepidation, in any suicidal or nonsuicidal self-injurious
and concern with regard to providing treat- behavior (NSSI). Although much of this behav-
ment (Aviram, Brodsky, & Stanley, 2006; ior is without lethal consequence, follow-up
Lequesne & Hersh, 2004; Paris, 2005). Per- studies of individuals with BPD have found sui-
haps of greatest concern is the generally high cide rates of about 7–8%, and the percentage
incidence of suicidal behavior among this pop- who eventually commit suicide is estimated at
ulation. Approximately 75% of clients who 10% (for a review, see Linehan, Rizvi, Shaw-
meet criteria for BPD have a history of suicide Welch, & Page, 2000). Among all individuals
365
366 CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS
who have committed suicide, from 7 to 38% personalization, dissociation, and delusions
meet criteria for BPD when personality disor- (including delusions about the self), are at
ders are assessed via a psychological autopsy, times brought on by stressful situations and
with the higher incidence occurring primarily usually cease when the stress is ameliorated.
among young adults with the disorder (Brent et Fourth, dysregulation of the sense of self is also
al., 1994; Isometsa et al., 1994, 1997; Lesage et common. Individuals with BPD frequently re-
al., 1994; Rich & Runeson, 1992). Individuals port that they have no sense of a self at all, feel
with BPD also have difficulties with anger and empty, and do not “know” who they are.
anger expression. Not infrequently, intense an- Finally, these individuals often experience in-
ger is directed at their therapists. The frequent terpersonal dysregulation. Their relationships
coexistence of BPD with both Axis I conditions may be chaotic, intense, and marked with diffi-
(e.g., mood or anxiety disorders) and other per- culties. Even though their relationships are so
sonality disorders clearly complicates treat- difficult, individuals with BPD often find it ex-
ment further. tremely hard to relinquish relationships. In-
The criteria for BPD, as defined within the stead, they may engage in intense and frantic
text revision of the fourth edition of the Diag- efforts to prevent significant individuals from
nostic and Statistical Manual of Mental Disor- leaving them. The polythetic format of the
ders (DSM-IV-TR; American Psychiatric As- DSM-IV-TR definition allows for considerable
sociation, 2000) and the Revised Diagnostic heterogeneity in diagnosis (indeed, the require-
Interview for Borderlines (DIB-R; Zanarini, ment that five of nine criteria be met for the di-
Gunderson, Frankenburg, & Chauncey, 1989), agnosis yields 256 ways in which the BPD diag-
the most commonly used research assessment nosis may be met), and clinical experience with
instrument, reflect a pervasive pattern of insta- these clients confirms that this diagnostic cate-
bility and dysregulation across all domains of gory comprises a heterogeneous group.
functioning. Other assessment measures used This chapter focuses primarily on describing
to diagnose BPD include the International dialectical behavior therapy (DBT), a compara-
Personality Disorders Examination (IPDE; tively new approach to treatment of BPD
Loranger, 1995) and the Diagnostic Interview (Linehan, 1993a, 1993b). It has the distinction
for DSM-IV Personality Disorders (DIPD-IV; of being one of the first psychosocial treat-
Zanarini, Frankenburg, Sickel, & Yong, 1996). ments demonstrated to be effective in a ran-
The Borderline Symptom List (BSL; Bohus et domized clinical trial (Linehan, Armstrong,
al., 2001) and the McLean Screening Instru- Suarez, Allmon, & Heard, 1991). Before de-
ment for Borderline Personality Disorder (MSI- scribing DBT, we first review other treatments
BPD; Zanarini et al., 2003) are both screening for BPD and provide information on their theo-
measures for BPD. retical rationales and supporting data (when
Linehan (1993a) has reorganized and sum- such data are available). This is followed by a
marized the diagnostic criteria of BPD into five more in-depth description of DBT—its philo-
domains. First, individuals with BPD generally sophical roots, underlying theory, and treat-
experience emotional dysregulation and insta- ment protocols.
bility. Emotional responses are reactive, and
the individuals generally have difficulties with
episodic depression, anxiety, and irritability, as OVERVIEW OF OTHER
well as problems with anger and anger expres- TREATMENT APPROACHES
sion. Second, individuals with BPD have pat-
terns of behavioral dysregulation, as evidenced Various approaches have been applied to the
by extreme and problematic impulsive behav- treatment of BPD. Although it is not our pur-
ior. As noted earlier, an important characteris- pose to present a scholarly review of all the
tic of these individuals is their tendency to di- many treatments for BPD, we believe it helpful
rect apparently destructive behaviors toward to review briefly the status of other, current
themselves. Attempts to injure, mutilate, or kill treatments before presenting DBT in detail.
themselves, as well as actual suicides, occur fre-
quently in this population. Third, individuals
Psychodynamic
with BPD sometimes experience cognitive dys-
regulation. Brief, nonpsychotic forms of Psychodynamic approaches currently receiving
thought and sensory dysregulation, such as de- the greatest attention include those of Kernberg
Borderline Personality Disorder 367
(1975, 1984; Clarkin et al., 2001; Kernberg, were analyzed. There were no significant reduc-
Selzer, Koenigsberg, Carr, & Appelbaum, tions in number of suicide attempts, number of
1989), Adler and Buie (1979; Adler, 1981, NSSI behaviors (referred to as “parasuicide” in
1985, 1993; Buie & Adler, 1982), and Bateman the article), medical risk of either type of self-
and Fonagy (2004). Among these, Kernberg’s injury, or physical condition after either type of
(1975, 1984) theoretical contributions are self-injury in the ITT sample. However, signifi-
clearly prominent. His object relations model is cant decreases in medical risk and physical con-
comprehensive as to theory and technique, and dition after NSSI behaviors occurred in the com-
has had considerable influence on the psy- pleter sample. Furthermore, the number of
choanalytic literature. His expressive psycho- hospitalizations over the course of the treatment
therapy for clients with “borderline personality year compared to the year prior to treatment re-
organization” (BPO) or BPD, transference- duced significantly for both groups. Given the
focused therapy (TFT), emphasizes three pri- lack of a control group in this study and the small
mary factors: interpretation, maintenance of sample size, these findings should be reviewed
technical neutrality, and transference analysis. with caution (Clarkin et al., 2001).
The focus of the therapy is on exposure and Mentalization therapy, developed by Bate-
resolution of intrapsychic conflict. Treatment man and Fonagy (2004), is an intensive therapy
goals include increased impulse control and grounded in attachment theory (i.e., BPD is
anxiety tolerance, ability to modulate affect, viewed as an attachment disorder), with a fo-
and development of stable interpersonal rela- cus on relationship patterns and nonconscious
tionships. TFT also uses a target hierarchy factors inhibiting change. “Mentalization” re-
approach to the first year of treatment. The tar- fers to one’s perception or interpretation of the
gets are (1) containment of suicidal and self- actions of others and oneself as intentional.
destructive behaviors, (2) therapy-destroying The treatment is based on the theory that indi-
behaviors, and (3) identification and recapitu- viduals with BPD have an inadequate capacity
lation of dominant object relational patterns, for mentalization. Treatment, therefore, is fo-
as experienced in the transference relationship cused on bringing the client’s mental experi-
(Clarkin et al., 2001). Kernberg has also distin- ences to conscious awareness, facilitating a
guished a supportive psychotherapy for more more complete, integrated sense of mental
severely disturbed clients with BPO or BPD. agency. The goal is to increase the client’s ca-
Like expressive psychotherapy, supportive psy- pacity for recognizing the existence of the
chotherapy also places great emphasis on the thoughts and feelings he or she is experiencing.
importance of the interpersonal relationship in A randomized trial of mentalization therapy
therapy (transference); however, interpreta- offered in a partial hospitalization setting pro-
tions are less likely to be made early in treat- vides additional supporting data for psychoan-
ment, and only the negative responses to the alytic treatment of BPD. This study by Bate-
therapist and to therapy (negative transference) man and Fonagy (1999) consisted of random
are explored. Both expressive and supportive assignment of clients to either standard psychi-
psychotherapy are expected to last several atric care constrained only by the requirement
years, with primary foci on suicidal behaviors that individual psychotherapy was not allowed
and therapy-interfering behaviors. The data (control condition) or to partial hospitaliza-
supporting the use of TFT are not extensive. tion, a treatment program with the following
Clarkin and colleagues have published results goals of therapy: (1) psychoanalytically in-
from a preliminary study of TFT. Additionally, formed engagement of clients in treatment; (2)
one completed randomized clinical trial has reduction of psychopathology, including de-
compared TFT to schema-focused therapy pression and anxiety; (3) reduction of suicidal
(SFT; Giesen-Bloo et al., 2006). The results of behavior; (4) improvement in social compe-
this study are described in the section on tence; and (5) reduction in lengthy hospitaliza-
cognitive-behavioral treatments. tions. The experimental treatment group re-
The preliminary study of TFT assessed pre- ceived once-weekly individual psychotherapy
and posttreatment changes over the course of a provided by psychiatric nurses, once-weekly
1-year treatment for adult women with BPD (N psychodrama-based expressive therapy, thrice-
= 23). Of the 23 clients who were considered in- weekly group therapy, a weekly community
tent-to-treat (ITT), 17 completed the treatment. meeting, a monthly meeting with a case admin-
Both the ITT sample and the completer sample istrator, and a monthly medications review. At
the end of the 18-month treatment, the group ty, interpersonal relationships, and global func-
receiving mentalization therapy showed signifi- tioning, and specifically, olanzapine was better
cant reductions in suicidal behavior (suicide at- than placebo relative to global functioning
tempts and self-mutilation), inpatient hospital- (Nose et al., 2006) and has been shown to
ization stays, measures of psychopathology decrease impulsive aggression and chronic dys-
(including depression and anxiety), and social phoria more effectively compared to fluoxetine
functioning relative to the control group. These (Zanarini, Frankenburg, & Parachini, 2004).
gains were maintained and increased during an In summary, although some drug treatments
18-month follow-up period consisting of twice- may be effective, caution is in order when con-
weekly group therapy (Bateman & Fonagy, sidering pharmacotherapy for this particular
2001). The researchers note that their program client population. Clients with BPD are notori-
contained three characteristics that they hy- ously noncompliant with treatment regimens,
pothesize to be related to treatment effective- may abuse the prescribed drugs or overdose,
ness: a consistent theoretical rationale for treat- and may experience unintended effects of the
ment, a relationship focus, and consistent drugs. With these caveats in mind, carefully
treatment over time. monitored pharmacotherapy may be a useful
and important adjunct to psychotherapy in the
treatment of BPD.
Psychopharmacological
Reviews of the literature regarding drug treat-
Cognitive-Behavioral
ments for BPD highlight a dilemma for the pre-
scribing pharmacotherapist: BPD involves dys- Treatment of BPD has received increasing at-
regulation in too many domains for a single tention from cognitive theorists. The cognitive
drug to serve as a panacea (Dimeff, McDavid, approach views the problems of the client with
& Linehan, 1999; Lieb, Zanarini, Linehan, & BPD as residing within both the content and
Bohus, 2004; Nose, Cipriani, Biancosino, the process of the individual’s thoughts. Beck’s
Grassi, & Barbui, 2006). In general, results in- approach to treating BPD (Beck & Freeman,
dicate that several agents may be useful for im- 1990) is representative of cognitive psychother-
proving global functioning, cognitive percep- apy generally, with the focus of treatment on
tual symptoms (e.g., suspiciousness, ideas of restructuring thoughts and on developing a col-
reference, transitory hallucinations), emotion laborative relationship through which more
dysregulation, or impulsive–behavioral dys- adaptive ways of viewing the world are devel-
control (for reviews, see Lieb et al., 2004; Nose oped. More specifically it focuses on decreasing
et al., 2006). Nose and colleagues (2006) con- negative and polarized beliefs that result in un-
ducted a meta-analysis of 22 randomized, stable affect and destructive behaviors (Brown,
placebo-controlled clinical trials, published be- Newman, Charlesworth, Crits-Christoph, &
tween 1986 and 2006, examining the effects of Beck, 2004). In an open clinical trial of cogni-
pharmacotherapy for individuals with BPD. tive therapy for clients with BPD, Brown and
Organization of results was based on five pri- colleagues found decreases in clients meeting
mary outcome measures: affective instability BPD criteria, depression, hopelessness, and sui-
and anger, impulsivity and aggression, interper- cide ideation at the end of the 12-month treat-
sonal relationships, suicidality, and global ment and 6-month follow-up posttreatment.
functioning. First, no medication had a more The cognitive-behavioral therapies of
positive effect than placebo on suicidality. Young, Klosko, and Weishaar (Kellogg &
Overall, across the studies, fluoxetine, an anti- Young, 2006; Young, 2000; Young, Klosko, &
depressant, and topiramate and lamotrigine, Weishaar, 2003; Pretzer, 1990); Blum and col-
mood stabilizers, showed more positive effects leagues (Blum, Pfohl, St. John, Monahan, &
than placebo for affective instability and anger. Black, 2002) and Schmidt and Davidson (as
Additionally, valproate, an anticonvulsant and cited in Weinberg, Gunderson, Hennen, & Cut-
mood stabilizer, has effectively treated behav- ter, 2006) attempt to address some of the diffi-
ioral dysregulation in clients with BPD, includ- culties experienced in applying traditional cog-
ing those with aggressive and impulsive be- nitive approaches to the treatment of BPD.
havior (Stein, Simeon, Frenkel, Islam, & Pretzer’s (1990) approach emphasizes modify-
Hollander, 1995). As a class, antipsychotics ing standard cognitive therapy to address diffi-
were more effective than placebo for impulsivi- culties often encountered in treating clients
with BPD, such as establishing a collaborative haviors and at least one in the last month; how-
relationship between therapist and client, ever, suicide was considered one of the
maintaining a directed treatment, and improv- exclusionary criteria for study participation.
ing homework compliance. Blum and col- Participants were randomly assigned to MACT
leagues (2002) developed a twice-weekly out- plus TAU or to TAU-alone conditions. Upon
patient group treatment that uses a completion of the 6-week treatment and at the
psychoeducational approach to teaching skills 6-month follow-up, individuals who received
to clients with BPD and to their support sys- MACT had significantly fewer and less severe
tems (e.g., family, friends, other care provid- NSSI behaviors than those in the TAU-alone
ers). The treatment focuses on destigmatization condition. The authors state that these results
of BPD, emotional control, and behavioral should be interpreted with caution due to small
control. At present, outcome data are limited sample size and the use of self-report measures
for Pretzer’s approach. A pilot study has shown only in assessment of NSSI behaviors.
potential for the group treatment developed by
Blum and colleagues and a randomized control
trial is currently being conducted (Van Wel et DIALECTICAL BEHAVIOR THERAPY
al., 2006).
Young’s schema-focused therapy (SFT) DBT evolved from standard cognitive-
(Young et al., 2003) postulates that stable behavioral therapy as a treatment for BPD,
patterns of thinking (“early maladaptive particularly for recurrently suicidal, severely
schemas”) can develop during childhood and dysfunctional individuals. The theoretical ori-
result in maladaptive behavior that reinforces entation to treatment is a blend of three theo-
the schemas. SFT includes a variety of interven- retical positions: behavioral science, dialectical
tions aimed at challenging and changing these philosophy, and Zen practice. Behavioral sci-
early schemas through the identification of a ence, the principles of behavior change, is
set of dysfunctional schema modes that control countered by acceptance of the client (with
the individual’s thoughts, emotions, and behav- techniques drawn both from Zen and from
iors (i.e., detached protector, punitive par- Western contemplative practice); these poles
ent, abandoned/abused child, angry/impulsive are balanced within the dialectical framework.
child). Giesen-Bloo and colleagues (2006) com- Although dialectics was first adopted as a de-
pleted the first randomized clinical trial of TFT scription of this emphasis on balance, dialectics
and SFT. Transference focused therapy was soon took on the status of guiding principles
compared to schema focused therapy in a study that have advanced the therapy in directions
where 88 participants received three years of not originally anticipated. DBT is based within
twice per week individual sessions of either a consistent behaviorist theoretical position.
schema focused therapy or transference based However, the actual procedures and strategies
therapy. Study results indicated an overall de- overlap considerably with those of various al-
crease in BPD symptoms for both treatments, ternative therapy orientations, including psy-
however, participants who received SFT had chodynamic, client-centered, strategic, and
significantly greater improvements overall and cognitive therapies.
a lower attrition rate. Suicide and NSSI behav-
iors were not assessed as an outcome measure
Efficacy
in this study.
Weinberg and colleagues (2006) completed a Although several treatments (Bateman &
randomized, controlled trial of Schmidt and Fonagy, 1999, 2001; Giesen-Bloo et al., 2006;
Davidson’s manual-assisted cognitive treat- Marziali & Munroe-Blum, 1994) have shown
ment (MACT) and treatment as usual (TAU). efficacy in the treatment of individuals with
MACT is a brief cognitive-behavioral treat- BPD, DBT has the most empirical support at
ment that incorporates strategies from DBT, present and is generally considered the
cognitive therapy, and bibliotherapy. The treat- frontline treatment for the disorder. DBT has
ment targets NSSI behaviors occurring in indi- been evaluated in six randomized controlled
viduals with BPD. MACT was provided as an trials (RCTs) conducted across three indepen-
adjunctive treatment to TAU for study partici- dent research teams (Koons et al., 2001;
pants (N = 30). Participants were 30 women di- Linehan et al., 1991, 1999, 2002, 2006;
agnosed with BPD, with a history of NSSI be- Linehan, Heard, & Armstrong, 1993; Linehan,
Tutek, Heard, & Armstrong, 1994; Verheul et the 6-month follow-up time point in a 28-week
al., 2003). Two of the RCTs specifically re- treatment program. DBT has also been adapted
cruited clients with suicidal behaviors (Linehan for use with individuals without BPD who are
et al., 1991, 1993, 1994, 1999). The results in diagnosed with binge-eating disorder (BED).
general have shown DBT to be an effective Telch, Agras, and Linehan (2001) compared
evidenced-based treatment for the disorder. In women diagnosed with BED receiving an
four of the six studies participants treated with adapted 20-week group DBT treatment to
DBT demonstrated significantly greater reduc- waiting-list controls. Participants in the DBT
tions in suicide attempts, intentional self-injury, condition had significantly fewer days of binge-
and suicidal ideation (Koons et al., 2001; eating episodes compared to those in the wait-
Linehan et al., 1991, 1999, 2002; Verheul et list control condition and were more likely to
al., 2003). Treatment superiority was main- abstain from bingeing at follow-up. Addi-
tained when DBT was compared to only those tionally, those in the wait-list control group
control subjects who received stable individual who were offered the DBT treatment after the
psychotherapy during the treatment year, and study had similar results. DBT continues to be
even after researchers controlled for number of examined in a variety of settings and for a vari-
hours of psychotherapy and of telephone con- ety of different diagnoses. However, it is impor-
tacts. (Linehan & Heard, 1993; Linehan et al., tant to highlight that when DBT is adapted for
1999). Two studies with participants with sub- use with different populations, it may not be as
stance dependence and BPD found DBT to be effective, given that many adaptations have not
more effective than control treatments in re- been rigorously tested. We recommend that un-
ducing substance use, and increasing global til it is tested in an RCT, adaptations should
and social adjustment (Linehan et al., 1999, not be made to DBT. If using DBT with differ-
2002). In the original study of recurrently sui- ent populations, then the most important
cidal patients with BPD, participants treated change should be in the examples used when
with DBT were significantly less likely than teaching, not in the content itself.
TAU participants to attempt suicide or NSSI
behaviors during the treatment year, had less
Philosophical Basis: Dialectics
medically severe NSSI behaviors, were less
likely to drop out of treatment, had fewer inpa- The term “dialectics” as applied to behavior
tient psychiatric days per participant, and im- therapy refers both to a fundamental nature
proved more on scores of both global and so- of reality and to a method of persuasive dia-
cial adjustment. More specifically, Linehan and logue and relationship. (See Wells [1972,
colleagues’ (2006) study showed that partici- cited in Kegan, 1982] for documentation of a
pants treated with DBT were half as likely to shift toward dialectical approaches across all
engage in suicidal behaviors compared to par- the sciences during the last 150 years; more
ticipants in the treatment by community ex- recently, Peng & Nisbett [1999] discuss both
perts (TBCE) condition, further indicating that Western and Eastern dialectical thought.) As
DBT is an effective treatment for reducing sui- a worldview or philosophical position, dialec-
cidal behavior. This study suggests that the effi- tics guide the clinician in developing theoreti-
cacy of DBT is due to specific treatment fac- cal hypotheses relevant to the client’s prob-
tors, and not general factors or the expertise of lems and to the treatment. Alternatively, as
the treating psychotherapists. In two studies to dialogue and relationship, dialectics refers to
date, DBT has been shown to be effective in re- the treatment approach or strategies used by
ducing substance use disorders (Linehan et al., the therapist to effect change. Thus, central
1999, 2002). to DBT are a number of therapeutic dialecti-
In addition to these studies of DBT for indi- cal strategies. These are described later in this
viduals with BPD, three studies have examined chapter.
its effectiveness with other disorders. First,
Lynch, Morse, Mendelson, and Robins (2003)
found that a DBT skills group plus anti-
Dialectics as a Worldview
depressant medication showed greater reduc- DBT is based on a dialectical worldview that
tions in depressive symptoms in older (over 60- emphasizes wholeness, interrelatedness, and
years-old) depressed individuals compared to process (change) as fundamental characteristics
TAU plus antidepressant medication group at of reality. The first characteristic, the Principle
of Interrelatedness and Wholeness, provides a sion and by making use of the oppositions in-
perspective of viewing the system as a whole herent in the therapeutic relationship rather
and how individuals relate to the system, rather than by formal impersonal logic. Through the
than seeing individuals as if they exist in isola- therapeutic opposition of contradictory posi-
tion. Similar to contextual and systems theo- tions, both client and therapist can arrive at
ries, a dialectical view argues that analysis of new meanings within old meanings, moving
parts of any system is of limited value unless closer to the essence of the subject under con-
the analysis clearly relates the part to the sideration. The spirit of a dialectical point of
whole. The second characteristic is the Princi- view is never to accept a proposition as a final
ple of Polarity. Although dialectics focuses on truth or an undisputable fact. Thus, the ques-
the whole, it also emphasizes the complexity of tion addressed by both client and therapist is
any whole. Thus dialectics asserts that reality is “What is being left out of our understanding?”
nonreducible; that is, within each single thing Dialectics as persuasion is represented in the
or system, no matter how small, there is polar- specific dialectical strategies described later in
ity. For example, physicists are unable to re- this chapter. As readers will see, when we dis-
duce even the smallest of molecules to one cuss the consultation strategies, dialectical dia-
thing. Where there is matter there is antimatter; logue is also very important in therapist consul-
even every atom is made up of both protons tation meetings. Perhaps more than any other
and electrons: A polar opposite is always pres- factor, attention to dialectics can reduce the
ent. The opposing forces are referred to as the chances of what psychodynamic therapists
thesis and antithesis, present in all existence. have labeled “staff splitting,” that is, the fre-
Dialectics suggests that the thesis and antithesis quent phenomenon of therapists’ disagreeing
move toward a synthesis, and inherent in the or arguing (sometimes vehemently) about how
synthesis will be a new set of opposing forces. to treat and interact with an individual client
It is from these opposing forces that the third who has BPD. This “splitting” among staff
characteristic is developed. This characteristic members is often due to one or more factions
of the dialectical perspective refers to the Prin- within the staff deciding that they (and some-
ciple of Continuous Change. Change is pro- times they alone) know the truth about a par-
duced through the constant synthesis of the ticular client or clinical problem.
thesis and the antithesis, and because new op-
posing forces are present within the synthesis,
change is ongoing. These dialectical principles
Dialectical Case Conceptualization
are inherent in every aspect of DBT and allow Dialectical assumptions influence case concep-
for continuous movement throughout the ther- tualization in DBT in a number of ways. First,
apy process. A very important dialectical idea dialectics suggests that a psychological disorder
is that all propositions contain within them is best conceptualized as a systemic dysfunction
their own oppositions. Or, as Goldberg (1980, characterized by (1) defining the disorder with
pp. 295–296) put it, “I assume that truth is respect to normal functioning, (2) assuming
paradoxical, that each article of wisdom con- continuity between health and the disorder,
tains within it its own contradictions, that and (3) assuming that the disorder results from
truths stand side by side. Contradictory truths multiple rather than single causes (Hollands-
do not necessarily cancel each other out or worth, 1990). Similarly, Linehan’s biosocial
dominate each other, but stand side by side, theory of BPD, presented below, assumes that
inviting participation and experimentation.” BPD represents a breakdown in normal func-
One way that the client and therapist address tioning, and that this disorder is best conceptu-
this in therapy is by repeatedly asking each alized as a systemic dysfunction of the emotion
other or oneself the question: “What is being regulation system. The theory proposes that
left out?” This simple question can assist in the pathogenesis of BPD results from numerous
finding a synthesis and letting go of an absolute factors: Some are genetic–biological predispo-
truth, a nondialectical stance. sitions that create individual differences in sus-
ceptibility to emotion dysregulation, known as
emotion vulnerability; others result from the
Dialectics as Persuasion individual’s interaction with the environment,
From the point of view of dialogue and rela- referred to as the invalidating environment. As-
tionship, dialectics refers to change by persua- suming a systemic view compels the theorist to
integrate work from a variety of fields and dis- A final assumption in our discussion regards
ciplines. the definition of behavior and the implications
A second dialectical assumption that under- of defining behavior broadly. Linehan’s theory,
lies Linehan’s biosocial theory of BPD is that and behaviorists in general, take “behavior” to
the relationship between the individual and the mean anything an organism does involving
environment is a process of reciprocal influ- action and responding to stimulation
ence, and that the outcome at any given mo- (Merriam-Webster’s New Universal Un-
ment is due to the transaction between the abridged Dictionary, 1983, p. 100). Conven-
person and the environment. Within social tionally, behaviorists categorize behavior as
learning theory, this is the principle of “recipro- motor, cognitive/verbal, and physiological, all
cal determinism.” Besides focusing on recipro- of which may be either public or private. There
cal influence, a transactional view also high- are several points to make here. First, dividing
lights the constant state of flux and change of behavior into these three categories is arbitrary
the individual–environment system. Therefore, and is done for conceptual clarity rather than
BPD can occur in multiple environments and in response to evidence that these response
families, including chaotic, perfect, and even modes actually are functionally separate sys-
ordinary families. Millon (1987) made much tems. This point is especially relevant to under-
the same point in discussing the etiology of standing emotion regulation, given that basic
BPD and the futility of locating the “cause” of research on emotions demonstrates that these
the disorder in any single event or time period. response systems are sometimes overlapping,
Both transactional and interactive models, somewhat independent, but definitely not
such as the diathesis–stress model of psycho- wholly independent, thus remaining consistent
pathology, call attention to the role of dysfunc- with the dialectical worldview. A related point
tional environments in bringing about disorder here is that in contrast to biological and cogni-
in the vulnerable individual. A transactional tive theories of BPD, biosocial theory suggests
model, however, highlights a number of points that there is no a priori reason for favoring ex-
that are easy to overlook in an interactive planations emphasizing one mode of behavior
diathesis–stress model. For example, a person as intrinsically more important or compelling
(Person A) may act in a manner stressful to an than others. Rather, from a biosocial perspec-
individual (Person B) only because of the stress tive, the crucial questions are under what con-
Person B is putting on Person A. Take the child ditions a given behavior–behavior relationship
who, due to an accident, requires most of the or response system–response system relation-
parents’ free time just to meet survival needs. ship holds, and under what conditions these re-
Or consider the client who, due to the need for lationships enter causal pathways for the etiol-
constant suicide precautions, uses up much of ogy and maintenance of BPD.
the inpatient nursing resources. Both of these
environments are stretched in their ability to
respond well to further stress. Both may invali- BIOSOCIAL THEORY
date or temporarily blame the victim if any fur-
Emotion Dysregulation
ther demand on the system is made. Although
the system (e.g., the family or the therapeutic Linehan’s biosocial theory suggests that BPD is
milieu) may have been predisposed to respond primarily a dysfunction of the emotion regula-
dysfunctionally in any case, such responses tion system. Behavioral patterns in BPD are
may have been avoided in the absence of expo- functionally related to or are unavoidable con-
sure to the stress of that particular individ- sequences of this fundamental dysregulation
ual. A transactional, or dialectical, account of across several, perhaps all, emotions, including
psychopathology may allow greater compas- both positive and negative emotions. From
sion, because it is incompatible with the assign- Linehan’s point of view, this dysfunction of the
ment of blame, by highlighting the reality of emotion regulation system is the core pathol-
the situation rather than judgments about the ogy; thus, it is neither simply symptomatic nor
individuals. This is particularly relevant with a definitional. Emotion dysregulation is a prod-
label as stigmatized among mental health pro- uct of the combination of emotional vulnera-
fessionals as “borderline” (for examples of the bility and difficulties in modulating emotional
misuse of the diagnosis, see Reiser & Levenson, reactions. Emotional vulnerability is conceptu-
1984). alized as high sensitivity to emotional stimuli,
intense emotional responses, and a slow return Invalidating Environments

to emotional baseline. Deficits in emotion
modulation may be due to difficulties in (1) in- Most individuals with an initial temperamental
hibiting mood-dependent behaviors; (2) orga- vulnerability to emotion dysregulation do not
nizing behavior in the service of goals, inde- develop BPD. Thus, the theory suggests further
pendently of current mood; (3) increasing or that particular developmental environments
decreasing physiological arousal as needed; (4) are necessary. The crucial developmental cir-
distracting attention from emotionally evoca- cumstance in Linehan’s theory is the transac-
tive stimuli; and/or (5) experiencing emotion tion between emotion vulnerability and the
without either immediately withdrawing or presence of the “invalidating environment”
producing an extreme secondary negative emo- (Linehan, 1987a, 1987b, 1989, 1993a), which
tion (see Gottman & Katz, 1990, for a further is defined by its tendency to negate, punish,
discussion). and/or respond erratically and inappropriately
Conceptually, the deficit in the emotion reg- to private experiences, independent of the va-
ulation system leads to not only immense emo- lidity of the actual behavior. Private experi-
tional suffering but also multiple behavioral ences, and especially emotional experiences
problems in individuals with BPD. When clini- and interpretations of events, are not taken as
cian’s ratings of characteristics associated with valid responses to events by others; are pun-
psychopathology are examined, tendencies to- ished, trivialized, dismissed, or disregarded;
ward being chronically anxious and unhappy, and/or are attributed to socially unacceptable
depressed, or despondent are the most highly characteristics, such as overreactivity, inability
descriptive of the BPD (Bradley, Zittel, & to see things realistically, lack of motivation,
Westen, 2005). Dysfunction leads the individ- motivation to harm or manipulate, lack of dis-
ual to attempt to escape aversive emotions, of- cipline, or failure to adopt a positive (or, con-
ten leading to further suffering. For example, a versely, discriminating) attitude. The invali-
female client may be experiencing intense anger dating environment can be any part of an
after a fight with her partner, and in an effort to individual’s social environment, including im-
escape the anger, she engages in cutting behav- mediate or extended family, school, work, or
iors. She begins to feel relief from her anger for community. Within each of these environments
a short period of time. However, once her an- are even more specific idiosyncrasies that may
ger begins to subside, shame in response to the impact the environment, such as birth order,
cutting behavior begins to increase and the cy- years between siblings, teachers and peers, and/
cle of emotion escape behavior continues. Al- or coworkers. It is important to note that be-
though the mechanisms of the initial dysregula- cause two children grew up in the same home
tion remain unclear, it is likely that biological does not mean that they were raised in identical
factors play a primary role. Siever and Davis environments. Furthermore, individuals are of-
(1991) hypothesized that deficits in emotion ten not aware of their invalidating behaviors
regulation for clients with BPD are related to and are not acting with a malicious intent.
both instability and hyperresponsiveness of There are three primary characteristics of the
catecholamine function. The etiology of this invalidating environment. First, the environ-
dysregulation may range from genetic influ- ment indiscriminately rejects communication
ences to prenatal factors to traumatic child- of private experiences and self-generated be-
hood events affecting development of the brain haviors. For example a person may be told,
and nervous system. Furthermore, adoption “You are so angry, but you won’t admit it” or
studies of monozygotic (MZ) twins (Davison “You can’t be hungry, you just ate.” Second,
& Neale, 1994) suggest a genetic vulnerability. the invalidating environment may punish emo-
However, researchers do not claim that genetic tional displays and intermittently reinforce
or biological factors accounted for all pathol- emotional escalation. For example, a woman
ogy. If pathology were solely determined by ge- breaks up with her partner and is feeling de-
netics, then 100% of the MZ twins would have pressed. Her friends and family begin telling
been presumed to share the same pathology. her to “Get over it,” “He wasn’t worth it,”
Because this does not occur, we can explain the “Don’t feel sad.” Over the course of the next
differences through the transactions between week, she becomes more depressed and is be-
biology, as described earlier, and the environ- ginning to withdraw from daily activities.
ment. Again, her environment responds in an invali-
dating manner. Finally after another 3 days of an expressive style later seen in the adult with
high emotional arousal she makes a suicide at- BPD—a style that vacillates from inhibition
tempt. At that moment the environment jumps and suppression of emotional experience to ex-
in and provides support by taking care of her. treme behavioral displays. Behaviors such as
Unfortunately, this type of pattern often results overdosing, cutting, and burning have impor-
in inadvertent reinforcement of extreme dys- tant affect-regulating properties and are addi-
functional behavior. Finally, the invalidating tionally quite effective in eliciting helping be-
environment may oversimplify the ease of haviors from an environment that otherwise
problem solving and meeting goals for an indi- ignores efforts to ameliorate intense emotional
vidual. pain. From this perspective, the dysfunctional
The high incidence of childhood sexual behaviors characteristic of BPD may be viewed
abuse reported among individuals with BPD as maladaptive solutions to overwhelming, in-
(Bryer, Nelson, Miller, & Krol, 1987; Herman, tensely painful negative affect.
1986; Herman, Perry, & van der Kolk, 1989;
Wagner, Linehan, & Wasson, 1989) suggests
that sexual abuse may be a prototypic invali- DIALECTICAL DILEMMAS
dating experience for children. The relation-
ship of early sexual abuse to BPD, however, is Linehan (1993a) describes “dialectical dilem-
quite controversial and is open to many inter- mas” as behavioral patterns of the client that
pretations. On the one hand, Silk, Lee, Hill, often interfere with therapy. These behavioral
and Lohr (1995) reported that the number of patterns, also referred to as “secondary tar-
criterion BPD behaviors met was correlated gets” in treatment (compared to other targets
with severity of childhood sexual abuse in a that we describe later) represent six behaviors
group of clients with BPD. On the other hand, that are dichotomized into a set of three dimen-
a review by Fossati, Madeddu, and Maffei sions of behavior defined by their opposite
(1999) suggested that sexual abuse is not a ma- poles (see Figure 9.1). At one end of each di-
jor risk factor for BPD. mension is the behavior that theoretically is
The overall results of this transactional pat- most directly influenced biologically via defi-
tern between the emotionally vulnerable indi- cits in emotion regulation. At the other end is
vidual and the invalidating environment are the behavior that has been socially reinforced in
emotional dysregulation and behavioral pat- the invalidating environment. These secondary
terns exhibited by the borderline adult. Such an targets are characteristics of individuals with
individual has never learned how to label and BPD that often interfere with change, thus in-
regulate emotional arousal, how to tolerate terfering with therapy.
emotional distress, or when to trust his or her
own emotional responses as reflections of valid
interpretations of events resulting in self-
invalidation (Linehan, 1993a). In more optimal
environments, public validation of one’s pri-
vate, internal experiences results in the devel-
opment of a stable identity. In the family of a
person with BPD, however, private experiences
may be responded to erratically and with insen-
sitivity. Thus, the individual learns to mistrust
his or her internal states, and instead scans the
environment for cues about how to act, think,
or feel. This general reliance on others results
in the individual’s failure to develop a coherent
sense of self. Emotional dysfunction also inter-
feres with the development and maintenance of
stable interpersonal relationships, which de-
pend on both a stable sense of self and a capac-
ity to self-regulate emotions. The invalidating
environment’s tendency to trivialize or ignore
the expression of negative emotion also shapes FIGURE 9.1. Dialectical dilemmas in DBT.
Emotion Vulnerability/Self-Invalidation pressed through willful suppression, meaning

that the individual actively denies the experi-
One dialectical dilemma is represented by bio- ence of all emotion. Often clients who come
logically influenced emotional vulnerability on into our offices simply state, “I don’t do emo-
the one hand (e.g., the sense of being out of tions.” As with emotion vulnerability, self-
control or falling into the abyss) and by socially invalidation needs to be attended to actively
influenced self-invalidation on the other (e.g., and directly with individuals with BPD, due to
hate and contempt directed toward the self, the lethal consequences of these behaviors.
dismissal of one’s accomplishments). Along this
dimension of behavior, clients with BPD often
Active Passivity/Apparent Competence
vacillate between acute awareness of their own
intense, unbearable, and uncontrollable emo- A second dimension of behavior is a tendency
tional suffering on the one hand, and dismissal, toward active passivity versus the socially me-
judgment, and invalidation of their own suffer- diated behavior of apparent competence. Ei-
ing and helplessness on the other. ther pole of this dimension can lead to anger,
Emotion vulnerability here refers to the cli- guilt, or shame on the part of the client, and a
ent’s acute experience and communication of tendency for the therapist to either under- or
emotional vulnerability and excruciating emo- overestimate the client’s capabilities.
tional pain. “Vulnerability” here means the “Active passivity” may be defined as passiv-
acute experience of vulnerability rather than ity in solving one’s own problems, while ac-
the sensitivity to emotional cues that defines tively engaging others to solve one’s problems.
the term when discussing the emotion dysregu- It can also be described as passivity that ap-
lation difficulties of the BPD person. In the case pears to be an active process of shutting down
here, vulnerability is experienced; in the latter in the face of seeing problems coming in the fu-
case, the vulnerability may not be experienced. ture. In a sense, individuals with BPD do not
Three reactions to emotional vulnerability are appear to have the ability to regulate them-
common in BPD: (1) freezing or dissociating in selves internally, particularly when the reg-
the face of intense emotion; (2) rage, often di- ulation required is non-mood-dependent be-
rected at society in general or at individuals haviors. Individuals with BPD appear to be
who are experienced as invalidating; and (3) in- “relational selves” rather than “autonomous
tense despair. Suicide here can function to com- selves”; that is, they are more highly regulated
municate to others the depth of one’s suffering by their environment than by internal dia-
(“I’ll show you”) and/or as an escape from an logues, choices and decisions. Their best form
unendurable life. of self-regulation is to regulate their environ-
On the other side of this polarity is self- ment, such that it then provides the regulation
invalidation. What is invalidated, in essence, is they need. The problem here is that managing
one’s own emotional experiencing and dysregu- one’s environment and getting the support one
lated responses. The most typical pattern here needs requires a good deal of emotional consis-
is a reaction to emotional pain with intense tency and regulation, characteristics that ordi-
self-blame and self-hate. These individuals narily are difficult for individuals with BPD.
identify themselves as perpetrators, which re- Lorna Benjamin has described this charac-
sults in intense levels of shame and contempt teristic as “My misery is your command”
toward the self (“There is nothing wrong with (1996, p. 192).
me, I’m just a bad person”). Mood-dependent On the opposite side of the polarity is appar-
perfectionism is also common. Here, the indi- ent competence. “Apparent competence” refers
vidual belittles, ignores, or discounts the diffi- to the tendency of other individuals to overesti-
culty of his or her own life or may overestimate mate the capabilities of the individual with
the ease of solving current problems. Unfortu- BPD. Thus, this characteristic is defined by the
nately, this may initiate the start of a cycle that behavior of the observer rather than the behav-
may eventually end in death. Extreme perfec- ior of the individual with BPD. This failure to
tionism often ultimately leads to failure, espe- accurately perceive their difficulties and “dis-
cially in individuals who overestimate their ability” has serious effects on individuals with
abilities; the failure then results in self-hatred, BPD. Not only do they not get the help they
which cues suicidal behaviors in these individu- need, but also their emotional pain and diffi-
als. Finally, self-invalidation can also be ex- culties may easily be invalidated, leading to a
further sense of being misunderstood. A num- riences related to current crises may result in
ber of behavioral patterns can precipitate this problem behaviors that add to existing crises.
overestimation of the competence of the indi- As with all of these dialectical dilemmas, the
vidual with BPD. Often, a significant discrep- solution is for therapist and client to work to-
ancy between the individual’s verbal and non- ward a more balanced position that represents
verbal presentations results in the individual a synthesis of the opposing poles.
with BPD believing that he or she has suffi- Individuals with BPD who experience unre-
ciently communicated his or her level of dis- lenting crises have lives that are often charac-
tress, when in fact the observer interprets the terized as chaotic and in crisis. “Crisis” is de-
individual as effectively managing a difficult fined as the occurrence of problems that are
situation. An example would be a woman extreme, with significant pressure to resolve
speaking nonchalantly and without emotion them quickly. The consequence of the unrelent-
about urges toward suicide after a fight with ing crisis is that the individual with BPD, as
her husband. Individuals with BPD also fre- well as the person’s environmental resources,
quently have difficulty generalizing behaviors such as family, friends, coworkers, and even the
across situations, especially in relationships. therapist, slowly wear down. There are three
For example, the person may be able to cope typical scenarios that result in a pattern of un-
well in the presence of one person, such as a relenting crisis. First, individuals with extreme
therapist, but be unable to cope when he or she impulsivity and emotion dysregulation engage
is alone or with someone other than the thera- in behaviors that result in crisis situations. Poor
pist. The therapist, understandably, may then judgment is a key element to assess when ana-
fail to predict the dysregulation that occurs as lyzing the impulsive behaviors of individuals
the client walks away from the therapy session. with BPD. Second, situations that do not start
Additionally, there may be a difficulty in gener- out as crises can quickly become critical due to
alizing coping behaviors across different the lack of resources available to many individ-
moods. In one mood, a problem is solvable; in uals with BPD. This may be due to socioeco-
another, it is not. This may not be so difficult nomic status, or to lack of family or peer sup-
for the observer to figure out if mood changes port. Finally, unrelenting crises can be due
are readily apparent to the observer, but often simply to fate or bad luck at a given moment, a
they are not. Thus, accurate estimates of the phenomenon that is out of the person’s control.
person’s competence actually require the ob- For example, an unexpected disaster in a cli-
server, such as the therapist, constantly to an- ent’s apartment due to the neighbors running
ticipate mood changes that might occur to be the water in their sink for an extended period
able to predict what a client might or might not of time, might occur. The floors in the client’s
do. It is this characteristic, more than any apartment are damaged by the water and he or
other, that leads so often to a client walking out she does not have the financial resources to pay
of a session, with the therapist believing all is for renter’s insurance or to replace the carpet in
well, only to end up in the emergency depart- the apartment. His or her apartment is now un-
ment with a suicide attempt 2 hours later. At inhabitable but he or she does not have any
times, client failures are nothing more than fail- place else to stay. This problem is out of the
ures of the therapist (and often the client, also) person’s control, but it is still that person’s re-
to predict future behavior accurately. sponsibility to solve.
At the other extreme, and often precipitated
by a crisis, is the phenomenon of “inhibited
Unrelenting Crisis/Inhibited Grieving
grieving.” In this context, “grief” refers to the
The third dimension of behavior is the ten- process of grieving, including experiencing mul-
dency of the client with BPD to experience life tiple painful emotions associated with loss, par-
as a series of unrelenting crises as opposed to ticularly traumatic loss, not just the one emotion
the behavior of “inhibited grieving” (i.e., an in- of deep sadness or grief. Individuals with BPD
ability to experience emotions associated with may not be able to experience or process the grief
significant trauma or loss). The client experi- related to the loss of the life they had expected
ences each of these extremes in a way that facil- for themselves, and ordinarily do not believe
itates movement to the other extreme; for they will recover from the grief if they actually
example, attempting to inhibit emotional expe- try to experience or to cope with it on their own.
As one client said to us, “I don’t do sadness.” An- addressed during this stage, are likely to be im-
other said, “I feel sad, I die.” Individuals with portant throughout all stages of treatment. In
BPD may not recognize their own emotional Stage 1 of therapy, the primary focus is on sta-
avoidance and shutdown. Thus, it is crucial that bilizing the client and achieving behavioral
the therapist attend to emotional avoidance, control. Out-of-control behaviors constitute
particularly of sadness and grief, and assist cli- those that are disordered due to the severity of
ents through the grief process. Areas that must the disorder (e.g., as seen in an actively psy-
be confronted, grieved, and finally accepted in- chotic client) or due to severity combined with
clude an insurmountably painful childhood, a complexity of multiple diagnoses (e.g., as seen
biological makeup that makes life harder rather in a suicidal client who has BPD with comorbid
than easier, inability to “fit in” in many environ- panic disorder and depression). Generally, the
ments, absence of loving people in the current criteria for putting a client in Stage 1 are based
environment, or loss of hope for a particular fu- on level of current functioning, together with
ture for which one had ardently hoped. What the inability of the client to work on any other
must be confronted by the therapist is that egre- goals before behavior and functioning come
gious losses can be real and clients might be under better control. As Mintz (1968) sug-
right: They really cannot get out of the abyss if gested in discussing treatment of the suicidal
they fall into it. Regardless of the situation to be client, all forms of psychotherapy are ineffec-
grieved, avoidance of these situations may lead tive with a dead client. In the subsequent stages
to increased shame. The shame is a result of be- (2–4), the treatment goals are to replace “quiet
lieving that one is unloved, being alone, or fear- desperation” with nontraumatic emotional ex-
ing that one will not be able to cope in the face of periencing (Stage 2); to achieve “ordinary”
emotional situations. Many of our clients be- happiness and unhappiness, and to reduce on-
lieve that if they begin to address any of these ar- going disorders and problems in living (Stage
eas, they will not be able to function in their lives, 3); and to resolve a sense of incompleteness and
and often this is true. They do not have the skills to achieve freedom (Stage 4). In summary, the
or resources to assist them with the process of ex- orientation of the treatment is first to get action
periencing emotions. We often tell clients that under control, then to help the client to feel
managing grief or processing emotions requires better, to resolve problems in living and resid-
going to the cemetery to pay tribute to what is ual disorder, and to find freedom (and, for
lost, but building a house at the cemetery and liv- some, a sense of transcendence). All research to
ing there is not a good idea. It is a place to visit, date has focused on the severely or multiply
experience the sadness of the loss, and then disordered clients who enter treatment at Stage
leave. The use of this metaphor has helped many 1. Understanding a client’s severity of disorder
of our clients to experience emotion without fall- and level of treatment through accurate and
ing into the abyss. thorough assessment can assist a therapist in
two ways. First, it aids in treatment planning
and conceptualization with the client, and in
STAGES OF THERAPY identifying the appropriate level of care
AND TREATMENT GOALS needed. Second, it can assist a therapist in de-
termining whether to accept the client into care
In theory, treatment of all clients with BPD can based on the level of severity. For example, if a
be organized and determined based on their therapist has multiple Stage 1 clients, he or she
levels of disorder, and is conceptualized as oc- may not want to take on one more Stage 1 cli-
curring in stages. “Level of disorder” is defined ent, until treatment is either completed with the
by the current severity, pervasiveness, complex- others or far enough along that the therapist
ity, disability, and imminent threat presented by does not have multiple clients in crisis at one
the client. Clients can enter into five stages of time. Furthermore, some therapists may also
treatment based on their current level of disor- use level of severity to determine that a client’s
der. First, a pretreatment stage prepares the cli- condition is not severe enough for the type of
ent for therapy and elicits a commitment to treatment the therapist provides; for example,
work toward the various treatment goals. Ori- DBT may be too intensive a treatment for
entation to specific goals and treatment strate- someone with a single diagnosis of major de-
gies, and commitment to work toward goals pressive disorder.
Pretreatment: Orienting and Commitment tional and stable. Furthermore, DBT does not
promote itself as a suicide prevention pro-
Specific tasks of orientation are twofold. First, gram; instead, it focuses on life improvement.
client and therapist must arrive at a mutually Therefore, the primary treatment goal in DBT
informed decision to work together. Typically, and in Stage 1 specifically is to assist clients
the first one to four sessions are presented to in building a life worth living. DBT attains
the client as opportunities for client and thera- this goal by focusing the treatment on specific
pist to explore this possibility. Diagnostic inter- behavioral targets agreed upon by both thera-
viewing, history taking, and formal behavioral pist and client. Specific targets in order of im-
analyses of high-priority, targeted behaviors portance are to reduce life-threatening behav-
can be woven into initial therapy sessions or be iors (e.g., suicide attempts, increase in suicide
conducted separately. Second, client and thera- ideation, NSSI behaviors, homicidal threats
pist must negotiate a common set of expectan- and behaviors), therapy-interfering behaviors
cies to guide the initial steps of therapy. Agree- (e.g., late to session, missing sessions, not fol-
ments outlining specifically what the client and lowing treatment plan, hostile attacks on the
therapist can expect from each other are dis- therapist), and quality-of-life–interfering be-
cussed and agreed to. When necessary, the ther- haviors (e.g., substance abuse, eating disorder,
apist attempts to modify the client’s dysfunc- homelessness, serious Axis I disorders), and
tional beliefs regarding the process of therapy. to increase behavioral skills. These targets are
Issues addressed include the rate and magni- approached hierarchically and recursively as
tude of change that can reasonably be ex- higher-priority behaviors reappear in each
pected, the goals of treatment and general session. However, this does not mean that
treatment procedures, and various myths the these behaviors must be addressed in this spe-
client may have about the process of therapy in cific order during a session; it means that
general. The dialectical/biosocial view of BPD based on the hierarchy, all relevant behavior
is also presented. Orientation covers several must be addressed at some point within the
additional points. First, DBT is presented as a session. For example, if a client is 10 minutes
supportive therapy requiring a strong collabo- late to session (therapy-interfering behavior)
rative relationship between client and thera- and has cut within the last week (life-
pist. DBT is not a suicide prevention program, threatening behavior), the therapist may
but a life enhancement program in which client choose to address the therapy-interfering
and therapist function as a team to create a life behavior first, then move on to address the
worth living. Second, DBT is described as a life-threatening behaviors.
cognitive-behavioral therapy with a primary With severely dysfunctional and suicidal cli-
emphasis on analyzing problematic behaviors ents, significant progress on first stage targets
and replacing them with skillful behaviors, and may take up to 1 year or more. In addition to
on changing ineffective beliefs and rigid think- these therapy targets, the goal of increasing di-
ing patterns. Third, the client is told that DBT alectical behaviors is universal to all modes of
is a skills-oriented therapy, with special empha- treatment. Dialectical thinking encourages cli-
sis on behavioral skills training. The commit- ents to see reality as complex and multifaceted,
ment and orienting strategies, balanced by vali- to hold contradictory thoughts simultaneously
dation strategies described later, are the most and learn to integrate them, and to be comfort-
important strategies during this phase of treat- able with inconsistency and contradictions. For
ment. The therapist places a strong effort into individuals with BPD, who are extreme and di-
getting the client to commit to not engaging in chotomous in their thinking and behavior, this
suicidal or NSSI behaviors for some specified is a formidable task indeed. A dialectical em-
period of time before allowing the client to phasis applies equally to a client’s patterns of
leave the session; it can be for 1 year, 6 months, behavior, because the client is encouraged to
until the next session, or until tomorrow. integrate and balance emotional and overt
behavioral responses. In particular, dialectical
Stage 1: Attaining Basic Capacities tensions arise in the areas of skills enhancement
versus self-acceptance, problem solving ver-
The primary focus of the first stage of ther- sus problem acceptance, and affect regulation
apy is attaining behavioral control in order to versus affect tolerance. Behavioral extremes,
build a life pattern that is reasonably func- whether emotional, cognitive, or overt re-
sponses, are constantly confronted while more that are iatrogenic (e.g., inadvertently reinforc-
balanced responses are taught. ing dysfunctional behaviors), as well as any
that cause the client unnecessary distress or
make progress difficult (e.g., therapist arriving
Life-Threatening Behaviors late to sessions, missing sessions, not returning
Keeping a client alive must, of course, be the phone calls within a reasonable time frame).
first priority in any psychotherapy. Thus, re- These behaviors are dealt with in therapy ses-
ducing suicide crisis behaviors (any behaviors sions, if brought up by either the client or the
that place the client at high and imminent risk therapist, and are also discussed during the
for suicide or threaten to do so, including credi- consultation/supervision meeting.
ble suicide threats, planning, preparations, ob-
taining lethal means, and high suicide intent) is
the highest priority in DBT. The target and its
Quality-of-Life–Interfering Behaviors
priority are made explicit in DBT during orien- The third target of Stage 1 addresses all other
tation and throughout treatment, simply be- behaviors that interfere with the client having
cause suicidal behavior and the risk of suicide a reasonable quality of life. Typical behaviors
are of paramount concern for clients with BPD. in this category include serious substance
Similarly, any acute, intentional NSSI behav- abuse, severe major depressive episodes, se-
iors share the top priority. The priority here is vere eating disorders, high-risk and out-of-
due both to the risk of suicidal and NSSI control sexual behaviors, extreme financial
behavior as the single best predictor of subse- difficulties (uncontrollable spending or gam-
quent suicide. Similarly, DBT also targets sui- bling, inability to handle finances), criminal
cide ideation and client expectations about the behaviors that are likely to lead to incarcera-
value and long-term consequences of suicidal tion, employment- or school-related dysfunc-
behavior, although these behaviors may not tional behaviors (a pattern of quitting jobs or
necessarily be targeted directly. school prematurely, getting fired or failing in
school, not engaging in any productive activi-
ties), housing-related dysfunctional behaviors
Therapy-Interfering Behaviors (living with abusive people, not finding stable
Keeping clients and therapists working to- housing), mental health–related patterns (go-
gether collaboratively is the second explicitly ing in and out of hospitals, failure to take or
targeted priority in DBT. The chronic nature of abuse of necessary medications), and health-
most problems among clients with BPD, in- related problems (failure to treat serious med-
cluding their high tendency to end therapy pre- ical disorders). The goal here is for the client
maturely, and the likelihood of therapist burn- to achieve a stable lifestyle that meets reason-
out and iatrogenic behaviors when treating able standards for safety and adequate func-
BPD require such explicit attention. Both client tioning.
and therapist behaviors that threaten the rela-
tionship or therapeutic progress are addressed
directly, immediately, consistently, and
Behavioral Skills
constantly—and most importantly, before The fourth target of Stage 1 is for the client to
rather than after either the therapist or the cli- achieve a reasonable capacity for acquiring and
ent no longer wants to continue. Interfering be- applying skillful behaviors in the areas of dis-
haviors of the client, including those that actu- tress tolerance, emotion regulation, interper-
ally interfere with receiving the therapy (e.g., sonal effectiveness, self-management, and the
lateness to sessions, missed sessions, lack of capacity to respond with awareness without
transportation to sessions, dissociating in ses- being judgmental (“mindfulness” skills). In our
sions) or with other clients benefiting from outpatient program, the primary responsibility
therapy (in group or milieu settings; e.g., selling for skills training lies with the weekly DBT
drugs to other clients in the program), and skills group. The individual therapist monitors
those that burn out or cross the personal limits the acquisition and use of skills over time, and
of the therapist (e.g., repeated crisis calls at aids the client in applying skills to specific
three in the morning, repeated verbal attacks problem situations in his or her own life. Addi-
on the therapist) are treated within therapy ses- tionally, it is the role of the individual therapist,
sions. Behaviors of the therapist include any not the skills group leader, to provide skills
coaching to the client as needed when problems independent self-respect. To this end, the client
arise. is helped to value, believe in, trust, and validate
him- or herself. The targets here are the
abilities to evaluate one’s own behavior
Stage 2: Posttraumatic Stress Reduction
nondefensively, to trust one’s own responses,
Stage 1 of DBT takes a direct approach to man- and to hold on to self-evaluations, independent
aging dysfunctional behavioral and regulating of the opinions of others. Ultimately, the thera-
emotional patterns. Although the connection pist must pull back and persistently reinforce
between current behavior and previous trau- the client’s independent attempts at self-
matic events (including those from childhood) validation, self-care, and problem solving. Al-
may be explored and noted, the focus of the though the goal is not for clients to become in-
treatment is distinctly on analyzing the rela- dependent of all people, it is important that
tionship among current thoughts, feelings, and they achieve sufficient self-reliance to relate to
behaviors, and on accepting and changing cur- and depend on others without self-invalidating.
rent patterns. The aim of Stage 2 DBT is to re-
duce “quiet desperation,” which can be defined
Stage 4: Attaining the Capacity
as extreme emotional pain in the presence of
for Freedom and Sustained Contentment
control of action (Linehan et al., 1999). A wide
range of emotional experiencing difficulties The final stage of treatment in DBT targets the
(e.g., avoidance of emotions and emotion- resolution of a sense of incompleteness and the
related cues) are targeted in this stage, with the development of a capacity for sustained con-
goal of increasing the capacity for normative tentment. The focus on freedom encompasses
emotional experiencing (i.e., the ability to ex- the goal of freedom from the need to have one’s
perience a full range of emotions without either wishes fulfilled, or one’s current life or behav-
severe emotional escalation or behavioral ioral and emotional responses changed. Here
dyscontrol). Because many individuals with the goals are expanded awareness, spiritual ful-
BPD have histories of severe and chronic trau- fillment, and the movement into experiencing
matic experiences, these problems frequently flow. For individuals at Stage 4, long-term
take the form of posttraumatic stress disorder insight-oriented psychotherapy, spiritual direc-
(PTSD) and related behaviors and are treated tion or practices, or other organized experien-
through exposure therapy (formal and infor- tial treatments and/or life experiences may be
mal). Stage 2 addresses four goals: remember- of most benefit.
ing and accepting the facts of earlier traumatic
events; reducing stigmatization and self-blame
commonly associated with some types of trau- STRUCTURING TREATMENT:
ma; reducing the oscillating denial and intru- FUNCTIONS AND MODES
sive response syndromes common among indi-
Functions of Treatment
viduals who have suffered severe trauma; and
resolving dialectical tensions regarding place- Treatment in DBT is structured around the five
ment of blame for the trauma. essential functions it serves. Treatment func-
tions to (1) enhance behavioral capabilities by
expanding the individual’s repertoire of skillful
Stage 3: Resolving Problems in Living
behavioral patterns; (2) improve the client’s
and Increasing Respect for Self
motivation to change by reducing reinforce-
In the third stage, DBT targets the client’s unac- ment for dysfunctional behaviors and high-
ceptable unhappiness and problems in living. probability responses (cognitions, emotions,
At this stage, the client with BPD has either actions) that interfere with effective behaviors;
done the work necessary to resolve problems in (3) ensure that new behaviors generalize from
the prior two stages or was never severely dis- the therapeutic to the natural environment; (4)
ordered enough to need it. Although problems enhance the motivation and capabilities of the
at this stage may still be serious, the individual therapist so that effective treatment is ren-
is functional in major domains of living. The dered; and (5) structure the environment so
goal here is for the client to achieve a level of that effective behaviors, rather than dysfunc-
ordinary happiness and unhappiness, as well as tional behaviors, are reinforced.
Modes of Treatment: problem, or if the behavior is currently not evi-

Who Does What and When dent, then the therapist shifts attention to
another treatment target according to the hier-
Responsibility for performing functions and archy. The consequence of this priority alloca-
meeting target goals of treatment in DBT is tion is that when high-risk suicidal behaviors
spread across the various modes of treatment, or intentional self-injury, therapy-interfering
with focus and attention varying according to behaviors, or serious quality-of-life–interfering
the mode of therapy. The individual therapist behaviors are occurring, at least part of the ses-
(who is always the primary therapist in DBT) sion agenda must be devoted to each of these
attends to one order of targets and is also, with topics. If these behaviors are not occurring at
the client, responsible for organizing the treat- the moment, then the topics to be discussed
ment so that all goals are met. In skills training, during Stages 1, 3, and 4 are set by the client.
a different set of goals is targeted; during phone The therapeutic focus (within any topic area
calls, yet another hierarchy of targets takes pre- discussed) depends on the stage of treatment,
cedence. In the consultation/supervision mode, the skills targeted for improvement, and any
therapists’ behaviors are the targets. Therapists secondary targets. During Stage 1, for example,
engaging in more than one mode of therapy any problem or topic area can be conceptual-
(e.g., individual, group, and telephone coach- ized in terms of interpersonal issues and skills
ing) must stay cognizant of the functions and needed, opportunities for emotion regulation,
order of targets specific to each mode, and and/or a necessity for distress tolerance. During
switch smoothly from one hierarchy to another Stage 3, regardless of the topic, the therapist fo-
as the modes of treatment change. cuses on helping the client decrease problems in
living and achieve independent self-respect,
Individual Therapy self-validation, and self-acceptance both within
the session and within everyday life. (These are,
DBT assumes that effective treatment must at- of course, targets all through the treatment, but
tend both to client capabilities and behavioral the therapist pulls back further during Stage 3
skills deficits, and to motivational and behav- and does less work for the client than during
ioral performance issues that interfere with use the two preceding stages.) During Stage 2, the
of skillful responses (function 2). Although major focus is on reducing pervasive “quiet
there are many ways to effect these principles, desperation,” as well as changing the extreme
in DBT the individual therapist is responsible emotions and psychological meanings associ-
for the assessment and problem solving of skill ated with traumatizing cues.
deficits and motivational problems, and for or- For highly dysfunctional clients, it is likely
ganizing other modes to address problems in that early treatment will necessarily focus on
each area. the upper part of the hierarchy. For example, if
Individual outpatient therapy sessions are suicidal or NSSI behavior has occurred during
scheduled on a once-a-week basis for 50–90 the previous week, attention to it takes prece-
minutes, although twice-weekly sessions may dence over attention to therapy-interfering be-
be held as needed during crisis periods or at the havior. In turn, focusing on therapy-interfering
beginning of therapy. The priorities of specific behaviors takes precedence over working on
targets within individual therapy are the same quality-of-life–interfering behaviors. Although
as the overall priorities of DBT discussed it is often possible to work on more than one
earlier. Therapeutic focus within individual target (including those generated by the client)
therapy sessions is determined by the highest- in a given session, higher-priority targets al-
priority treatment target relevant at the mo- ways take precedence, but all relevant targets
ment. This ordering does not change over the must be addressed adequately during the ses-
course of therapy; however, the relevance of a sion. Again, targets do not need to be ad-
target does change. Relevance is determined dressed in sequential order, they just have to be
by either the client’s most recent, day-to-day addressed during the session. Determining the
behavior (since the last session) or by current relevance of targeted behaviors is assisted by
behavior during the therapy session. If satisfac- the use of diary cards. These cards are filled out
tory progress on one target goal has been by the client during at least the first two stages
achieved or the behavior has never been a of therapy and are brought to weekly sessions.
Failure to complete or to bring in a card is con- hour group skills training sessions that clients
sidered a therapy-interfering behavior and must attend, ordinarily for a minimum of 6
should be openly addressed as such. Diary months and preferably for a year. Skills train-
cards record daily instances of suicidal and ing can also be done individually, although it is
NSSI behavior, urges to self-harm or to engage often more difficult to stay focused on teaching
in suicide behaviors (on a 0- to 5-point scale), new skills in individual than in group therapy.
“misery,” use of substances (licit and illicit), After a client has gone through all skills mod-
and use of behavioral skills. Other targeted be- ules twice (i.e., for 1 year), remaining in skills
haviors (bulimic episodes, daily productive ac- training is a matter of personal preference and
tivities, flashbacks, etc.) may also be recorded need. Some DBT programs have developed
on the blank area of the card. The therapist do- graduate groups for individuals who have ac-
ing DBT must develop the pattern of routinely quired the skills but still need weekly consulta-
reviewing the card at the beginning of each ses- tion in applying the skills effectively to every-
sion. The card acts as a road map for each ses- day difficulties. It is important to note that
sion; therefore, a session cannot begin until a there is no research to date on the effectiveness
diary card has been completed. If the card indi- of graduate groups. In adolescent programs,
cates that a life-threatening behavior has oc- family members are usually invited. Some pro-
curred, it is noted and discussed. If high suicide grams include a separate friends and families
or self-harm urges are recorded, or there is a skills training group as well.
significant increase (e.g., an increase of 3 points Each group typically has a leader and a
or higher on the 0- to 5-point scale for urges) coleader. Whereas the primary role of the
over the course of the week, they are assessed leader is to teach the skills, the coleader focuses
to determine whether the client is at risk for on managing group process by keeping mem-
suicide. If a pattern of substance abuse or de- bers both focused and attending to the material
pendence appears, it is treated as a quality-of- being taught, as well as processing the informa-
life–interfering behavior. tion (e.g., ensuring everyone is on the correct
Work on targeted behaviors involves a coor- page, noticing when the leader’s invalidation
dinated array of treatment strategies, described has led to a member shutting down, waking
later in this chapter. Essentially, each session is someone up, sitting next to a member who is
a balance between structured, as well as un- crying during group). We have found that it is
structured, problem solving (including simple difficult to keep the group focused and the
interpretive activities by the therapist) and un- leader on schedule for teaching the skills if the
structured validation. The amount of the thera- leader attempts to manage both roles on his or
pist’s time allocated to each—problem solving her own. Oftentimes, the coleader role is the
and validating—depends on (1) the urgency of more difficult position to learn.
the behaviors needing change or problems to Skills training in DBT follows a psychoedu-
be solved, and (2) the urgency of the client’s cational format. In contrast to individual ther-
needs for validation, understanding, and accep- apy, in which the agenda is determined primar-
tance without any intimation of change being ily by the problem to be solved, the skills
needed. However, there should be an overall training agenda is set by the skill to be taught.
balance in the session between change (prob- As mentioned earlier, skills training also has a
lem solving) and acceptance (validation) strate- hierarchy of treatment targets that are used to
gies. Unbalanced attention to either side may keep the group focused: (1) therapy-destroying
result in a nondialectical session, in addition to behaviors (e.g., using drugs on premises, which
impeding client progress. could lead to the clinic being shut down; prop-
erty damage; threatening imminent suicide or
homicidal behavior to a fellow group member
Skills Training or therapist); (2) increasing skills acquisition
The necessity of crisis intervention and atten- and strengthening; and (3) decreasing therapy-
tion to other primary targets makes skills ac- interfering behaviors (e.g., refusing to talk in a
quisition within individual psychotherapy very group setting, restless pacing in the middle of
difficult. Thus, a separate component of treat- sessions, attacking the therapist and/or the
ment directly targets the acquisition of behav- therapy). However, therapy-interfering behav-
ioral skills (function 1). In DBT this usually iors are not given the attention in skills training
takes the form of separate, weekly, 2- to 2½- that they are given in the individual psycho-
therapy mode. If such behaviors were a pri- or control them. Distress tolerance skills com-
mary focus, there would never be time for prise two types of skills. First, crisis survival
teaching behavioral skills. Generally, therapy- skills are used to regulate behavior in order to
interfering behaviors are put on an extinction manage painful situations without making
schedule, while a client is “dragged” through them worse (e.g., without engaging in life-
skills training and simultaneously soothed. In threatening behavior) until the problem can be
DBT, all skills training clients are required to be solved. Second, accepting reality skills are used
in concurrent individual psychotherapy. to tolerate the pain of problems that cannot be
Throughout group or individual skills training, solved in either the short-term future or that
each client is urged to address other problem- may have occurred in the past and, therefore,
atic behaviors with his or her primary thera- cannot be changed ever. Emotion regulation
pist; if a serious risk of suicide develops, the skills target the reduction of emotional distress
skills training therapist refers the problem to through exposure to the primary emotion in a
the primary therapist. nonjudgmental atmosphere. Emotion regula-
Although all of the strategies described be- tion skills include affect identification and la-
low are used in both individual psychotherapy beling, mindfulness to the current emotions
and skills training, the mix is decidedly dif- (i.e., experiencing nonjudgmentally), identify-
ferent. Skills acquisition, strengthening, and ing obstacles to changing emotions, increasing
generalization strategies are the predominant positive emotional events, and behavioral ex-
change strategies in skills training. In addition, pressiveness opposite to the emotion. Interper-
skills training is highly structured, much more sonal effectiveness skills teach effective meth-
so than the individual psychotherapy compo- ods for deciding on objectives within conflict
nent. Half of each skills training session is de- situations (either asking for something or say-
voted to reviewing homework practice of the ing “no” to a request) and teach strategies that
skills currently being taught, and the other half maximize the chances of obtaining those objec-
is devoted to presenting and practicing new tives without harming the relationship or sacri-
skills. Except when interpersonal process issues ficing self-respect. Self-management skills are
seriously threaten progress, the agenda and taught in conjunction with the other behavioral
topics for discussion in skills training are usu- skills; however, there is not a specific module
ally set by the group leader. allocated to these skills, because behavioral
Four skills modules are taught on a rotating principles are inherent in all of DBT. Self-
basis over the course of 6 months. In standard management skills include knowledge of the
DBT, mindfulness skills are taught in 2 consec- fundamental principles of learning and behav-
utive weeks at the beginning of each of the sub- ior change, and the ability to set realistic goals,
sequent modules. New members are able to to conduct one’s own behavioral analysis, and
join a group during either the 2 weeks of mind- to implement contingency management plans.
fulness or the first 2 weeks of the subsequent
module. If a new member is not ready to join
after this point, he or she must wait until the
Telephone Consultation
start of the next mindfulness module. Telephone calls between sessions (or other
Mindfulness skills are viewed as central in extratherapeutic contact when DBT is con-
DBT; thus, they are labeled the “core” skills. ducted in other settings, e.g., inpatient units)
These skills represent a behavioral translation are an integral part of DBT. Telephone consul-
of meditation (including Zen and contempla- tation calls also follow a target hierarchy: (1) to
tive prayer) practice and include observing, provide emergency crisis intervention and si-
describing, spontaneous participating, being multaneously break the link between suicidal
nonjudgmental, focusing awareness, and focus- behaviors and therapist attention; (2) to pro-
ing on effectiveness. Unlike standard behavior vide coaching in skills and promote skills gen-
and cognitive therapies, which ordinarily focus eralization (function 3); and (3) to provide a
on changing distressing emotions and events, a context for repairing the therapeutic relation-
major emphasis of DBT is on learning to man- ship, without requiring the client to wait until
age pain skillfully. Mindfulness skills reflect the the next session. With respect to calls for skills
ability to experience and to observe one’s coaching, the focus of a phone call varies de-
thoughts, emotions, and behaviors without pending on the complexity and severity of the
evaluation, and without attempting to change problem to be solved and the amount of time
the therapist is willing to spend on the phone. It client who does not try using actual skills to
is important to note that these calls are not manage the problem at hand prior to calling
considered therapy sessions and should not be the therapist.
used as such. Therapists must keep the function Additionally, the therapist is balancing the
of the call in mind so that they do not begin change-focused strategies with validation
conducting sessions over the phone; this behav- throughout the call. It is important that the
ior could easily lead to therapist burnout with therapist be aware of the contingency manage-
the client. With easy or already clear situations, ment principles that may be occurring during
in which it is reasonably easy to determine the phone calls to avoid inadvertently reinforc-
what the client can or should do in the situa- ing crisis behaviors and to increase therapist–
tion, the focus is on helping the client use client contact between sessions.
behavioral skills (rather than dysfunctional be- A skills trainer uses phone calls for only one
haviors) to address the problem. Alternatively, reason: to keep a client in the therapy (includ-
with complex problems, or with problems too ing, of course, when necessary, keeping the cli-
severe for the client to resolve soon, the focus is ent alive). All other problems are handled by
on ameliorating and tolerating distress, and in- the primary therapist, and suicidal crises are
hibiting dysfunctional problem-solving behav- turned over to the primary therapist as soon as
iors until the next therapy session. In the latter possible. We have learned that this can be one
case, resolving the problem that set off the cri- of the most difficult distinctions for group lead-
sis is not the target of telephone coaching calls. ers to uphold. Clients may call group leaders
With the exception of taking necessary steps for a variety of reasons, and it is the role of the
to protect the client’s life when he or she has group leader consistently to refer the client
threatened suicide, all calls for help are handled back to the individual therapist. For example, a
as much alike as possible. This is done to break client may call a group leader to ask for assis-
the contingency between suicidal and NSSI be- tance with the homework assigned the previous
haviors, and increased phone contact. To do week. Although this may seem appropriate for
this, the therapist can do one of two things: re- the skills trainer to address, it should be re-
fuse to accept any calls (including suicide crisis ferred back to the individual therapist. At
calls), or insist that the client who calls during most, the group leader may repeat what the as-
suicidal crises also call during other crises and signment was but should not provide any
problem situations. As Linehan (1993b) notes, coaching in how to complete the assignment.
experts on suicidal behaviors uniformly say The final priority for phone calls to individ-
that therapist availability is necessary with sui- ual therapists is relationship repair. Clients
cidal clients. Thus, DBT chooses the latter with BPD often experience delayed emotional
course and encourages (and at times insists) on reactions to interactions that have occurred
calls during nonsuicidal crisis periods. In DBT, during therapy sessions. From a DBT perspec-
calling the therapist too infrequently, as well tive, it is not reasonable to require clients to
as too frequently, is considered therapy- wait up to a whole week before dealing with
interfering behavior. Through orientation to these emotions, and it is appropriate for a cli-
coaching calls during pretreatment the client ent to call for a brief “heart-to-heart” talk. In
learns what to expect during the calls. For ex- these situations, the role of the therapist is to
ample, a therapist may communicate to the cli- soothe and to reassure. In-depth analyses
ent in session what the therapist will ask during should wait until the next session.
the call, “What’s the problem? What skills have
you used? Where is your skills book? Go get it,
and let’s figure out what other skills you can
Consultation Team
use to get through this situation.” It is impor- DBT assumes that effective treatment of BPD
tant to highlight that clients and therapists can must pay as much attention to the therapist’s
easily fall into the trap of considering the act of behavior and experience in therapy as it does to
calling for phone consultation a skill. Although the client’s. Treating clients with BPD is enor-
asking for help may be a current target of treat- mously stressful, and staying within the DBT
ment, it is not considered a skill to be used therapeutic frame can be tremendously difficult
when the client is in distress. Therapists want (function 4). Thus, an integral part of the ther-
to reinforce the client for effectively reaching apy is the treatment of the therapist. Every
out; however, they do not want to reinforce the therapist is required to be on a consultation
team either with one other person or with a TABLE 9.1. DBT Consultation Team
group. DBT consultation meetings are held Commitment Session
weekly and are attended by therapists currently 1. To keep the agreements of the team, especially
providing DBT to clients. At times, the clinical remaining compassionate, mindful, and
setting may require that the team be part of an dialectical.
administrative meeting due to time and space 2. To be available to see a client in whatever role
restraints. When this occurs, it is important to one has joined the team for (e.g., individual
set a specific agenda and time limitations on therapist, group skills trainer, clinical
supervisor, pharmacotherapist).
each part of the meeting (administration, DBT) 3. To function as a therapist in the group (to the
to ensure that therapist consultation issues are group) and not just be a silent observer or a
addressed. The roles of consultation are to hold person that only speaks about his or her own
the therapist within the therapeutic frame and problems.
to address problems that arise in the course of 4. To treat team meetings in the same way one
treatment delivery. Thus, the fundamental tar- treats any other group therapy session (i.e.,
attending the weekly meetings [not double
get is increasing adherence to DBT principles
scheduling other events or clients], on time,
for each member of the consultation group. until the end, with pagers, PDAs, and phones
The DBT consultation team is viewed as an in- out of sight and off or, if necessarily on, on
tegral component of DBT; that is, it is consid- silent).
ered peer group therapy for the therapists, in 5. To come to team meetings adequately
which each member is simultaneously a thera- prepared.
pist to other members and a client. The focus is 6. To be willing to give clinical advice to people
who have more experience (especially when
on applying DBT strategies to increase DBT- it’s hard to imagine yourself as being able to
adherent behaviors and decrease non-DBT be- offer anything useful).
haviors. 7. To have the humility to admit your mistakes/
There are three primary functions of consul- difficulties and the willingness to have the
tation to the therapist in DBT. First, a consulta- group help you solve them.
tion team helps to keep each individual thera- 8. To be nonjudgmental and compassionate of
your fellow clinicians and clients. To ring the
pist in the therapeutic relationship. The role bell of nonjudgmentalness to remind yourself
here is to cheerlead and to support the thera- to not be judgmental or unmindful, but not to
pist. Second, the supervisor or consultation ring it as a proxy for criticizing someone. The
team balances the therapist in his or her inter- bell is a reminder, not a censor.
actions with the client. In providing balance, 9. To properly assess the problem before giving
consultants may move close to the therapist, solutions (do unto others as you wish they
would more often do unto you).
helping him/her maintain a strong position. Or
10. To call out “Elephant in the room” when
consultants may move back from the therapist, others are ignoring or not seeing the elephant.
requiring the therapist to move closer to the cli- 11. To be willing to go through a chain analysis
ent to maintain balance. Third, within pro- even though you were only 31 seconds late
grammatic applications of DBT, the team pro- and you would have been there on time if it
vides the context for the treatment. were not for that traffic light that always
takes all day to change.
12. To participate in team by sharing the roles of
JOINING THE CONSULTATION TEAM Leader, Observer, Note Taker or other tasks
critical to team functioning.
Each team comprises therapists who are cur- 13. If you feel that the consult team is not being
rently treating a DBT client or are available to useful or don’t like the way it is being run,
take on a DBT client. Prior to joining the team, it then say something about it rather than
is important that the therapist be completely silently stewing in frustration.
14. To repair with the team in some way when
aware of his or her commitment. As with clients team meetings are missed, because the team is
during the pretreatment phase of DBT, thera- only as strong as the weakest link. Therefore,
pists must make a commitment to the team (see the absence of any team member is felt.
Table 9.1). A commitment session between the 15. To carry on even when feeling burnt out,
new member and either the team leader, a team frustrated, tired, overworked,
member, or, in some cases, the entire team can be underappreciated, hopeless, ineffective (easier
committed to than done, of course).
extraordinarily helpful here. The team member
conducting the commitment session will use the
same strategies and techniques used in a first
session with a DBT client (e.g., devil’s advocate, tion team agreements (see Table 9.2) have been
pros and cons, troubleshooting). In addition to developed to facilitate a DBT frame and help to
the commitment items listed in Table 9.1, two create a supportive environment for managing
fundamental commitments must be agreed to by client–therapist and therapist–therapist diffi-
each member of the team. First, as mentioned culties. Therefore, a team may elect to read one
previously, the primary function of the team is or all of the team agreements during the team
to increase therapists’ motivation and capability meeting. Most importantly, an agenda is set by
in providing DBT. Therefore, each member the team following the DBT hierarchy of tar-
agrees to work actively toward increasing the gets, with a specific focus on the needs of the
team member’s effectiveness and adherence therapist rather than the problems of the cli-
when applying DBT principles and strategies to ents. Our agenda at the University of Washing-
clients and to other team members. Second, the ton uses the following format; however, the
consultation team is a community of therapists following items can be prioritized differently
treating a community of clients. Thus, each based on the needs of an individual team: (1)
team member agrees to be responsible for treat- the therapists’ need for consultation around cli-
ment and outcomes of all clients treated by the ents’ suicidal crises or other life-threatening be-
team. For example, members of the team are haviors; (2) therapy-interfering behaviors (in-
agreeing that if a client being treated by any cluding client absences and dropouts, as well
member of the team commits suicide, then all as therapist therapy-interfering behaviors); (3)
members will say “Yes” when asked if they have therapist team-interfering behaviors and burn-
ever had a client commit suicide. out; (4) severe or escalating deterioration in
quality-of-life behaviors; (5) reportage of good
news and therapists’ effective behaviors; (6) a
CONSULTATION MEETING FORMAT
summary of the work of the previous skills
There are multiple ways to run a DBT team group and graduate group by group leaders;
meeting. The following is the way we conduct and (7) discussion of administrative issues (re-
our meetings at the University of Washington quests to miss team or be out of town, new cli-
(although it is important to note that even this ent contacts; changes in skills trainers or group
format could change as needs of members time, format of consultation group, etc.). This
change). Each of our DBT teams has an identi- agenda spans the 1-hour consultation meeting.
fied team leader. This person is typically the Although the agenda may look impossibly
most experienced DBT therapist on the team, long, therapists ordinarily manage the time by
and his or her role is to articulate the DBT prin- being explicit about their need for help and
ciples when necessary for overseeing the fidel- consultation from the team.
ity of the treatment provided. Additionally, a
team may have an observer who rings a bell
whenever team members make judgmental
Ancillary Care
comments (in content or tone) about them- When problems in the client’s environment in-
selves, each other, or a client; stay polarized terfere with the client’s functioning or progress,
without seeking synthesis; fall out of mindful- the therapist moves to the case management
ness by doing two things at once; or jump in to strategies. Although not new, case management
solve a problem before assessing the problem. strategies direct the application of core strate-
The point of these observations is not to lay gies (discussed later) to case management prob-
blame, but to focus the team’s awareness on the lems. There are three case management strat-
behavior and move past it. egies: the consultant-to-the-client strategy,
A team may begin with a mindfulness prac- environmental intervention, and the consul-
tice. There are several functions of mindfulness tation/supervision team meeting (described
on a team. First, it helps members transition above). Because DBT is grounded in dialectics
into the team by participating fully and focus- and avoids becoming rigid, a therapist inter-
ing on only one thing in the moment, using a venes in the client’s environment only under
DBT mindset. Second, it can provide an oppor- very specific conditions: (1) The client is unable
tunity for team members to enhance their skills to act on her own behalf and outcome is ex-
in leading and providing feedback about the tremely important; (2) the environment will
practice with other team members. Consulta- only speak with someone who is in high power
TABLE 9.2. DBT Consultation (e.g., the therapist instead of the client); (3)
Team Agreements when the client’s or others lives are in imminent
danger; (4) when it is the humane thing to do
1. Dialectical agreement: We agree to accept a
dialectical philosophy: There is no absolute and will cause no harm; and (5) when the client
truth. When caught between two conflicting is a minor.
opinions, we agree to look for the truth in
both positions and to search for a synthesis by
asking questions such as “What is being left CONSULTATION TO THE CLIENT STRATEGY
out?” The consultation-to-the-client strategy was de-
2. Consultation to the client agreement: We agree veloped with three objectives in mind. First, cli-
that the primary goal of this group is to ents must learn how to manage their own lives
improve our own skills as DBT therapists, and and care for themselves by interacting effec-
not serve as a go-between for clients to each
other. We agree to not treat clients or each
tively with other individuals in the environ-
other as fragile. We agree to treat other group ment, including health care professionals. The
members with the belief that others can speak consultation-to-the-client strategy emphasizes
on their own behalf. clients’ capacities and targets their ability to
3. Consistency agreement: Because change is a take care of themselves. Second, this strategy
natural life occurrence, we agree to accept was designed to decrease instances of “split-
diversity and change as they naturally come ting” between DBT therapists and other indi-
about. This means that we do not have to viduals interacting with clients. Splitting occurs
agree with each others’ positions about how to when different individuals in a client’s network
respond to specific clients, nor do we have to
hold differing opinions on how to treat the cli-
tailor our own behavior to be consistent with
everyone else’s. ent. A fundamental tenet of this strategy is that
therapists do not tell others, including other
4. Observing limits agreement: We agree to health care professionals, how to treat the cli-
observe our own limits. As therapists and
group members, we agree to not judge or ent. The therapist may suggest, but may not de-
criticize other members for having different mand. What this means in practice is that the
limits from our own (e.g., too broad, too therapist is not attached to others treating a cli-
narrow, “just right”). ent in a specific way. By remaining in the role
5. Phenomenological empathy agreement: All of a consultant to the client, the therapist
things being equal, we agree to search for stays out of such arguments. Finally, the
nonpejorative or phenomenologically empathic consultation-to-the-client strategy promotes re-
interpretations of our clients’, our own, and spect for clients by imparting the message that
other members’ behavior. We agree to assume they are credible and capable of performing in-
that we and our clients are trying our best and
want to improve. We agree to strive to see the
terventions on their own behalf.
world through our clients’ eyes and through As mentioned previously, it is the responsi-
one another’s eyes. We agree to practice a bility of the individual DBT therapist to coordi-
nonjudgmental stance with our clients and with nate and organize care with ancillary treatment
one another. providers (function 5; e.g., case managers,
6. Fallibility agreement: We agree ahead of time pharmacotherapists). The consultation-to-the-
that we are each fallible and make mistakes. client strategy balances the consultation-to-the-
We agree that we have probably either done therapist strategy described earlier, primarily
whatever problematic things we’re being by providing direct consultation to the client in
accused of, or some part of it, so that we can how to interact with other providers, rather
let go of assuming a defensive stance to prove
our virtue or competence. Because we are than consulting with the environment on how
fallible, it is agreed that we will inevitably to interact with the client. Except for special
violate all of these agreements, and when this is circumstances listed earlier, DBT therapists do
done, we will rely on each other to point out not discuss clients with ancillary providers, or
the polarity and move to a synthesis. other individuals in the client’s environment,
without the client present. The therapist works
with the client to problem-solve difficulties he
or she has with his or her network, leaving the
client to act as the intermediary between the
therapist and other professionals.
ENVIRONMENTAL INTERVENTION However, evidence supports the assumption

that effective therapy for clients with BPD re-
As outlined earlier, the bias in DBT is toward quires the proficient balancing of acceptance
teaching the client how to interact effectively and change strategies (Shearin & Linehan,
with his or her environment. The consultation-to- 1992). This research also found that therapists’
the-client strategy is thus the dominant case nonpejorative perceptions of clients were asso-
management strategy and is used whenever ciated with less suicidal behavior.
possible. There are times, however, when inter- Linehan (1993b) describes requisite therapist
vention by the therapist is needed. In general, characteristics in terms of three bipolar dimen-
the environmental intervention strategy is sions that must be balanced in the conduct of
used over the consultation-to-the-client strat- therapy. The first dimension represents the bal-
egy when substantial harm may befall the client ance of an orientation of acceptance with an ori-
if the therapist does not intervene. The general entation of change. The therapist must be able to
rule for environmental intervention is that inhibit judgmental attitudes (often under very
when clients lack abilities that they need to trying circumstances) and to practice acceptance
learn or that are impossible to obtain, or are of the client, of him- or herself, and of the thera-
not reasonable or necessary, the therapist may peutic relationship and process exactly as these
intervene. are in the current moment. Nevertheless, the
therapist remains cognizant that the therapeutic
Client Variables relationship has originated in the necessity of
change, and he or she assumes responsibility for
DBT was developed to treat the multidiag- directing the therapeutic influence. Second, the
nostic, difficult-to-treat individuals. Therefore, therapist must balance unwavering centeredness
there are a number of requisite client character- with compassionate flexibility. “Unwavering
istics for Stage 1 DBT. Of these, voluntary par- centeredness” is the quality of believing in one-
ticipation and a commitment to a specified self, the therapy, and the client. “Compassionate
time period (e.g., 16 weeks, 6 months to 1 year) flexibility” is the ability to take in relevant infor-
are critical. The effective application of DBT mation about the client and to modify one’s posi-
requires a strong interpersonal relationship be- tion accordingly by letting go of a previously
tween therapist and client. The therapist must held position. In balancing these two dimen-
first work to become a major reinforcer in the sions, the therapist must be able to observe his or
life of the client, then use the relationship to her own limits without becoming overly rigid,
promote change in the client. Continuing the especially in the face of attempts by the client to
relationship can only be used as a positive con- control the therapist’s behaviors. Finally, the
tingency when a client wants to be in treat- DBT therapist must be able to balance a high de-
ment; thus, contingency management is seri- gree of nurturing with benevolent demanding.
ously compromised with involuntary clients. “Nurturing” refers to teaching, coaching, assist-
Court-ordered treatment is acceptable, if cli- ing, and strengthening the client, whereas “be-
ents agree to remain in therapy even if the or- nevolent demanding” requires the therapist to
der is rescinded. A client characteristic neces- recognize existing capabilities, to reinforce
sary for group therapy is the ability to control adaptive behavior, and to refuse to “do” for the
overtly aggressive behavior toward others. client when the client can “do” for him- or her-
DBT was developed and evaluated with per- self. Above all, the ability to demand requires a
haps the most severely disturbed portion of the concomitant willingness to believe in the client’s
population with BPD; all clients accepted into ability to change; the effective DBT therapist
treatment had histories of multiple suicidal and must see his or her client as empowered.
NSSI behaviors. However, the treatment has
been designed flexibly and is likely to be effec-
tive with less severely disturbed individuals. TREATMENT STRATEGIES
Therapist Variables “Treatment strategies” in DBT refer to the role

and focus of the therapist, as well as to a coor-
In comparison to other aspects of therapy, the dinated set of procedures that function to
therapist characteristics that facilitate DBT achieve specific treatment goals. Although
have received comparatively little attention. DBT strategies usually consist of a number of
steps, use of a strategy does not necessarily re- skillful behaviors; and certain specific strate-
quire the application of every step. It is consid- gies used during the conduct of treatment.
erably more important that the therapist apply
the intent of the strategy than that he or she
should inflexibly lead the client through a se-
Dialectics of the Relationship:
ries of prescribed maneuvers.
Balancing Treatment Strategies
DBT employs five sets of treatment strategies “Dialectical strategies” in the most general
to achieve the previously described behavioral sense of the term have to do with how the ther-
targets: (1) dialectical strategies, (2) core strate- apist balances the dialectical tensions within
gies, (3) stylistic strategies, (4) case manage- the therapy relationship. As noted earlier, the
ment strategies (discussed earlier), and (5) inte- fundamental dialectic within any psychothera-
grated strategies. DBT strategies are illustrated py, including that with a client who has BPD, is
in Figure 9.2. Within an individual session and that between acceptance of what is and efforts
with a given client, certain strategies may be to change what is. A dialectical therapeutic po-
used more than others, and all strategies may sition is one of constant attention to combining
not be necessary or appropriate. An abbrevi- acceptance and change, flexibility and stability,
ated discussion of the first three types of DBT nurturing and challenging, and a focus on ca-
treatment strategies follows. For greater detail, pabilities and a focus on limitations and defi-
the reader is referred to the treatment manual cits. The goals are to bring out the opposites,
(Linehan, 1993a). both in therapy and in the client’s life, and to
provide conditions for syntheses. The pre-
sumption is that change may be facilitated by
Dialectical Strategies
emphasizing acceptance, and acceptance by
Dialectical strategies permeate the entire ther- emphasizing change. The emphasis upon oppo-
apy, and their use provides the rationale for sites sometimes takes place over time (i.e., over
adding the term “dialectical” to the title of the the whole of an interaction), rather than simul-
therapy. There are three types of dialectical taneously or in each part of an interaction. Al-
strategies: those having to do with how the though many, if not all, psychotherapies, in-
therapist structures interactions; those pertain- cluding cognitive and behavioral treatments,
ing to how the therapist defines and teaches attend to these issues of balance, placing the
FIGURE 9.2. Treatment strategies in DBT. From Linehan (1993b). Copyright 1993 by The Guilford
Press. Reprinted by permission.
concept of balance at the center of the treat- sessing dialectically by always asking the ques-
ment ensures that the therapist remains attention “What is being left out here?” Due to
tive to its importance. space limitations, a selection of these strategies
Three primary characteristics are needed to is included in the following sections. For a
maintain a dialectical stance in the therapeutic complete review, the interested reader is re-
relationship: movement, speed, and flow. ferred to the DBT treatment manual (Linehan,
Movement refers to acting with certainty, 1993a).
strength, and total commitment on the part of
the therapist. If the therapist only moves half-
ENTERING THE PARADOX
heartedly, the client will only move halfheart-
edly. Speed is of the essence and entails keeping Entering the paradox is a powerful technique
the therapy moving, so that it does not become because it contains the element of surprise. The
rigid or stuck. Finally, flow refers to being therapist presents the paradox without ex-
mindful to the moment-to-moment unfolding plaining it and highlights the paradoxical con-
of a session and responding smoothly, and with tradictions within the behavior, the therapeutic
apparent effortlessness. process, and reality in general. The essence of
the strategy is the therapist’s refusal to step in
with rational explanation; the client’s attempts
Teaching Dialectical Behavior Patterns at logic are met with silence, a question, or a
Dialectical thinking is emphasized throughout story designed to shed a small amount of light
the entire treatment. Not only does the thera- on the puzzle to be solved. The client is pushed
pist maintain a dialectical stance in his or her to achieve understanding, to move toward syn-
treatment of the client but he or she also fo- thesis of the polarities, and to resolve the di-
cuses on teaching and modeling dialectical lemma him- or herself. Linehan (1993b) has
thinking to the client. The therapist helps the highlighted a number of typical paradoxes and
client move from an “either–or” position to a their corresponding dialectical tensions en-
“both–and” position, without invalidating the countered over the course of therapy. Clients
first idea or its polarity when asserting the are free to choose their own behavior but can-
second. Behavioral extremes and rigidity— not stay in therapy if they do not work at
whether cognitive, emotional, or overtly changing their behavior. They are taught to
behavioral —are signals that synthesis has not achieve greater independence by becoming
been achieved; thus, they can be considered more skilled at asking for help from others. Cli-
nondialectical. Instead, a “middle path” simi- ents have a right to kill themselves, but if they
lar to that advocated in Buddhism is advocated ever convince the therapist that suicide is immi-
and modeled. The important thing in following nent, they may be locked up. Clients are not re-
the path to Enlightenment is to avoid being sponsible for being the way they are, but they
caught and entangled in any extreme and al- are responsible for what they become. In high-
ways follow the Middle Way (Kyokai, 1966). lighting these paradoxical realities, both client
This emphasis on balance is similar to the ap- and therapist struggle with confronting and let-
proach advocated in relapse prevention models ting go of rigid patterns of thought, emotion,
proposed by Marlatt and his colleagues (e.g., and behavior, so that more spontaneous and
Marlatt & Gordon, 1985) for treating addic- flexible patterns may emerge.
tive behaviors.
USING METAPHOR: PARABLE, MYTH, ANALOGY,
Specific Dialectical Strategies AND STORYTELLING
There are eight specific dialectical treatment The use of metaphor, stories, parables, and
strategies: (1) entering and using paradox, (2) myth is extremely important in DBT and pro-
using metaphor, (3) playing the devil’s advo- vides an alternative means of teaching dialecti-
cate, (4) extending, (5) activating the client’s cal thinking. Stories are usually more interest-
“wise mind,” (6) making lemonade out of lem- ing, are easier to remember, and encourage the
ons (turning negatives into positives), (7) al- search for other meanings of events under scru-
lowing natural change (and inconsistencies tiny. Additionally, metaphors allow clients to
even within the therapeutic milieu), and (8) as- distance themselves from the problem being
discussed and can therefore be less threatening. would be considered overweight by someone.
In general, the idea of metaphor is to take That must mean they’d all be better off dead!”
something the client does understand and use it Or “Gosh, I’m about 5 pounds overweight. I
as an analogy for something the client does not guess that means I’d be better off dead, too.”
understand. Used creatively, metaphors aid un- Any reservations the client proposes can be
derstanding, suggest solutions to problems, countered by further exaggeration, until the
and reframe the problems of both clients and self-defeating nature of the belief becomes ap-
the therapeutic process. Furthermore, meta- parent. The devil’s advocate technique is often
phors and stories can be developed by both used in the first several sessions to elicit a
therapist and client taking turns throughout a strong commitment from the client and in com-
session or over the course of treatment. When mitment sessions with new therapists joining
the therapist and client relate to a metaphor, it the DBT team. The therapist argues to the cli-
can be a powerful tool to use throughout the ent that since the therapy will be painful and
treatment, reminding the client what he or she difficult, it is not clear how making such a com-
is working on. For example, changing behavior mitment (and therefore being accepted into
by learning new skills can be compared to treatment) could possibly be a good idea. This
building a new hiking trail in the woods. At usually has the effect of moving the client to
first, the current trail is defined and easy to take the opposite position in favor of therapeu-
navigate; however, it always leads to a dead tic change. To employ this technique success-
end (old dysfunctional behavior). To build a fully, it is important that the therapist’s argu-
new trail (skillful behaviors), the hiker must re- ment seem reasonable enough to invite
peatedly go through a new, undefined area un- counterargument by the client, and that the de-
til it becomes worn in. This takes time and the livery be made with a straight face, in a naive
hiker moves slowly and deliberately clearing but offbeat manner.
away the brush. Additionally, while the new
path is developing, the old path is slowly be- EXTENDING
coming grown over. This story can be returned
to throughout treatment, each time the client The term “extending” has been borrowed from
begins to struggle between trying new skills aikido, a Japanese form of self-defense. In that
and returning to old dysfunctional behavior. context, extending occurs when the student of
aikido waits for a challenger’s movements to
reach their natural completion, then extends a
PLAYING DEVIL’S ADVOCATE
movement’s endpoint slightly further than
The devil’s advocate technique is quite simi- what would naturally occur, leaving the chal-
lar to the argumentative approach used in lenger vulnerable and off balance. In DBT, ex-
rational–emotive and cognitive restructuring tending occurs when the therapist takes the se-
therapies as a method of addressing a client’s verity or gravity of what the client is
dysfunctional beliefs or problematic rules. communicating more seriously than the client
With this strategy, the therapist presents a intends. This strategy is the emotional equiva-
propositional statement that is an extreme ver- lent of the devil’s advocate strategy. It is partic-
sion of one of the client’s own dysfunctional be- ularly effective when the client is threatening
liefs, then plays the role of devil’s advocate to dire consequences of an event or problem to in-
counter the client’s attempts to disprove the ex- duce change in the environment. Take the inter-
treme statement or rule. For example, a client action with the following client, who threatens
may state, “Because I’m overweight, I’d be suicide if an extra appointment time for the
better off dead.” The therapist argues in favor next day is not scheduled. The following inter-
of the dysfunctional belief, perhaps by suggest- change between therapist and client occurs af-
ing that because this is true for the client, it ter attempts to find a mutually acceptable time
must be true for others as well; hence, all over- have failed.
weight people would be better off dead. The
therapist may continue along these lines: “And CLIENT: I’ve got to see you tomorrow, or I’m
since the definition of what constitutes being sure I will end up killing myself. I just can’t
overweight varies so much among individuals, keep it together by myself any longer.
there must be an awful lot of people who THERAPIST: Hmm, I didn’t realize you were so
upset! We’ve got to do something immedi- Core Strategies

ately if you are so distressed that you might
Validation
kill yourself. What about hospitalization?
Maybe that is needed. Validation and problem-solving strategies, to-
CLIENT: I’m not going to the hospital! Why gether with dialectical strategies, make up the
won’t you just give me an appointment? core of DBT and form the heart of the treat-
ment. Validation strategies are the most obvi-
THERAPIST: How can we discuss such a mun-
ous acceptance strategies, whereas problem-
dane topic as session scheduling when your
solving strategies are the most obvious change
life is in danger? How are you planning to
strategies. Both validation and problem-solving
kill yourself?
strategies are used in every interaction with the
CLIENT: You know how. Why can’t you cancel client, although the relative frequency of each
someone or move an appointment around? depends on the particular client, the current sit-
You could put an appointment with one of uation, and the vulnerabilities of that client.
your students off until another time. I can’t However, throughout an entire session, there
stand it any more! should be an overall balance between the ac-
THERAPIST: I’m really concerned about you. Do ceptance and change strategies. Many treat-
you think I should call an aid car? ment impasses are due to an imbalance of one
type of strategy over the other. We discuss vali-
The aspect of the communication that the dation strategies in this section and problem-
therapist takes seriously (suicide as a possible solving strategies in the next.
consequence of not getting an appointment) is Clients with BPD present themselves clini-
not the aspect (needing an extra appointment cally as individuals in extreme emotional pain.
the next day) that the client wants taken seri- They plead, and at times demand, that their
ously. The therapist takes the consequences therapists do something to change this state of
seriously and extends the seriousness even fur- affairs. It is very tempting to focus the energy
ther. The client wants the problem taken seri- of therapy on changing the client by modifying
ously, and indeed is extending the seriousness irrational thoughts, assumptions, or schemas;
of the problem. critiquing interpersonal behaviors or motives
contributing to interpersonal problems; giving
medication to change abnormal biology; reduc-
MAKING LEMONADE OUT OF LEMONS
ing emotional overreactivity and intensity; and
Making lemonade out of lemons is similar to so on. In many respects, this focus recapitulates
the notion in psychodynamic therapy of utiliz- the invalidating environment by confirming the
ing a client’s resistances; therapeutic problems client’s worst fears: The client is the problem
are seen as opportunities for the therapist to and indeed cannot trust his or her own reac-
help the client. The strategy involves taking tions to events. Mistrust and invalidation of
something that is apparently problematic and how one responds to events, however, are ex-
turning it into an asset. Problems become op- tremely aversive and can elicit intense fear, an-
portunities to practice skills; suffering allows ger, and shame, or a combination of all three.
others to express empathy; weaknesses become Thus, the entire focus of change-based therapy
one’s strengths. To be effective, this strategy re- can be aversive, because the focus by necessity
quires a strong therapeutic relationship be- contributes to and elicits self-invalidation.
tween therapist and client; the client must be- However, an entire focus of acceptance-based
lieve that the therapist has a deep compassion therapy can also be invalidating when it ap-
for his or her suffering. The danger in using this pears to the client that the therapist does not
strategy is that it is easily confused with the intake his or her problems seriously. Therefore,
validating refrain repeatedly heard by clients once again, a dialectical stance focuses on a
with BPD. The therapist should avoid the ten- balance between the two poles.
dency to oversimplify a client’s problems, and Validation (according to the Oxford English
refrain from implying that the lemons in the cli- Dictionary; Simpson & Weiner, 1989) means
ent’s life are really lemonade. While recogniz- “the action of validating or making valid . . . a
ing that the cloud is indeed black, the therapist strengthening, reinforcement, confirming; an es-
assists the client in finding the positive charac- tablishing or ratifying.” It also encompasses ac-
teristics of a situation—thus, the silver lining. tivities such as corroborating, substantiating,
verifying, and authenticating. The act of validat- of six levels. Each level is correspondingly more
ing is “to support or corroborate on a sound or complete than the previous one, and each level
authoritative basis . . . to attest to the truth or va- depends on one or more of the previous levels.
lidity of something” (Merriam-Webster, Inc., They are definitional of DBT and are required
2006). To communicate that a response is valid in every interaction with the client. These levels
is to say that it is “well-grounded or justifiable: are described most fully in Linehan (1997), and
being at once relevant and meaningful . . . logi- the following definitions are taken from her
cally correct . . . appropriate to the end in view discussion.
[or effective] . . . having such force as to compel
serious attention and [usually] acceptance”
LISTENING AND OBSERVING (V1)
(Webster’s Dictionary, 1991). Being “valid im-
plies being supported by objective truth or gen- Level 1 validation requires listening to and ob-
erally accepted authority” (Webster’s Dictio- serving what the client is saying, feeling, and
nary, 1991); “being well-founded on fact, or doing, as well as a corresponding active effort
established on sound principles, and thoroughly to understand what is being said and observed.
applicable to the case or circumstances,” and The essence of this step is that the therapist is
“soundness and strength,” “value or worth,” staying awake and interested in the client, pay-
and “efficacy” (Simpson & Weiner, 1989). ing attention to what the client says and does in
These are precisely the meanings associated with the current moment. The therapist notices the
the term when used in the context of psychother- nuances of response in the interaction. Valida-
apy in DBT: tion at Level 1 communicates that the client per
se, as well as the client’s presence, words, and
The essence of validation is this: The therapist responses in the session have “such force as to
communicates to the client that her [sic] responses compel serious attention and [usually] accep-
make sense and are understandable within her tance” (see earlier definitions of validation;
[sic] current life context or situation. The thera- pp. 360–361)
pist actively accepts the client and communicates
this acceptance to the client. The therapist takes
the client’s responses seriously and does not dis- ACCURATE REFLECTION (V2)
count or trivialize them. Validation strategies re-
quire the therapist to search for, recognize, and re-
The second level of validation is the accurate
flect to the client the validity inherent in her [sic] reflection back to the client of his or her own
response to events. With unruly children, parents feelings, thoughts, assumptions, and behaviors.
have to catch them while they’re good in order to The therapist conveys an understanding of the
reinforce their behavior; similarly, the therapist client by hearing what the client has said and
has to uncover the validity within the client’s re- seeing what the client does, and how he or she
sponse, sometimes amplify it, and then reinforce responds. Validation at Level 2 sanctions, em-
it. (Linehan, 1993b, pp. 222–223, original em- powers, or authenticates that the individual is
phasis) who he or she actually is (p. 362).
Two things are important to note here. First,

ARTICULATING THE UNVERBALIZED (V3)
validation means the acknowledgment of that
which is valid. It does not mean “making” In Level 3 of validation, the therapist commu-
valid. Nor does it mean validating that which is nicates understanding of aspects of the client’s
invalid. The therapist observes, experiences, experience and response to events that have not
and affirms, but he or she does not create valid- been communicated directly by the client. The
ity. Second, “valid” and “scientific” are not therapist “mind-reads” the reason for the cli-
synonyms. Science may be one way to deter- ent’s behavior and figures out how the client
mine what is valid, logical, sound in principle, feels and what he or she is wishing for, think-
and/or generally accepted as authority or nor- ing, or doing just by knowing what has hap-
mative knowledge. However, an authentic ex- pened to the client. The therapist can make the
perience or apprehension of private events (at link between precipitating event and behavior
least, when similar to the same experiences of without being given any information about the
others or when in accord with other, more ob- behavior itself. Emotions and meanings the cli-
servable events) is also a basis for claiming va- ent has not expressed are articulated by the
lidity. Validation can be considered at any one therapist (p. 364).
VALIDATING IN TERMS OF PAST LEARNING dation at the highest level is the validation of the
OR BIOLOGICAL DYSFUNCTION (V4) individual as “is.” The therapist sees more than
the role, more than a “client” or “disorder.”
At Level 4, behavior is validated in terms of its Level 6 validation is the opposite of treating the
causes. Validation here is based on the notion client in a condescending manner or as overly
that all behavior is caused by events occurring fragile. It is responding to the individual as ca-
in time; thus, in principle, it is understandable. pable of effective and reasonable behavior
The therapist justifies the client’s behavior by rather than assuming that he or she is an invalid.
showing that it is caused by past events. Even Whereas Levels 1–5 represent sequential steps
though information may not be available to de- in validation of a kind, Level 6 represents
termine all the relevant causes, the client’s feel- change in both level and kind (p. 377).
ings, thoughts and actions make perfect sense Cheerleading strategies constitute another
in the context of the client’s current experience, form of validation and are the principal strate-
physiology, and life to date. At a minimum, gies for combating the active passivity and ten-
what “is” can always be justified in terms of dencies to hopelessness in clients with BPD. In
sufficient causes; that is, what is “should be,” cheerleading, therapists communicate the belief
in that whatever was necessary for it to occur that clients are doing their best and validate cli-
had to have happened (p. 367). ents’ ability to eventually overcome their diffi-
culties (a type of validation that, if not handled
VALIDATION IN TERMS OF PRESENT CONTEXT carefully, can simultaneously invalidate clients’
OR NORMATIVE FUNCTIONING (V5) perceptions of their helplessness). In addition,
therapists express a belief in the therapy rela-
At Level 5, the therapist communicates that tionship, offer reassurance, and highlight any
behavior is justifiable, reasonable, well- evidence of improvement. Within DBT, cheer-
grounded, meaningful, and/or efficacious in leading is used in every therapeutic interaction.
terms of current events, normative biological Although active cheerleading by therapists
functioning, and/or the client’s ultimate life should be reduced as clients learn to trust and
goals. The therapist looks for and reflects the to validate themselves, cheerleading strategies
wisdom or validity of the client’s response and always remain an essential ingredient of a
communicates that the response is understand- strong therapeutic alliance.
able. The therapist finds the relevant facts in Finally, functional validation, another form
the current environment that support the cli- of validation that is used regularly in DBT, is a
ent’s behavior. The therapist is not blinded by form of nonverbal or behavioral validation
the dysfunctionality of some of the client’s re- that at times may be more effective than verbal
sponse patterns to those aspects of a response validation. For example, a therapist drops a
pattern that may be either reasonable or ap- 50-pound block on the client’s foot. It would be
propriate to the context. Thus, the therapist considered invalidating for the therapist simply
searches the client’s responses for their inherent to respond verbally, saying, “Wow, I can see
accuracy or appropriateness, or reasonableness that really hurts! You must be in a lot of pain.”
(as well as commenting on the inherent Functional validation would entail the thera-
dysfunctionality of much of the response, if pist removing the block from the client’s foot.
necessary) (pp. 370–371).
Problem Solving
RADICAL GENUINENESS (V6)
We have previously discussed how therapies
In Level 6, the task is to recognize the person as with a primary focus on client change are typi-
he or she is, seeing and responding to the cally experienced as invalidating by clients with
strengths and capacities of the client, while BPD. However, therapies that focus exclusively
keeping a firm empathic understanding of his or on validation can prove equally problematic.
her actual difficulties and incapacities. The ther- Exhortations to accept one’s current situation
apist believes in the client and his or her capacity offer little solace to an individual who experi-
to change and move toward ultimate life goals ences life as painfully unendurable. Within
just as the therapist may believe in a friend or DBT, problem-solving strategies are the core
family member. The client is responded to as a change strategies, designed to foster an active
person of equal status, due equal respect. Vali- problem-solving style. For clients with BPD,
however, the application of these strategies is Answers to these questions guide the thera-
fraught with difficulties. The therapist must pist in the selection of appropriate treatment
keep in mind that with clients with BPD the procedures, such as contingency management,
process will be more difficult than with many behavioral skills training, exposure, or cogni-
other client populations. In work with clients tive modification. Thus, the value of an analy-
who have BPD, the need for sympathetic un- sis lies in helping the therapist assess and un-
derstanding and interventions aimed at en- derstand a problem fully enough to guide
hancing current positive mood can be ex- effective therapeutic response. The first step in
tremely important. The validation strategies conducting a behavioral analysis is to help the
just described, as well as the irreverent commu- client identify the problem to be analyzed and
nication strategy described later, can be tre- describe it in behavioral terms. Identifying the
mendously useful here. Within DBT, problem problem can be the most difficult task for the
solving is a two-stage process that concentrates therapist, and if not done accurately and specif-
first on understanding and accepting a selected ically, can lead the therapist and client down a
problem, then generating alternative solutions. path of solving only a related problem, without
The first stage involves (1) behavioral analysis; getting to the true heart of the problem behav-
(2) insight into recurrent behavioral context ior at hand. Problem definition usually evolves
patterns; and (3) giving the client didactic in- from a discussion of the previous week’s events,
formation about principles of behaviors, often in the context of reviewing diary cards.
norms, and so on. The second stage specifically The assumption of facts not in evidence is per-
targets change through (4) analysis of possible haps the most common mistake at this point.
solutions to problems; (5) orienting the client Defining the problem is followed by a chain
to therapeutic procedures likely to bring about analysis—an exhaustive, blow-by-blow de-
desired changes; and (6) strategies designed to scription of the chain of events leading up to
elicit and strengthen commitment to these pro- and following the behavior. In a chain analysis,
cedures. The following sections specifically ad- the therapist constructs a general road map of
dress behavioral analysis, solution analysis, how the client arrives at dysfunctional re-
and problem-solving procedures. sponses, including where the road actually
starts (highlights vulnerability factors and
prompting events), and notes possible alterna-
Behavioral Analysis
tive adaptive pathways or junctions along the
Behavioral analysis is one of the most impor- way. Additional goals are to identify events
tant strategies in DBT. It is also the most diffi- that automatically elicit maladaptive behavior,
cult. The purpose of a behavioral analysis is behavioral deficits that are instrumental in
first to select a problem, then to determine em- maintaining problematic responses, and envi-
pirically what is causing it, what is preventing ronmental and behavioral events that may be
its resolution, and what aids are available for interfering with more appropriate behaviors.
solving it. Behavioral analysis addresses four The overall goal is to determine the function of
primary questions: the behavior, or, from another perspective, the
problem the behavior was instrumental in solv-
1. Are ineffective behaviors being reinforced, ing.
are effective behaviors followed by aversive Chain analysis always begins with a specific
outcomes, or are rewarding outcomes de- environmental event. Pinpointing such an event
layed? may be difficult, because clients are frequently
2. Does the client have the requisite behavioral unable to identify anything in the environment
skills to regulate his or her emotions, re- that set off the problematic response. Never-
spond skillfully to conflict, and manage his theless, it is important to obtain a description
or her own behavior? of the events co-occurring with the onset of the
3. Are there patterns of avoidance, or are ef- problem. The therapist then attempts to iden-
fective behaviors inhibited by unwarranted tify both environmental and behavioral events
fears or guilt? for each subsequent link in the chain. Here the
4. Is the client unaware of the contingencies therapist must play the part of a very keen ob-
operating in his or her environment, or are server, thinking in terms of very small chunks
effective behaviors inhibited by faulty be- of behavior, and repeatedly identifying what
liefs or assumptions? the client was thinking, feeling, and doing, and
what was occurring in the environment from solutions. DBT posits that there are five re-
moment to moment. The therapist asks the cli- sponses to any one problem: (1) Solve the
ent, “What happened next?” or “How did you problem; (2) change the emotional reaction to
get from there to there?” Although, from the the problem; (3) tolerate the problem; or (4)
client’s point of view, such links may be self- stay miserable. An alert client suggested an-
evident, the therapist must be careful not to other response, which we have added: (5)
make assumptions. For example, a client who Make things worse. These five options are pre-
had attempted suicide once stated that she de- sented to the client at pretreatment and
cided to kill herself because her life was too throughout sessions prior to problem solving
painful for her to live any longer. From the cli- to ensure that therapist and client are working
ent’s point of view, this was an adequate expla- toward the same goal at any given point.
nation for her suicide attempt. For the thera- At times, solutions are discussed throughout
pist, however, taking one’s life because life is the behavioral analysis, and pointing to these
too painful was only one solution. One could alternative solutions may be all that is required,
decide life is too painful, then decide to change rather than waiting until the behavioral analy-
one’s life. Or one could believe that death sis is completed. The therapist may ask, “What
might be even more painful and decide to toler- do you think you could have done differently
ate life despite its pain. In this instance, careful here?” Throughout this process, the therapist is
questioning revealed that the client actually as- actively modeling effective problem solving
sumed she would be happier dead than alive. and solution generation, with a heavier empha-
Challenging this assumption, then, became a sis on modeling and guiding the client early on
key to ending her persistent suicide attempts. It in treatment. At other times, a more complete
is equally important to pinpoint exactly what solution analysis is necessary. Here the task is
consequences are maintaining the problematic to “brainstorm” or generate as many alterna-
response. Similarly, the therapist should also tive solutions as possible. Solutions should then
search for consequences that serve to weaken be evaluated in terms of the various outcomes
the problem behavior. As with antecedent expected. The final step in solution analysis is
events, the therapist probes for both environ- to choose a solution that will somehow be ef-
mental and behavioral consequences, obtaining fective. Throughout the evaluation, the thera-
detailed descriptions of the client’s emotions, pist guides the client in choosing a particular
somatic sensations, actions, thoughts, and as- behavioral solution. Here, it is preferable that
sumptions. A rudimentary knowledge of the the therapist pay particular attention to long-
rules of learning and principles of reinforce- term over short-term gain, and that chosen so-
ment is crucial. lutions render maximum benefit to the client
The final step in behavioral analysis is to rather than benefit to others.
construct and test hypotheses about events that
are relevant to generating and maintaining the
Problem-Solving Procedures
problem behavior. The biosocial theory of BPD
suggests several factors of primary importance. DBT employs four problem-solving procedures
For example, DBT focuses most closely on in- taken directly from the cognitive and behavior-
tense or aversive emotional states; the amelio- al treatment literature. These four—skills train-
ration of negative affect is always suspected as ing, contingency procedures, exposure, and
being among the primary motivational vari- cognitive modification—are viewed as primary
ables for dysfunctional behavior in BPD. The vehicles of change throughout DBT, since they
theory also suggests that typical behavioral influence the direction that client changes take
patterns, such as deficits in dialectical thinking from session to session. Although they are dis-
or behavioral skills, are likely to be instrumen- cussed as distinct procedures by Linehan
tal in producing and maintaining problematic (1993b), it is not clear that they can in fact be
responses. differentiated in every case in clinical practice.
The same therapeutic sequence may be effec-
tive because it teaches the client new skills
Solution Analysis
(skills training), provides a consequence that
Once the problem has been identified and ana- influences the probability of preceding client
lyzed, problem solving proceeds with an active behaviors occurring again (contingency proce-
attempt at finding and identifying alternative dures), provides nonreinforced exposure to
cues associated previously but not currently quences whenever possible. An important con-
with threat (exposure procedures), or changes tingency for most clients with BPD is the thera-
the client’s dysfunctional assumptions or sche- pist’s interpersonal behavior with such clients.
matic processing of events (cognitive modifica- The ability of the therapist to influence the cli-
tion). In contrast to many cognitive and behav- ent’s behavior is directly tied to the strength of
ioral treatment programs in the literature, these the relationship between the two. Thus, contin-
procedures (with some exceptions noted be- gency procedures based on the relationship are
low) are employed in an unstructured manner, less useful in the very early stages of treatment
interwoven throughout all therapeutic dia- (except, possibly, when the therapist is the
logue. Thus, the therapist must be well aware “only game in town”).
of the principles governing the effectiveness of A first requirement for effective contingency
each procedure in order to use each in immedi- management is that the therapist orient the cli-
ate response to events unfolding in a particular ent to the principles of contingency manage-
session. The exceptions are in skills training, ment and explain how learning takes place.
where skills training procedures predominate, The therapist must attend to the client’s behav-
and Stage 2, where exposure procedures pre- iors and use the principles of shaping to rein-
dominate. force those behaviors that represent progress
toward DBT targets. Equally important is that
the therapist takes care not to reinforce behav-
Skills Training iors targeted for extinction. In theory, this may
An emphasis on skills building is pervasive seem obvious, but in practice, it can be quite
throughout DBT. In both individual and group difficult. The problematic behaviors of clients
therapy, the therapist insists at every opportu- with BPD are often quite effective in obtaining
nity that the client actively engage in the acqui- reinforcing outcomes or in stopping painful
sition and practice of behavioral skills. The events. Indeed, the very behaviors targeted for
term “skills” is used synonymously with “abil- extinction have been intermittently reinforced
ity” and includes, in its broadest sense, cogni- by mental health professionals, family mem-
tive, emotional, and overt behavioral skills, as bers, and friends. Contingency management at
well as their integration, which is necessary for times requires the use of aversive consequences,
effective performance. Skills training is called similar to “setting limits” in other treatment
for when a solution requires skills not currently modalities. Three guidelines are important
in the individual’s behavioral repertoire, or when using aversive consequences. First, pun-
when the individual has the component behav- ishment should “fit the crime,” and a client
iors but cannot integrate and use them effec- should have some way of terminating its appli-
tively. Skills training in DBT incorporates three cation. For example, in DBT, a detailed behav-
types of procedures: (1) skills acquisition (mod- ioral analysis follows a suicidal or NSSI act;
eling, instructing, advising); (2) skills strength- such an analysis is an aversive procedure for
ening (encouraging in vivo and within-session most clients. Once it has been completed, how-
practice, role playing, feedback); and (3) skills ever, a client’s ability to pursue other topics is
generalization (phone calls to work on apply- restored. Second, it is crucial that therapists use
ing skills; taping therapy sessions to listen to punishment with great care, in low doses, and
between sessions; homework assignments). very briefly, and that a positive interpersonal
atmosphere be restored following any client
improvement. Third, punishment should be
Contingency Procedures just strong enough to work. Although the ulti-
Every response within an interpersonal interac- mate punishment is termination of therapy, a
tion is potentially a reinforcement, a punish- preferable fallback strategy is putting clients on
ment, or a withholding or removal of rein- “vacations from therapy.” This approach is
forcement. Contingency management requires considered when all other contingencies have
therapists to organize their behavior strategi- failed, or when a situation is so serious that a
cally so that client behaviors that represent therapist’s therapeutic or personal limits have
progress are reinforced, while unskillful or been crossed. When utilizing this strategy, the
maladaptive behaviors are extinguished or lead therapist clearly identifies what behaviors must
to aversive consequences. Natural conse- be changed and clarifies that once the condi-
quences should be used over arbitrary conse- tions have been met, the client can return. The
therapist maintains intermittent contact by enting a client to DBT as a whole and to

phone or letter, and provides a referral or treatment procedures as they are imple-
backup while the client is on vacation. (In col- mented.
loquial terms, the therapist kicks the client out,
then pines for his or her return.) Observing lim-
Exposure
its constitutes a special case of contingency
management involving the application of All of the change procedures in DBT can be
problem-solving strategies to client behaviors reconceptualized as exposure strategies. Many
that threaten or cross a therapist’s personal lim- of the principles of exposure as applied to DBT
its. Such behaviors interfere with the therapist’s have been developed by researchers in expo-
ability or willingness to conduct the therapy, sure techniques (see Foa & Kozak, 1986; Foa,
thus constituting a special type of therapy- Steketee, & Grayson, 1985). These strategies
interfering behavior. Therapists must take re- work by reconditioning dysfunctional associa-
sponsibility for monitoring their own personal tions that develop between stimuli (e.g., an
limits and clearly communicate to their clients aversive stimulus, hospitalization, may become
which behaviors are tolerable and which are associated with a positive stimulus, nurturing
not. Therapists who do not do this eventually in the hospital; a client may later work to be
burn out, terminate therapy, or otherwise harm hospitalized) or between a response and a stim-
their clients. DBT favors natural over arbitrary ulus (e.g., an adaptive response, healthy ex-
limits. Thus, limits vary among therapists, and pression of emotions, is met with an aversive
with the same therapist over time and circum- consequent stimulus, rejection by a loved one;
stance. Limits should also be presented as for a client may then try to suppress emotions). As
the good of the therapist, not for the good of noted earlier, the DBT therapist conducts a
the client. The effect of this is that although cli- chain analysis of the eliciting cue, the problem
ents may argue about what is in their own best behavior (including emotions), and the conse-
interests, they do not have ultimate say over quences of the behavior. Working within a
what is good for their therapists. behavior therapy framework, the therapist op-
erates according to three guidelines for expo-
sure in DBT. First, exposure to the cue that
Cognitive Modification precedes the problem behavior must be non-
The fundamental message given to clients in reinforced (e.g., if a client is fearful that dis-
DBT is that cognitive distortions are just as cussing suicidal behavior will lead to his or her
likely to be caused by emotional arousal as to being rejected, the therapist must not reinforce
be the cause of the arousal in the first place. the client’s shame by ostracizing him/her). Sec-
The overall message is that, for the most ond, dysfunctional responses are blocked in the
part, the source of a client’s distress is the ex- order of the primary and secondary targets of
tremely stressful events of his or her life treatment (e.g., suicidal or NSSI behavior re-
rather than a distortion of events that are ac- lated to shame is blocked by getting the client’s
tually benign. Although direct cognitive re- cooperation in throwing away hoarded medi-
structuring procedures, such as those advo- cations). Third, actions opposite to the dys-
cated by Beck and colleagues (Beck, Brown, functional behavior are reinforced (e.g., the
Berchick, Stewart, & Steer, 1990; Beck, Rush, therapist reinforces the client for talking about
Shaw, & Emery, 1979) and by Ellis (1962, painful, shame-related suicidal behavior).
1973), are used and taught as part of emo- Therapeutic exposure procedures are used
tion regulation, they do not hold a dominant informally throughout the whole of therapy
place in DBT. In contrast, contingency clarifi- and formally during Stage 2, in which the client
cation strategies are used relentlessly, high- is systematically exposed to cues of previous
lighting contingent relationships operating in traumatic events. Exposure procedures of the
the here and now. Emphasis is placed on DBT therapist involve first orienting the client
highlighting immediate and long-term effects to the techniques and to the fact that exposure
of clients’ behavior (both on themselves and to cues is often experienced as painful or fright-
on others), clarifying the effects of certain sit- ening. Thus, the therapist does not remove the
uations on clients’ own responses, and exam- cue to emotional arousal, and at the same time
ining future contingencies that clients are he or she blocks both the action tendencies (in-
likely to encounter. An example here is ori- cluding escape responses) and the expressive
tendencies associated with the problem emo- the interests of the client, are encouraged to in-
tion. In addition, the DBT therapist works to crease problem solving or to reinforce
assist the client in achieving enhanced control therapeutic activities. Self-involving self-
over aversive events. A crucial step of exposure disclosure is the therapist’s immediate, personal
procedures is that the client be taught how to reactions to the client and his or her behavior.
control the event. It is critical that the client This strategy is used frequently throughout
have some means of titrating or ending expo- DBT. For example, a therapist whose client
sure when emotions become unendurable. The complained about his coolness said, “When
therapist and client should collaborate in devel- you demand warmth from me, it pushes me
oping positive, adaptive ways for the client to away and makes it harder to be warm.” Simi-
end exposure voluntarily, preferably after some larly, when a client repeatedly failed to fill out
reduction in the problem emotion has oc- diary cards but nevertheless pleaded with her
curred. therapist to help her, the therapist responded,
“You keep asking me for help, but you won’t
do the things I believe are necessary to help
Stylistic Strategies
you. I feel frustrated because I want to help
DBT balances two quite different styles of com- you, but I feel that you won’t let me.” Such
munication that refer to how the therapist exe- statements serve both to validate and to chal-
cutes other treatment strategies. The first, re- lenge. They constitute both an instance of con-
ciprocal communication, is similar to the tingency management, because therapist state-
communication style advocated in client- ments about the client are typically experienced
centered therapy. The second, irreverent com- as either reinforcing or punishing, and an in-
munication, is quite similar to the style advo- stance of contingency clarification, because the
cated by Whitaker (1975) in his writings on client’s attention is directed to the conse-
strategic therapy. Reciprocal communication quences of his or her interpersonal behavior.
strategies are designed to reduce a perceived Self-disclosure of professional or personal in-
power differential by making the therapist formation is used to validate and model coping
more vulnerable to the client. In addition, they and normative responses. The key point here is
serve as a model for appropriate but equal in- that a therapist should only use personal exam-
teractions within an important interpersonal ples in which he or she has successfully mas-
relationship. Irreverent communication is usu- tered the problem at hand. This may seem like
ally riskier than reciprocity. However, it can fa- an obvious point, but it is very easy to fall into
cilitate problem solving or produce a break- this pit by trying actively to validate the client’s
through after long periods when progress has dilemma. For example, when working with a
seemed thwarted. To be used effectively, irrev- client whose goal is to wake up early each
erent communication must balance reciprocal morning to exercise but who is having diffi-
communication, and the two must be woven culty getting out of bed, the therapist may at-
into a single stylistic fabric. Without such bal- tempt to validate the behavior as normative by
ancing, neither strategy represents DBT. stating, “Yeah, I struggle with getting up every
morning, too, even though I tell myself every
night that I am going to exercise in the morn-
Reciprocal Communication ing.” However, this self-disclosure is only be
Responsiveness, self-disclosure, warm engage- useful to the client if the therapist continues by
ment, and genuineness are the basic guidelines stating what skillful behavior he or she uses to
of reciprocal communication. Responsiveness get up each morning and exercise successfully.
requires attending to the client in a mindful (at-
tentive) manner and taking the client’s agenda
and wishes seriously. However, this does not
Irreverent Communication
mean that the therapist gives priority to the cli- Irreverent communication is used to push the
ent’s agenda over the treatment hierarchy. It re- client “off balance,” get the client’s attention,
fers to the therapist validating the importance present an alternative viewpoint, or shift affec-
of the client’s agenda openly. It is a friendly, af- tive response. It is a highly useful strategy when
fectionate style reflecting warmth and engage- the client is immovable, or when therapist and
ment in the therapeutic interaction. Both self- client are “stuck.” It has an “offbeat” flavor
involving and personal self-disclosure, used in and uses logic to weave a web the client cannot
escape. Although it is responsive to the client, attempts, including cutting an artery in her
irreverent communication is almost never the neck. At the time of referral, Cindy met DSM-
response the client expects. For irreverence to III-R (American Psychiatric Association, 1987)
be effective it must be both genuine (vs. sarcas- as well as Gunderson’s (1984) criteria for BPD.
tic or judgmental) and come from a place of She was also taking a variety of psychotropic
compassion and warmth toward the client. drugs. Until age 27, Cindy was able to function
Otherwise, the client may become even more well in work and school settings, and her mar-
rigid. When using irreverence the therapist riage was reasonably satisfactory to both part-
highlights some unintended aspect of the cli- ners, although her husband complained about
ent’s communication or “reframes” it in an un- Cindy’s excessive anger. When Cindy was in the
orthodox manner. For example, if the client second year of medical school, a classmate she
says, “I am going to kill myself,” the therapist knew only slightly committed suicide. Cindy
might say, “I thought you agreed not to drop stated that when she heard about the suicide,
out of therapy.” Irreverent communication has she immediately decided to kill herself also, but
a matter-of-fact, almost deadpan style that is in had very little insight into what about the situa-
sharp contrast to the warm responsiveness of tion actually elicited her inclination to kill her-
reciprocal communication. Humor, a certain self. Within weeks she left medical school and
naivete, and guilelessness are also characteristic became severely depressed and actively sui-
of the style. A confrontational tone is also ir- cidal. Although Cindy self-presented as a per-
reverent, communicating “bullshit” to re- son with few psychological problems before
sponses other than the targeted adaptive re- the classmate’s suicide, further questioning re-
sponse. For example, the therapist might say, vealed a history of severe anorexia nervosa,
“Are you out of your mind?” or “You weren’t bulimia nervosa, and alcohol and prescription
for a minute actually believing I would think medication abuse, originating at the age of 14
that was a good idea, were you?” The irrever- years. Indeed, she had met her husband at an
ent therapist also calls the client’s bluff. For the Alcoholics Anonymous (AA) meeting while at-
client who says, “I’m quitting therapy,” the tending college. Nevertheless, until the stu-
therapist might respond, “Would you like a re- dent’s suicide in medical school, Cindy had
ferral?” The trick here is to time the bluff care- been successful at maintaining an overall ap-
fully, with the simultaneous provision of a pearance of relative competence.
safety net; it is important to leave the client a
way out.
Treatment
At the initial meeting, Cindy was accompanied
CASE STUDY by her husband, who stated that he and Cindy’s
family considered his wife too lethally suicidal
Background
to be out of a hospital setting. Consequently, he
At the initial meeting, “Cindy,” a 30-year-old, and Cindy’s family were seriously contemplat-
white, married woman with no children, was ing the viability of finding long-term outpatient
living in a middle-class suburban area with her care. However, Cindy stated a strong prefer-
husband. She had a college education and had ence for inpatient treatment, although no ther-
successfully completed almost 2 years of medi- apist in the local area other than M. M. L. ap-
cal school. Cindy was referred to one of us (M. peared willing to take her into outpatient
M. L.) by her psychiatrist of 1½ years, who treatment. The therapist agreed to accept
was no longer willing to provide more than Cindy into therapy, contingent on the client’s
pharmacotherapy following a recent hospital- stated commitment to work toward behavioral
ization for a near-lethal suicide attempt. In the change and to stay in treatment for at least 1
2 years prior to referral, Cindy had been hospi- year. (It was later pointed out repeatedly that
talized at least 10 times (once for 6 months) for this also meant the client had agreed not to
psychiatric treatment of suicidal ideation; had commit suicide.) Thus, the therapist began the
engaged in numerous instances of both NSSI crucial first step of establishing a strong thera-
behavior and suicide attempts, including at peutic alliance by agreeing to accept the client
least 10 instances of drinking Clorox bleach, despite the fact that no one else was willing to
multiple deep cuts, and burns; and had had do so. She pointed out, however, that accep-
three medically severe or nearly lethal suicide tance into therapy did not come without a cost.
In this manner, the therapist communicated ac- of events would often begin with an interper-
ceptance of the client exactly as she was in the sonal encounter (almost always with her
current moment, while concomitantly making husband), which culminated in her feeling
clear that Cindy’s commitment toward change threatened, criticized, or unloved. These feel-
was the foundation of the therapeutic alliance. ings were often followed by urges either to self-
At the fourth therapy session, Cindy reported mutilate or to kill herself, depending somewhat
that she felt she could no longer keep herself on the covarying levels of hopelessness, anger,
alive. When reminded of her previous commit- and sadness. Decisions to self-mutilate and/or
ment to stay alive for 1 year of therapy, Cindy to attempt suicide were often accompanied by
replied that things had changed and she could the thought, “I’ll show you.” At other times,
not help herself. Subsequent to this session, al- hopelessness and a desire to end the pain per-
most every individual session for the next 6 manently seemed predominant. Both are exam-
months revolved around the topic of whether ples of emotional vulnerability. Following the
(and how) to stay alive versus committing sui- conscious decision to self-mutilate or to at-
cide. Cindy began coming to sessions wearing tempt suicide, Cindy would then immediately
mirrored sunglasses and would slump in her dissociate and at some later point cut or burn
chair or ask to sit on the floor. Questions from herself, usually while in a state of “automatic
the therapist were often met with a minimal pilot.” Consequently, Cindy often had diffi-
comment or long silences. In response to the culty remembering specifics of the actual acts.
therapist’s attempts to discuss prior self- At one point, Cindy burned her leg so badly
injurious behavior, Cindy would become angry (and then injected it with dirt to convince the
and withdraw (slowing down the pace of ther- doctor that he should give her more attention)
apy considerably). The client also presented that reconstructive surgery was required.
with marked dissociative reactions, which Behavioral analyses also revealed that dissocia-
would often occur during therapy sessions. tion during sessions usually occurred following
During these reactions, Cindy would appear Cindy’s perception of the therapist’s disap-
unable to concentrate or hear much of what proval or invalidation, especially when the
was being said. When queried by the therapist, therapist appeared to suggest that change was
Cindy would describe her experience as feeling possible. The therapist targeted in-session dis-
“spacey” and distant. The client stated that she sociation by immediately addressing it as it oc-
felt she could no longer engage in many activi- curred.
ties, such as driving, working, or attending By several months into therapy, an appar-
school. Overall, the client viewed herself as in- ently long-standing pattern of suicidal behav-
competent in all areas. iors leading to inpatient admission was ap-
The use of diary cards, which Cindy filled parent. Cindy would report intense suicidal
out weekly (or at the beginning of the session, ideation, express doubts that she could resist
if she forgot), assisted the therapist in carefully the urge to kill herself, and request admission
monitoring Cindy’s daily experiences of sui- to her preferred hospital; or, without warning,
cidal ideation, misery, and urges to harm her- she would cut or burn herself severely and re-
self, as well as actual suicide attempts and NSSI quire hospitalization for medical treatment. At-
behaviors. Behavioral analyses that attempted tempts to induce Cindy to stay out of the hospi-
to identify the sequence of events leading up to tal or to leave the hospital before she was ready
and following Cindy’s suicidal behavior soon typically resulted in an escalation of suicidality,
became an important focus of therapy. At every followed by her pharmacotherapist’s (a psychi-
point the therapist presented self-injurious atrist) insistence on her admission or the hospi-
behavior as to be expected, given the strength tal’s agreement to extend her stay. Observation
of the urge (but considered it ultimately of this behavioral pattern led the therapist to
beatable), and pointed out repeatedly that if hypothesize that the hospitalization itself was
the client committed suicide, therapy would be reinforcing suicidal behavior; consequently,
over, so they had better work really hard now, she attempted to change the contingencies for
while Cindy was alive. suicidal behaviors. Using didactic and con-
Over the course of several months, the tingency clarification strategies, the therapist
behavioral analyses began to identify a fre- attempted to help Cindy understand how hos-
quently recurring behavioral pattern that pre- pitalization might be strengthening the very
ceded suicidal behaviors. For Cindy, the chain behavior they were working to eliminate. This
issue became a focal point of disagreement able to get her to agree to a consultation
within the therapy, with Cindy viewing the meeting with all of her treatment providers,
therapist’s position as unsympathetic and lack- and, with some tenacity, the therapist actually
ing understanding of her phenomenal experi- got Cindy to make all the calls to set up the
ence. In Cindy’s opinion, the intensity of her meeting (including inviting her insurance moni-
emotional pain rendered the probability of sui- tor, who was coordinating payment for treat-
cide so high that hospitalization was necessary ment).
to guarantee her safety. She would buttress her At the case conference, the therapist pre-
position by citing frequently her difficulties sented her hypothesis that contingent hospital-
with dissociative reactions, which she reported ization was reinforcing Cindy’s suicidal behav-
as extremely aversive and which, in her opin- ior. She also assisted Cindy in making the case
ion, made her unable to function much of the that she (the therapist) was wrong. Using recip-
time. From the therapist’s perspective, the dele- rocal communication and contingency man-
terious long-term risk of suicide created by re- agement, the therapist stated that she simply
peated hospitalization in response to suicidal could not conduct a therapy she thought might
behavior was greater than the short-term risk kill the client (and she had to go along with
of suicide if hospitalization stays were reduced. what she thought was best even if she were
These differences in opinion led to frequent dis- wrong—“to do otherwise would be unethi-
agreements within sessions. It gradually be- cal”), and she requested that a new system of
came clear that Cindy viewed any explanations contingencies be agreed upon to disrupt the
of her behavior as influenced by reinforcement functional relationship between Cindy’s sui-
as a direct attack; she implied that if hospital- cidal behavior and hospitalization. Therefore,
ization was reinforcing her suicidal behavior, a plan was developed wherein the client was
then the therapist must believe that the purpose not required to be suicidal to gain hospital ad-
of her suicidality was for admission into the mittance. Under this new set of contingencies,
hospital. This was obviously not the case (at Cindy could elect, at will, to enter the hospital
least some of the time), but all attempts to ex- for a stay of up to 3 days, at the end of which
plain reinforcement theory in any other terms time she would always be discharged. If she
failed. The therapist compensated somewhat convinced people that she was too suicidal for
for insisting on the possibility that she (the discharge, she would be transferred to her
therapist) was correct by doing three things. least-preferred hospital for safety. Suicidal and
First, she repeatedly validated the client’s expe- NSSI behaviors would no longer be grounds
rience of almost unendurable pain. Second, she for admission except to a medical unit, when
made certain to address the client’s dissociative required. Although there was some disagree-
behavior repeatedly, explaining it as an auto- ment as to the functional relationship between
matic reaction to intensely painful affect (or the suicidal behavior and hospitalization, this sys-
threat of it). Third, she frequently addressed tem was agreed upon. Following this meeting,
the quality of the relationship between Cindy Cindy’s husband announced that he was no
and herself to strengthen the relationship and longer able to live with or tolerate his wife’s
maintain Cindy in therapy, even though to do suicidal behavior, and that the constant threat
so was a source of even more emotional pain. of finding her dead had led to his decision to
By the fifth month, the therapist became con- file for divorce. The focus of therapy then
cerned that the current treatment regimen was shifted to helping Cindy grieve over this event
going to have the unintended consequence of and find a suitable living arrangement. Cindy
killing the client (via suicide). At this point, the alternated between fury that her husband
therapist’s limits for effective treatment were would desert her in her hour of need (or “ill-
crossed; therefore, she decided to employ the ness,” as she put it) and despair that she could
consultation-to-the-client strategy to address ever cope alone. She decided that “getting her
Cindy’s hospitalizations. The first-choice strat- feelings out” was the only useful therapy. This
egy would have been to get Cindy to negotiate led to many tearful sessions, with the therapist
a new treatment plan with her preferred hospi- simultaneously validating the pain; focusing on
tal and admitting psychiatrist. Cindy refused to Cindy’s experiencing the affect in the moment,
go along, however, because she disagreed with without escalating or blocking it; and cheer-
the wisdom of changing her current unlimited leading Cindy’s ability to manage without go-
access to the inpatient unit. The therapist was ing back into the hospital. Due to Cindy’s high
level of dysfunctionality, she and her therapist stating that she could not drive at night due to
decided that she would enter a residential treat- night blindness. Although considered a
ment facility for a 3-month period. The facility therapy-interfering behavior and frequently ad-
had a coping skills orientation and provided dressed over the course of therapy, missing
group but not individual therapy. Cindy saw skills training was not a major focus of treat-
her therapist once a week and talked to her sev- ment, due to the continuing presence of higher-
eral times a week during this period. With some priority suicidal behavior. The therapist’s
coaching, Cindy looked for and found a room- efforts to engage the client in active skills ac-
mate to live with and returned to her own quisition during individual therapy sessions
home at the end of 3 months (the ninth month were also somewhat limited and were always
of therapy). Over the course of treatment, the preceded by obtaining Cindy’s verbal commit-
therapist used a number of strategies to treat ment to problem solving. The stylistic strategy
Cindy’s suicidal, NSSI, and therapy-interfering of irreverent communication was of value to
behaviors. In-depth behavioral chain and solu- the therapeutic process. The therapist’s irrever-
tion analysis helped the therapist (and some- ence often served to “shake up” the client, re-
times the client) gain insight into the factors in- sulting in a loosening of dichotomous thinking
fluencing current suicidal behavior. For Cindy, and maladaptive cognitions. The result of this
as for most clients, performing these analyses was Cindy’s increased willingness to explore
was quite difficult, because the process usually new and adaptive behavioral solutions. Finally,
generated intense feelings of shame, guilt, or relationship strategies were heavily employed
anger. Thus, behavioral analysis also func- as tools to strengthen the therapeutic alliance
tioned as an exposure strategy, encouraging the and to keep it noncontingent on suicidal and/or
client to observe and experience painful affect. dissociative behaviors. Included here were
It additionally served as a cognitive strategy in between-session therapist-initiated telephone
helping to change Cindy’s expectancies con- calls to see how Cindy was doing, the therapist
cerning the advantages and disadvantages of routinely giving out phone numbers when she
suicidal behavior, especially as the therapist re- was traveling, and sending the client postcards
peatedly made statements such as “How do when she was out of town.
you think you would feel if I got angry at you By the 12th month of therapy, Cindy’s sui-
and then threatened suicide if you didn’t cidal and self-injurious behavior, as well as
change?” Finally, behavioral analysis served as urges to engage in such behavior, receded. In
contingency management, in that the client’s addition, her hospital stays were reduced
ability to pursue topics of interest in therapy markedly, with none occurring after the eighth
sessions was made contingent on the successful month. While living at home with a roommate,
completion of chain and solution analysis. Cindy was readmitted to medical school. Part
Cindy presented early in therapy with ex- of the reason for returning to school was to
ceedingly strong perceptions as to her needs turn her life around, so that she could try to re-
and desires, and with a concomitant willing- gain her husband’s love and attention, or at
ness to engage in extremely lethal suicidal least his friendship. As the therapy continued
behavior. As previously mentioned, several of to focus on changing the contingencies of sui-
these acts were serious attempts to end her life, cidal behavior, reducing both emotional pain
whereas others functioned as attempts to gain and inhibition, and tolerating distress, a further
attention and care from significant others. This focus on maintaining sobriety and reasonable
client also presented with an extreme sensitiv- food intake was added. During the first months
ity to any attempts at obvious change proce- of living in her home without her husband,
dures, which she typically interpreted as com- Cindy had several alcoholic binges, and her
municating a message about her incompetence food intake dropped precipitously. These be-
and unworthiness. Although Cindy initially haviors became immediate targets. The thera-
committed herself to attending weekly group pist’s strong attention to these behaviors also
skills training for the first year of therapy, her communicated to Cindy that the therapist
attendance at group meetings was quite erratic, would take her problems seriously even if she
and she generally tended either to miss entire were not suicidal. Therapy focused as well on
sessions (but never more than three in a row) or expanding her social network. As with suicidal
to leave during the break. Cindy answered the behaviors, attention to these targets served as a
therapist’s attempts to address this issue by pathway to treating associated problems. As
crisis situations decreased in frequency, much competent nurse with training and supervisory
greater attention was paid to analyzing family responsibilities. Therapy with Betty was then fo-
patterns, including experiences of neglect and cused on maintaining her self-esteem in the face
invalidation, that might have led to Cindy’s of very powerful significant others (e.g., her su-
problems in later life. Cindy did not report a pervisor) who constantly invalidated her. Com-
history of sexual or physical abuse. Thus, the ponents of the treatment included the therapist’s
explicit goal of Stage 2 (which was being cau- noting and highlighting for Betty her tendency to
tiously entered as an overlap to Stage 1) was to modify her self-opinion in accordance with that
understand Cindy’s history and its relationship of others, persistent attempts to extract from
to her current problems. Betty self-validation and self-soothing, and im-
In other cases, especially when there has agery exercises wherein the client imagined and
been sexual and/or physical abuse in child- verbalized herself standing up to powerful oth-
hood, movement to Stage 2 before Stage 1 tar- ers. Much of the therapy focus was on Betty’s in-
gets have been mastered is likely to result in terpersonal behavior within the therapy session,
retrogression to previously problematic behav- with attention to relating this behavior to her in-
iors. For example, another client treated by the teractions with other important people. Thus,
same therapist (M. M. L.), Terry, had been treatment at that point was very similar to the
quite seriously abused physically by her mother functional-analytic psychotherapy regimen de-
throughout childhood and sexually abused by veloped by Kohlenberg and Tsai (1991). Over-
her father, beginning at age 5. The sexual ad- all, this third stage of therapy involved the move-
vances were nonviolent at first but became ment to a more egalitarian relationship between
physically abusive at approximately age 12. the client and the therapist, in which emphasis
Prior to this therapy, Terry had not disclosed was placed on the client’s standing up for her
the incidents of abuse to anyone. own opinions and defending her own actions.
After successful negotiation of Stage 1 tar- This approach required that the therapist both
gets, the therapist proceeded to expose Terry to reinforce the client’s assertions, and step back
trauma-related cues by simply having her begin and refrain from validating and nurturing the
to disclose details of the abuse. These exposure client in the manner characteristic of Stages 1
sessions were intertwined with work on current and 2. In addition, therapy sessions were re-
problems in Terry’s life. Following one expo- duced to every other week, and issues surround-
sure session focused on the sexual abuse, Terry ing eventual termination were periodically dis-
reverted to some of her previously problematic cussed.
behaviors, evidenced by withdrawal and si- Stage 4 of DBT targets the sense of incom-
lence in sessions, suicidal ideation, and medica- pleteness that can preclude the experience of
tion noncompliance. The appearance of such joy and freedom. Sally started Stage 1 treat-
behavior marked the necessity of stopping ment with the same therapist (M. M. L.) 15
Stage 2 discussions of previous sexual abuse to years ago. Stage 1 lasted 2 years; this was fol-
address Stage 1 targets recursively. Three ses- lowed by a break of 1 year, after which treat-
sions were devoted to a behavioral analysis of ment resumed for several years of bimonthly
Terry’s current suicidal, therapy-interfering, sessions leading to monthly sessions, and cur-
and quality-of-life–interfering behaviors; these rently consists of four or five sessions a year.
were eventually linked both to fears about how Sally has been married for 30 years to an irreg-
the therapist would view her childhood emo- ularly employed husband who, though devoted
tional responses to her father, and to holiday and loyal, is quite invalidating of her. Although
visits with her father that precipitated conflicts apparently brilliant, he is usually dismissed
over how Terry should be feeling about him in from jobs for his interpersonal insensitivity. She
the present. This two-steps-forward, one-step- has been employed full-time at the same place
back approach is common to therapy for cli- for years, working with children. The son she
ents with BPD, and in particular may mark the felt closest to died in a plane accident 2 years
transition between Stage 1 and Stage 2. ago; her mother died last year, and her father is
As previously mentioned, Stage 3 targets the very ill. Despite having a stable marriage,
client’s self-respect, regardless of the opinions of working in a stable and quite fulfilling job,
others. Betty, who was also in treatment with the having raised two well-adjusted sons, and still
same therapist (M. M. L.), had successfully ne- being athletic, life feels meaningless to Sally. In
gotiated Stages 1 and 2, and had become a highly the past she was very active in spiritual activi-
ties; following meditation retreats or extended THERAPIST: How so?

periods of daily meditation, she would report CLIENT: Umm, I don’t know. I just can’t even
contentment and some sense of joy. Since her cope with everyday life right now. And I
son died, Sally has let go of most of her spiri- can’t even . . . I’m just a mess. I don’t know
tual activities. Following 2 years of focusing on how to deal with anything.
grieving, she is now ready for Stage 4. Treat-
ment planning focused on actively practicing THERAPIST: So what does that mean exactly?
and keeping track of progress in radical accep- CLIENT: Umm, well, everything I try these days
tance (or “letting go of ego,” in Zen terminol- just seems overwhelming. I couldn’t keep up
ogy), either alone or with group support. on my job, and now I’m on medical leave.
Plus everyone’s sick of me being in the hospi-
tal so much. And I think my psychiatrist
TRANSCRIPTS wants to send me away because of all my
self-harming.
The following (composite) transcripts repre- THERAPIST: How often do you self-harm?
sent actual examples of the process of therapy CLIENT: Maybe once or twice a month. I use
occurring over several sessions with different my lighter or cigarettes, sometimes a razor
clients. These particular dialogues between blade.
therapist and client have been chosen to pro-
vide the reader with comprehensive examples THERAPIST: Do you have scars all over?
of the application of a wide range of DBT treat- CLIENT: (Nods yes.)
ment strategies. The session targets in the fol- THERAPIST: Your psychiatrist tells me you’ve
lowing transcript were orienting and commit- also drunk Clorox. Why didn’t you mention
ment. The strategies used were validation, that?
problem solving (insight, orienting, and com-
CLIENT: I guess it didn’t enter my mind.
mitment), dialectical (devil’s advocate), and
integrated (relationship enhancement). THERAPIST: Do things just not enter your mind
Obtaining the client’s commitment is a cru- very often?
cial first step in beginning therapy with clients CLIENT: I don’t really know. Maybe.
who have BPD. As illustrated in the following
THERAPIST: So maybe with you I’m going to
transcript, the dialectical technique of devil’s
have to be a very good guesser.
advocate can be highly effective when used as a
commitment strategy. In this first therapy ses- CLIENT: Hmm.
sion, the therapist’s ultimate goal was to obtain THERAPIST: Unfortunately, though, I’m not the
the client’s commitment to therapy, as well as a greatest guesser. So we’ll have to teach you
commitment to eliminate suicidal behavior. She how to have things come to mind. So what is
began by orienting the client to the purpose of it exactly that you want out of therapy with
this initial session. me? To quit harming yourself, quit trying to
kill yourself, or both?
THERAPIST: So are you a little nervous about CLIENT: Both. I’m sick of it.
me?
THERAPIST: And is there anything else you want
CLIENT: Yeah, I guess I am. help with?
THERAPIST: Well, that’s understandable. For the CLIENT: Um, well, I don’t know how to handle
next 50 minutes or so, we have this opportu- money, and I don’t know how to handle rela-
nity to get to know each other and see if we tionships. I don’t have friends; they don’t
want to work together. So what I’d like to do connect with me very often. I’m a former al-
is talk a little bit about the program and how coholic and a recovering anorexic/bulimic. I
you got here. So tell me, what do you want still have a tendency toward that.
out of therapy with me, and what are you
doing here? THERAPIST: Do you think maybe some of what
is going on with you is that you’ve replaced
CLIENT: I want to get better. your alcoholic and anorexic behaviors with
THERAPIST: Well, what’s wrong with you? self-harm behaviors?
CLIENT: I’m a mess. (Laughs.) CLIENT: I don’t know. I haven’t thought about
it that way. I just feel that I don’t know how consistent. It’s worse, you know, because
to handle myself, and—you know, and I when I’m . . . I know that, like with budget-
guess work through stuff, and that is obvi- ing money or whatever, I know I need to do
ously getting to me, because if it wasn’t, I it, and then when I don’t do it, it makes me
wouldn’t be trying to kill myself. even more upset.
THERAPIST: So from your perspective, one THERAPIST: Why would you ever want to do
problem is that you don’t know how to do something you’re not in the mood for?
things. A lot of things. CLIENT: Because I’ve got to. Because I can’t sur-
CLIENT: Yeah, and a lot of it is, I do know how, vive that way if I don’t.
but for some reason I don’t do it anyway. THERAPIST: Sounds like a pretty easy life to me.
THERAPIST: Um hmm. CLIENT: Yeah, but I can’t afford to live if I just
CLIENT: You know, I mean I know I need to spend my money on fun and stupid, frivo-
save money, and I know that I need to bud- lous things that I . . .
get myself, and I do every single month, but THERAPIST: Well, I guess maybe you should
every single month I get in debt. But, um, have some limits and not be too off the wall,
you know, it’s really hard for me. You know, but in general, I mean, why clean the house if
it’s like sometimes I know it, or I know I you’re not in the mood?
shouldn’t eat something and I do it anyway.
CLIENT: Because it pisses me off when it’s a
THERAPIST: So it sounds like part of the prob- mess. And I can’t find things, like I’ve lost
lem is you actually know how to do things; bills before and then I end up not paying
you just don’t know how to get yourself to them. And now I’ve got collection agencies
do the things you know how to do. on my back. I can’t deal with all this, and I
CLIENT: Exactly. end up self-harming and going into the hos-
THERAPIST: Does it seem like maybe your emo- pital. And then I just want to end it all. But it
tions are in control—that you are a person still doesn’t seem to matter, because if I’m
who does things when you’re in the mood? not in the mood to clean it, I won’t.
CLIENT: Yes. Everything’s done by the mood. THERAPIST: So the fact that it makes horrible
things happen in your life so far hasn’t been
THERAPIST: So you’re a moody person.
enough of a motivation to get you to do
CLIENT: Yes. I won’t clean the house for 2 things against your mood, right?
months, and then I’ll get in the mood to
CLIENT: Well, obviously not (laughs), because
clean. Then I’ll clean it immaculately and
it’s not happening.
keep it that way for 3 weeks—I mean, just
immaculate—and then when I’m in the THERAPIST: Doesn’t that tell you, though? This
mood I go back to being a mess again. is going to be a big problem, don’t you
think? This isn’t going to be something sim-
THERAPIST: So one of the tasks for you and me
ple. It’s not like you’re going to walk in here
would be to figure out a way to get your
and I’m going to say, “OK, magic wand,”
behavior and what you do less hooked up
and then all of a sudden you’re going to
with how you feel?
want to do things that you’re not in the
CLIENT: Right. mood for.
CLIENT: Yeah.
The therapist used insight to highlight for
the client the observed interrelationship be- THERAPIST: Yeah, so it seems to me that if
tween the client’s emotions and her behavior. you’re not in the mood for things, if you’re
She then began the process of shaping a com- kind of mood-dependent, that’s a very tough
mitment through the dialectical strategy of thing to crack. As a matter of fact, I think it’s
devil’s advocate. one of the hardest problems there is to deal
with.
THERAPIST: That, of course, is going to be hell CLIENT: Yeah, great.
to do, don’t you think? Why would you THERAPIST: I think we could deal with it, but I
want to do that? It sounds so painful. think it’s going to be hell. The real question
CLIENT: Well, I want to do it, because it’s so in- is whether you’re willing to go through hell
to get where you want to get or not. Now I self, is going to be exactly like quitting alco-
figure that’s the question. hol. Do you think this is going to be hard?
CLIENT: Well, if it’s going to make me happier, CLIENT: Stopping drinking wasn’t all that hard.
yeah. THERAPIST: Well, in my experience, giving up
THERAPIST: Are you sure? self-harm behavior is usually very hard. It
CLIENT: Yeah, I’ve been going through this will require both of us working, but you will
since I was 11 years old. I’m sick of this shit. have to work harder. And like I told you
I mean, excuse my language, but I really am, when we talked briefly, if you commit to
and I’m backed up against the wall. Either I this, it’s for 1 year—individual therapy with
need to do this or I need to die. Those are my me once a week, and group skills training
two choices. once a week. So the question is, are you will-
ing to commit for 1 year?
THERAPIST: Well, why not die?
CLIENT: I said I’m sick of this stuff. That’s why
CLIENT: Well, if it comes down to it, I will. I’m here.
THERAPIST: Um hmm, but why not now? THERAPIST: So you’ve agreed to not drop out of
CLIENT: Because, this is my last hope. Because therapy for a year, right?
if I’ve got one last hope left, why not take it? CLIENT: Right.
THERAPIST: So, in other words, all things being THERAPIST: And do you realize that if you don’t
equal, you’d rather live than die, if you can drop out for a year, that really does, if you
pull this off. think about it, rule out suicide for a year?
CLIENT: If I can pull it off, yeah. CLIENT: Logically, yeah.
THERAPIST: OK, that’s good; that’s going to be THERAPIST: So we need to be absolutely clear
your strength. We’re going to play to that. about this, because this therapy won’t work
You’re going to have to remember that when if you knock yourself off. The most funda-
it gets tough. But now I want to tell you mental mood-related goal we have to work
about this program and how I feel about you on is that, no matter what your mood is, you
harming yourself, and then we’ll see if you won’t kill yourself or try to.
still want to do this.
CLIENT: All right.
As illustrated by the foregoing segment, the THERAPIST: So that’s what I see as number
therapist’s relentless use of the devil’s advocate one priority—not our only one but number
strategy successfully “got a foot in the door” one—that we will work on that. And getting
and achieved an initial client commitment. The you to agree—meaningfully, of course—and
therapist then “upped the ante” with a brief ex- actually follow through on staying alive and
planation of the program and its goals. not harming yourself and not attempting sui-
cide, no matter what your mood is. Now the
THERAPIST: Now the most important thing to question is whether you agree to that.
understand is that we are not a suicide pre- CLIENT: Yes, I agree to that.
vention program; that’s not our job. But we
are a life enhancement program. The way we The therapist, having successfully obtained
look at it, living a miserable life is no the client’s commitment to work on suicidal
achievement. If we decide to work together, behavior again employed the strategy of devil’s
I’m going to help you try to improve your advocate to reinforce the strength of the com-
life, so that it’s so good that you don’t want mitment.
to die or hurt yourself. You should also
know that I look at suicidal behavior, includ- THERAPIST: Why would you agree to that?
ing drinking Clorox, as problem-solving
CLIENT: I don’t know. (Laughs.)
behavior. I think of alcoholism the same way.
The only difference is that cutting, burning, THERAPIST: I mean, wouldn’t you rather be in a
unfortunately—it works. If it didn’t work, therapy where, if you wanted to kill yourself,
nobody would do it more than once. But it you could?
only works in the short term, not the long CLIENT: I don’t know. I mean, I never really
term. So to quit cutting, trying to hurt your- thought about it that way.
THERAPIST: Hmm. THERAPIST: That’s part of the reason we’re hav-

CLIENT: I don’t want to . . . I want to be able to ing this conversation, to try to structure our
get to the point where I could feel like I’m relationship so that it’s very clear for both of
not being forced into living. us. And that way, at least, we’ll try to cut
down on how much you get overwhelmed by
THERAPIST: So are you agreeing with me be- not knowing what’s going on with me. OK?
cause you’re feeling forced into agreeing?
CLIENT: Um hmm.
CLIENT: You keep asking me all these ques-
tions. THERAPIST: And so I just want to be clear on
what our number one goal is, and how hard
THERAPIST: What do you think?
this is, because if you want to back out,
CLIENT: I don’t know what I think right now, now’s the time. Because I’m going to take
honestly. you seriously if you say, “Yes, I want to do
it.”
A necessary and important skill for the DBT CLIENT: I don’t want to back out.
therapist is the ability to sense when a client
has been pushed to his or her limits, as well as THERAPIST: OK. Good. Now I just want to say
the concomitant skill of being willing and able that this seems like a good idea right now.
to step back and at least temporarily refrain You’re in kind of an energized mood today,
from further pressuring the client. In these in- getting started on a new program. But in 5
stances, continued pressure from the therapist hours, it might not seem like such a good
is likely to boomerang and have the opposite idea. It’s kind of like it’s easy to commit to a
effect of what the therapist intends. Here the diet after a big meal, but it’s much harder
therapist noticed the client’s confusion and when you’re hungry. But we’re going to
sensed that further pushing was likely to result work on how to make it keep sounding like a
in the client’s reducing the strength of her com- good idea. It’ll be hell, but I have confidence.
mitment. Consequently, the therapist stepped I think we can be successful working to-
back and moved in with validation. gether.
THERAPIST: So you’re feeling pushed up against Note how the therapist ended the session by
the wall a little bit, by me? preparing the client for the difficulties she was
likely to experience in keeping her commitment
CLIENT: No, not really. (Starts to cry.)
and working in therapy. Cheerleading and rela-
THERAPIST: What just happened just now? tionship enhancement laid the foundation for a
CLIENT: (pause) I don’t know. I mean, I don’t strong therapeutic alliance. The following ses-
think I really want to kill myself. I think I sion occurred approximately 4 months into
just feel like I have to. I don’t think it’s really therapy. The session target was suicidal behav-
even a mood thing. I just think it’s when I ior. The therapist used validation, problem
feel like there’s no other choice. I just say, solving (contingency clarification, didactic in-
“Well, you know there’s no other choice, so formation, behavioral analysis, and solution
do it.” You know. And so right now, I don’t analysis), stylistic (irreverent communication),
see any ray of hope. I’m going to therapy, dialectical (metaphor, making lemonade out of
which I guess is good. I mean, I know it’s lemons), and skills training (distress tolerance)
good, but I don’t see anything any better strategies.
than it was the day I tried to kill myself. The therapist reviewed the client’s diary card
THERAPIST: Well, that’s probably true. Maybe it and noted a recent, intentional self-injury, in
isn’t any better. I mean, trying to kill yourself which the client opened up a previously self-
doesn’t usually solve problems. Although it inflicted wound following her physician’s re-
actually did do one thing for you. fusal to provide pain medication. The therapist
began by proceeding with a behavioral analy-
CLIENT: It got me in therapy. sis.
THERAPIST: Yeah. So my asking you all these
questions makes you start to cry. You look THERAPIST: OK. Now you were in here last
like you must be feeling pretty bad. week telling me you were never going to hurt
CLIENT: Just overwhelmed, I guess the word is. yourself again because this was so ridicu-
lous, you couldn’t stand it, you couldn’t hurt CLIENT: I believe firmly, and I even wrote it in
yourself any more. So let’s figure out how my journal, that if I’d gotten pain medica-
that broke down on Sunday, so we can learn tion when I really needed it, I wouldn’t have
something from it. OK. So when did you even thought of self-harming.
start having urges to hurt yourself?
CLIENT: My foot began to hurt on Wednesday. I The therapist proceeded by obtaining a de-
started to have a lot of pain. scription of the events co-occurring with the
onset of the problem. Here it became apparent
THERAPIST: It hadn’t hurt before that?
that maladaptive thinking was instrumental in
CLIENT: No. the client’s decision to self-harm. In the follow-
THERAPIST: So the nerves were dead before that ing segment, the therapist used the dialectical
or something, huh? So you started having a strategy of metaphor to highlight for the client
lot of pain. Now when did you start having her cognitive error.
the pain, and when did the urge to harm
yourself come? THERAPIST: Now let me ask you something—
CLIENT: At the same time. you’ve got to imagine this, OK? Let’s imag-
ine that you and I are on a raft together out
THERAPIST: They just come at the identical mo- in the middle of the ocean. Our boat has
ment? sunk and we’re on the raft. And when the
CLIENT: Just about. boat sank, your leg got cut really badly. And
together we’ve wrapped it up as well as we
The specification of an initial prompting en- can. But we don’t have any pain medicine.
vironmental event is always the first step in And we’re on this raft together and your leg
conducting a behavioral chain analysis. Here really hurts, and you ask me for pain medi-
the therapist began by directly inquiring when cine, and I say no. Do you think you would
the urges toward suicide and NSSI began. Note then have an urge to hurt yourself and make
also the therapist’s use of irreverent communi- it worse?
cation early in the session. CLIENT: No, it would be a different situation.
THERAPIST: So how is it that feeling pain sets THERAPIST: OK, but if I did have the pain medi-
off an urge to self-harm? Do you know how cation and I said no because we had to save
that goes? How you get from one to the it, what do you think?
other? CLIENT: If that were logical to me, I’d go along
CLIENT: I don’t know. Maybe it wasn’t till with it and wouldn’t want to hurt myself.
Thursday, but I asked my nurse. I go, “Look, THERAPIST: What if I said no because I didn’t
I’m in a lot of pain, you know. I’m throwing want you to be a drug addict?
up my food because the pain is so bad.” And CLIENT: I’d want to hurt myself.
the nurse tried. She called the doctor and
THERAPIST: OK. So we’ve got this clear. The
told him I was in a lot of pain, and asked if
pain is not what’s setting off the desire to
he’d give me some painkillers. But no! So I
self-harm. It’s someone not giving you some-
kept asking, and the answer kept being no,
thing to help, when you feel they could if
and I got madder and madder and madder.
they wanted to.
So I felt like I had to show somebody that it
hurt, because they didn’t believe me. CLIENT: Yes.
THERAPIST: So let’s figure this out. So is it that
The therapist used contingency clarification
you’re assuming that if someone believed it
to point out the effects of others’ responses on
hurt as bad as you said it does, they would
the client’s own behavior. In the following seg-
actually give you the painkillers?
ment, the therapist again employed contin-
CLIENT: Yes. gency clarification in a continued effort to
THERAPIST: OK. That’s where the faulty think- highlight for the client the communication
ing is. That’s the problem. You see, it’s function of NSSI.
entirely possible that people know how bad
the pain is but still aren’t giving you medica- THERAPIST: So, in other words, hurting yourself
tion. is communication behavior, OK? So what we
have to do is figure out a way for the com- getting treatment for her diabetes, and it got
munication behavior to quit working. real bad, and they gave her pain medication.
CLIENT: Why? THERAPIST: Now we’re not on the same wave-
THERAPIST: Because you’re not going to stop length in this conversation.
doing it until it quits working. It’s like trying CLIENT: Yes, we are. What wavelength are you
to talk to someone; if there’s no one in the on?
room, you eventually quit trying to talk to THERAPIST: I’m on the wavelength that it may
them. It’s like when a phone goes dead, you have been reasonable for you to get pain
quit talking. medicine, and I certainly understand your
CLIENT: I tried three nights in a row in a per- wanting it. But I’m also saying that no mat-
fectly assertive way and just clearly stated I ter what’s going on, hurting yourself is some-
was in a lot of pain. thing we don’t want to happen. You’re func-
THERAPIST: You know, I think I’ll switch chairs tioning like if I agreed with you that you
with you. You’re not hearing what I’m say- should get pain medication, I would think
ing. this was OK.
CLIENT: And they kept saying, “No,” and then CLIENT: Hmm?
some little light came on in my head. THERAPIST: You’re talking about whether they
THERAPIST: I’m considering switching chairs should have given you pain medication or
with you. not. I’m not talking about that. Even if they
should have, we’ve got to figure out how you
CLIENT: And it was like, “Here, now can you could have gotten through without hurting
tell that it hurts a lot?” yourself.
THERAPIST: I’m thinking of switching chairs
with you. As illustrated by the foregoing exchange, a
CLIENT: Why? client with BPD often wants to remain focused
on the crisis at hand. This poses a formidable
THERAPIST: Because if you were sitting over
challenge for the therapist, who must necessar-
here, I think you would see that no matter
ily engage in a back-and-forth dance between
how bad the pain is, hurting yourself to get
validating the client’s pain and pushing for
pain medication is not a reasonable re-
behavioral change. This segment also illus-
sponse. The hospital staff may not have been
trates how validation does not necessarily im-
reasonable either. It may be that they should
ply agreement. Although the therapist vali-
have given you pain medicine. But we don’t
dated the client’s perception that the nurse’s
have to say they were wrong in order to say
refusal to provide pain medication may have
that hurting yourself was not the appropri-
been unreasonable, she remained steadfast in
ate response.
maintaining the inappropriateness of the cli-
CLIENT: No, I don’t think it was the appropri- ent’s response.
ate response.
THERAPIST: Good. So what we’ve got to do is CLIENT: I tried some of those distress tolerance
figure out a way to get it so that the response things and they didn’t work.
doesn’t come in, even if you don’t get pain THERAPIST: OK. Don’t worry, we’ll figure out a
medicine. So far, it has worked very effec- way. I want to know everything you tried.
tively as communication. And the only way But first I want to be sure I have the picture
to stop it is to get it to not work any more. clear. Did the urges start building after
And of course, it would be good to get other Wednesday and get worse over time?
things to work. What you’re arguing is
“Well, OK, if I’m not going to get it this way, CLIENT: Yeah. They started growing with the
then I should be able to get it another way.” pain.
CLIENT: I tried this time! THERAPIST: With the pain. OK. But also they
started growing with their continued refusal
THERAPIST: Yes, I know you did, I know you to give you pain medicine. So you were
did. thinking that if you hurt yourself, they
CLIENT: A lady down the hallway from me was would somehow give you pain medicine?
CLIENT: Yeah. ‘Cause if they wouldn’t listen to So you keep up the good fight here. Now
me, then I could show them. what else did you try?
THERAPIST: OK, so you were thinking, “If they CLIENT: I tried talking about it with other cli-
won’t listen to me, I’ll show them.” And ents.
when did that idea first hit? Was that on THERAPIST: And what did they have to say?
Wednesday?
CLIENT: They said I should get pain medica-
CLIENT: Yeah. tion.
THERAPIST: OK. Well, we’ve got to figure out a THERAPIST: Right. But did they say you should
way for you to tolerate bad things without cut yourself or hurt yourself if you didn’t get
harming yourself. So let’s figure out all the it?
things you tried, and then we have to figure
out some other things, because those didn’t CLIENT: No. And I tried to get my mind off my
work. So what was the first thing you tried? pain by playing music and using mindful-
ness. I tried to read and do crossword puz-
zles.
At this juncture the behavioral analysis re-
mained incomplete, and it would normally THERAPIST: Um hmm. Did you ever try radical
have been premature to move to the stage of acceptance?
solution analysis. However, in the therapist’s CLIENT: What’s that?
judgment, it was more critical at this point to THERAPIST: It’s where you sort of let go and ac-
reinforce the client’s attempts at distress toler- cept the fact that you’re not going to get the
ance by responding to the client’s communica- pain medication. And you just give yourself
tion that she had attempted behavioral skills. up to that situation. You just accept that it
ain’t going to happen, that you’re going to
CLIENT: I thought that if I just continued to be have to cope in some other way.
assertive about it that the appropriate mea-
CLIENT: Which I did yesterday. I needed a little
sures would be taken.
Ativan to get me there, but I got there.
THERAPIST: OK, but that didn’t work. So why
THERAPIST: Yesterday?
didn’t you harm yourself right then?
CLIENT: Yeah. I took a nap. When I woke up I
CLIENT: I didn’t want to.
basically said, “Hey, they’re not going to
THERAPIST: Why didn’t you want to? change, so you’ve just got to deal with this
CLIENT: I didn’t want to make it worse. the best that you can.”
THERAPIST: So you were thinking about pros THERAPIST: And did that acceptance help
and cons —that if I make it worse, I’ll feel some?
worse? CLIENT: I’m still quite angry about what I
CLIENT: Yeah. believe is discrimination against borderline
personalities. I’m still very angry about that.
One aspect of DBT skills training stresses the THERAPIST: OK. That’s fine. Did it help,
usefulness of evaluating the pros and cons of though, to accept?
tolerating distress as a crisis survival strategy. CLIENT: Um hmm.
Here the therapist employed the dialectical
strategy of turning lemons into lemonade by THERAPIST: That’s good. That’s great. That’s a
highlighting for the client how she did, in fact, great skill, a great thing to practice. When
use behavioral skills. Note in the following re- push comes to shove, when you’re really at
sponse how the therapist immediately rein- the limit, when it’s the worst it can be, radi-
forced the client’s efforts with praise. cal acceptance is the skill to practice.
CLIENT: That’s AA.
THERAPIST: That’s good thinking. That’s when
you’re thinking about the advantages and During a solution analysis, it is often neces-
disadvantages of doing it. OK, so at that sary that the therapist facilitate the process by
point the advantages of making it worse helping the client “brainstorm,” or by making
were outweighed by the disadvantages. OK. direct suggestions for handling future crises.
Here the therapist suggested a solution that is THERAPIST: So what did she do? Did she say she
also taught in the DBT skills training module would call?
on distress tolerance. The notion of radical ac- CLIENT: She called.
ceptance stresses the idea that acceptance of
one’s pain is a necessary prerequisite for ending THERAPIST: OK. And then what happened?
emotional suffering. CLIENT: She came back. She was really sweet,
and she just said, “I’m really sorry, but the
THERAPIST: OK. Now let’s go back to how you doctor said no.”
gave in to the urge. Because you really man- THERAPIST: Then did you feel anger?
aged to battle all the way till then, right? CLIENT: I don’t know if I was really angry, but I
OK. Usually, with you, we can assume that was hurt.
something else happened. So let’s figure out
Sunday and see if there wasn’t an interper- THERAPIST: Oh, really? Oh, that’s pretty inter-
sonal situation that day that made you feel esting. OK. So you were hurt . . .
criticized, unloved, or unacceptable. CLIENT: Because I ended up hugging my teddy
CLIENT: Well, on Saturday I was so pissed off bear and just crying for a while.
and I went to an AA meeting. And it got on THERAPIST: Before or after you decided to hurt
my brain how alcohol would steal away my yourself?
pain. I went looking all around the neighbor- CLIENT: Before.
hood for an open store. I was going to go get
THERAPIST: OK. So you didn’t decide right
drunk. That’s how much my pain was influ-
away to hurt yourself. You were thinking
encing me. But I couldn’t find a store that
about it. But when did you decide to do it?
was open, so I went back to the hospital.
CLIENT: Later on Saturday.
THERAPIST: So you got the idea of getting alco-
hol to cure it, and you couldn’t find any, so THERAPIST: When?
you went back to the hospital. You were in a CLIENT: After I got sick of crying.
lot of pain, and then what happened? THERAPIST: So you laid in bed and cried, feeling
CLIENT: I told the nurse, “I’ve been sober al- uncared about and hurt, abandoned proba-
most 10 years and this is the first urge I’ve bly, and unlovable, like you weren’t worth
had to drink; that’s how bad my pain is.” helping?
And that wasn’t listened to. CLIENT: Yes.
THERAPIST: So you figured that should have THERAPIST: That’s a really adaptive response.
done it? That’s what I’m going to try to teach you.
CLIENT: Yeah. Except that you’ve already done it without
THERAPIST: Yeah. ‘Cause that’s a high-level my teaching it to you. So how did you get
communication, that’s like a suicide threat. from crying, feeling unloved and not cared
Very good, though. I want you to know, about, and you cry and sob—how did you
that’s better than a suicide threat, because get from there to deciding to hurt yourself,
that means you had reduced the severity of instead of like going to sleep?
your threats. CLIENT: Because then I got angry. And I said,
“Fuck this shit, I’ll show him.”
The response above was very irreverent, in THERAPIST: Now did you quit crying before
that most clients would not expect their thera- you got angry, or did getting angry make you
pists to view making a threat as a sign of thera- stop crying?
peutic progress. The therapeutic utility of irrev-
CLIENT: I think getting angry made me stop
erence often lies in its “shock” value, which
crying.
may temporarily loosen a client’s maladaptive
beliefs and assumptions, and open the client up THERAPIST: So you kind of got more energized.
to the possibility of other response solutions. So you must have been ruminating while you
were lying there, thinking. What were you
CLIENT: And I just told her how I was feeling thinking about?
about it, and I thought that would do it. And CLIENT: For a long time I was just wanting
the doctor still wouldn’t budge. somebody to come care about me.
THERAPIST: Um hmm. Perfectly reasonable feel- THERAPIST: See, the question is, is there any
ings. Makes complete sense. Now maybe other way for you to feel validated and cared
there you could have done something differ- about, other than them giving it to you?
ent. What would have happened if you had CLIENT: No.
asked the nurse to come in and talk to you,
THERAPIST: Now is this a definite, like “I’m not
hold your hand?
going to let there be any other way,” or is it
more open, like “I can’t think of another
An overall goal of behavioral analysis is the
way, but I’m open to the possibility?”
construction of a general road map of how the
client arrives at dysfunctional responses, with CLIENT: I don’t think there’s another way.
notation of possible alternative pathways. Here THERAPIST: Does that mean you’re not even
the therapist was searching for junctures in the open to learning another way?
map where possible alternative responses were CLIENT: Like what?
available to the client.
THERAPIST: I don’t know. We have to figure it
out. See, what I think is happening is that
CLIENT: They don’t have time to do that.
when you’re in a lot of pain and you feel ei-
THERAPIST: They don’t? Do you think that ther not cared about or not taken seriously,
would have helped? invalidated, that’s what sets you up to hurt
CLIENT: I don’t know. She couldn’t help me. yourself, and also to want to die. The prob-
THERAPIST: She could have made you feel cared lem that we have to solve is how to be in a
about. That would have been a caring thing situation that you feel is unjust without hav-
to do. ing to harm yourself to solve it. Are you
open to that?
CLIENT: Yeah, but I don’t think it would have
helped. CLIENT: Yeah.
THERAPIST: What would have helped?
As illustrated here, behavioral analysis is of-
CLIENT: Getting pain medication. ten an excruciating and laborious process for
THERAPIST: I thought you’d say that. You have client and therapist alike. The therapist often
a one-track mind. Now listen, we’ve got to feels demoralized and is tempted to abandon
figure out something else to help you, be- the effort, which may be likened to trying to
cause it can’t be that nothing else can help. find a pair of footprints hidden beneath layers
That can’t be the way the world works for of fallen leaves; the footprints are there, but it
you. There’s got to be more than one way to may take much raking and gathering of leaves
get everywhere, because we all run into boul- before they are uncovered. With repeated anal-
ders on the path. Life is like walking on a yses, however, the client learns that the thera-
path, you know, and we all run into boul- pist will not “back down.” Such persistence on
ders. It’s got to be that there are other paths the part of the therapist eventually extinguishes
to places. And for you, it really isn’t the pain a client’s refusal to attempt new and adaptive
in your ankle that’s the problem; it’s the feel- problem-solving behaviors. As clients increas-
ing of not being cared about. And probably a ingly acquire new behavioral skills, more adap-
feeling that has something to do with anger, tive attempts at problem resolution eventually
or a feeling that other people don’t respect become discernible.
you—a feeling of being invalidated. In the following session (approximately 10
CLIENT: Yes. months into therapy), the client arrived wear-
ing mirrored sunglasses (again) and was angry
THERAPIST: So I think it’s not actually the pain because collection agencies were persistent in
in your ankle that’s the problem. Because if pressuring her for payment on delinquent ac-
you were out on that raft with me, you counts. In addition, her therapist had been out
would have been able to handle the pain if I of town for a week. The session targets were
hadn’t had any medicine, right? So it’s really emotion regulation and interpersonal effective-
not the pain; it’s the sense of being invali- ness. Dialectical (metaphor), validation (cheer-
dated and the sense of not being cared about. leading), problem solving (contingency clar-
That’s my guess. Do you think that’s correct? ification, contingency management), stylistic
CLIENT: Yes. (reciprocal communication, irreverent commu-
nication), and integrated (relationship en- be angry, and we just have to deal with that,
hancement) strategies were used. In this first you and me. It’s just a problem to be solved.
segment, the therapist used cheerleading, con- It’s not a catastrophe; it’s not the worst thing
tingency clarification, and the contingency anyone ever did. It’s just a problem that you
management strategy of shaping to get the cli- have, and that’s what you and I do. We solve
ent to remove her sunglasses and work on ex- problems; we’re a problem-solving team.
pressing her anger. (pause)
CLIENT: (Removes sunglasses.) All right.
THERAPIST: It’s not a catastrophe that the col-
THERAPIST: Thank you. That’s a big step, I
lector did this to you, and it’s not a catastro-
know, for you.
phe to be mad at the collector. It’s made your
life a lot harder, but you can handle this. You
can cope with this. This is not more than you The therapist’s use of reciprocal communica-
can cope with. You’re a really strong tion informed the client of her feelings regard-
woman; you’ve got it inside you. But you’ve ing the sunglasses. Note the matter-of-fact atti-
got to do it. You’ve got to use it. I’m willing tude taken by the therapist and her continued
to help you, but I can’t do it alone. You have attempt to normalize the issue (i.e., “There’s
to work with me. nothing freakish about that . . . it’s not the
worst thing anyone ever did”). Also note the
CLIENT: How? framing of the issue as a problem to be solved,
THERAPIST: Well, by taking off your sunglasses, as well as the therapist’s use of the relationship
for starters. strategy to enhance the therapeutic alliance.
The therapist also made a point of validating
The therapist began the exchange by at- the client by letting her know that she realized
tempting to normalize the issue (“It’s not a ca- this was difficult.
tastrophe”), validating the client (“It’s made
your life a lot harder”), and cheerleading (“You THERAPIST: Now, c’mon, I want you to find it
can handle this. You can cope. . . . You’re a inside yourself. I know you’ve got it; I know
really strong woman”). The therapist then you can do it. You can’t give up. You can’t let
moved to contingency clarification by pointing your feet slip. Keep going. Just express di-
out that provision of the therapist’s assistance rectly to me how you feel. That you’re angry
was contingent on the client’s willingness to at yourself, that you’re angry at the collec-
work. She immediately followed this by re- tion agency, and that you’re damn angry
questing a response well within the client’s with me. (long pause)
behavioral repertoire. CLIENT: (barely audible) I’m angry at you, at
myself, and the collection agency.
CLIENT: I knew you’d say that.
THERAPIST: And I knew you knew I’d say that. The therapist continued to rely on cheerlead-
CLIENT: Sunglasses are your biggest bitch, I ing and praise as she continued the shaping
think. process in an attempt to get the client to ex-
press her anger directly.
THERAPIST: Well, how would you like to look at
yourself talking to someone else? (long THERAPIST: Good, did that kill you? (long
pause) They make it difficult for me. And I pause) That’s great. Is that hard? (long
figure they make it harder for you. I think pause) It was, wasn’t it? Now say it with a
you do better when you’re not wearing those little vigor. Can’t you say it with a little en-
sunglasses. It’s like a step; you always do ergy?
better when you go forward. And when you
do, you feel better. I’ve noticed that. (long CLIENT: (Shakes her head no.)
pause) So that’s what you should do; you THERAPIST: Yes, you can. I know you’ve got it
should take off your sunglasses, and then we in you. I have a good feel for what your
should problem-solve on how to cope when strengths are. I don’t know how I’ve got this
you can’t get angry. There’s nothing freakish good feel, but I do. And I know you can do it
about that. Something has happened in your and you need to do it, and you need to say it
life that has made it so that you’re afraid to with some energy. Express how angry you
are. You don’t have to yell and scream or THERAPIST: Um hmm.

throw things. Just say it aloud—“I’m an- CLIENT: They’re persistent.
gry!” (long pause) You can scream, of
course, if you want; you can say, “I’m an- THERAPIST: Um hmm. (pause) Who’s the safest
gry!” to be angry at? Yourself, me, or the collec-
tion agency?
CLIENT: That’s it. That’s all I can do.
CLIENT: Collection agency.
THERAPIST: Listen, you have to take the risk.
THERAPIST: OK, then, tell me how angry you
You’re not going to get past this or through
are. You don’t have to make it sound like
this. You have to take the risk. You are like a
100. Try to make it sound like 50.
person mountain climbing and we’ve come
to this crevasse and it’s very deep, but we CLIENT: They really pissed me off! (said in a
can’t go back because there’s an avalanche, loud, angry voice)
and the only way to go forward is for you to THERAPIST: Well, damn right. They piss me off,
jump over this crevasse. You’ve got to do it. too.
Tell me how mad you are, in a way that I can
understand how you really feel. As illustrated by the foregoing exchange, a
CLIENT: (long pause) I can’t do any of it. primary difficulty in working with clients who
THERAPIST: That is bullshit. have BPD is their not uncommon tendency to
refuse to engage in behavioral work. Thus, it is
CLIENT: You want me to get angry at you, don’t absolutely necessary that the therapist main-
you? tain persistence and not give up in the face of a
THERAPIST: I don’t care who you get angry at. I client’s “I can’t” statements. In situations like
think you already are angry. I just want you these, the use of irreverent communication of-
to express it. I’m not going to ask you to do ten succeeds in producing a breakthrough and
anything more today, by the way. I figure the gaining client compliance.
only thing today you have to do is say “I’m
angry,” in a voice that sounds angry, and I
figure you’re capable of that. And I might be POSTVENTION
angry if you don’t do it. I don’t think I will
be, but I might. That’s OK. I can be angry, After completing the writing of Cindy’s case
you can be angry, we can be angry some- history for publication in this Handbook, 14
times, and it isn’t going to kill either one of months into therapy, Cindy died of a prescrip-
us. tion drug overdose plus alcohol. We considered
dropping the case history and replacing it with
Cheerleading and metaphor were unsuccess- a more successful case. However, in Cindy’s
ful in moving the client to express her anger honor, and because we think much can be
more forcefully. Consequently, the therapist learned from both failed and successful ther-
switched to irreverent communication in an at- apy, we decided to leave the case in. The imme-
tempt to get the client to “jump track.” Also diate precipitant for Cindy’s overdose was a
note how the therapist communicated to the call to her estranged husband, during which
client the potential negative consequences of she discovered that another woman was living
her continued refusal to express her anger (i.e., with him. As Cindy told her therapist during a
“. . . I might be angry . . .”). In this manner, the phone call the next morning, her unverbalized
therapist used the relationship as a contingency hope that they might someday get back to-
in order to promote change in the client. gether, or at least be close friends, had been
shattered. She phoned again that evening in
THERAPIST: OK, so how angry are you? On a tears, stating that she had just drunk half a fifth
scale of 1 to 100, how angry would you say of liquor. Such drinking incidents had occurred
you are? At 100, you’re ready to kill. You’re several times before, and the phone call was
so enraged, you’d go to war if you could. spent “remoralizing” Cindy, offering hope,
CLIENT: (barely audible) Maybe 100. problem-solving how she could indeed live
without her husband, and using crisis interven-
THERAPIST: Really? tion techniques to get her through the evening,
CLIENT: They know my situation. until her appointment the following day.
Cindy’s roommate was home and agreed to which the client had cried that she might not be
talk with her, watch a TV movie together, and able to hold on, during the last call the client
go to bed (plans on which the roommate did made plans for the evening, agreed to stop
follow through). Cindy stated that although drinking and not to do anything suicidal or
she felt suicidal, she would stop drinking and self-destructive, and seemed to the therapist
would not do anything self-destructive before (and the roommate) to be in better spirits fol-
her appointment. She was instructed to call the lowing the phone call. Her roommate was
therapist back later that evening if she wanted home and available. Thus, the therapist did not
to talk again. The next day, when Cindy did take extraordinary measures that evening to
not arrive for her appointment, the therapist prevent suicide. Indeed, the problem behavior
called her home, just as her roommate discov- focused on during the call was the drinking.
ered Cindy dead, still in bed from the night be- The topic of suicide was brought up by the
fore. At this point, the therapist was faced with therapist, in the course of conducting a risk as-
a number of tasks. The therapist called to in- sessment.
form other therapists who had been treating Could the therapist have known? Only (per-
the client, and she spoke with a legal consultant haps) if she had paid more attention to the pre-
to review the limits of confidentiality when a cipitant and less to the affect expressed at the
client has died. Once the family (Cindy’s par- end of the phone call. In reviewing notes about
ents and estranged husband) were alerted, the the client, the therapist saw that each previous
therapist called each to offer her condolences. near-lethal attempt was a result of the client’s
The next day, the therapist (who was the senior believing that the relationship with her hus-
therapist and supervisor on the treatment band had irrevocably ended. Although the cli-
team) called a meeting of the treatment team to ent could tolerate losing her husband, she
discuss and process the suicide. It was espe- could not tolerate losing all hope for a reconcil-
cially important to notify the individual thera- iation at some point, even many years hence.
pists of the remaining three members of Cindy’s Had the therapist linked these two ideas (com-
skills training group. Group members were no- plete loss of hope and suicide attempt), she
tified of the suicide by their individual psycho- might have been able to work out a better plan
therapists. Within minutes of the beginning of with the client for a reemergence of the crisis
the next group session, however, two members later in the evening. The value of both conduct-
became seriously suicidal, and one of them had ing thorough behavioral assessments and orga-
to be briefly hospitalized. (By the third week nizing them into a coherent pattern is high-
following the suicide, however, both had re- lighted in this case. Second, when all is said and
gained their forward momentum.) A third done, an individual with BPD must ultimately
group member took this occasion to quit DBT be able and willing to tolerate the almost un-
and switch to another therapy, saying that this imaginable pain of his or her life until the ther-
proved the treatment did not work. In the days apy has a chance to make a permanent differ-
and weeks following the suicide, the therapist ence. Ultimately, the therapist cannot save the
attended the funeral and met with Cindy’s client; only the client can do that. Even if mis-
roommate and with her parents. takes are made, the client must nonetheless per-
What can we learn from this suicide? First, it severe. In this case, the DBT protocol of “no le-
is important to note that even when a treat- thal drugs for lethal people” was violated, even
ment protocol is followed almost to the letter, it though the client had a past history of near-
may not save a client. Even an effective treat- lethal overdoses. Why was the protocol not en-
ment can fail in the end. In this case, DBT forced? There were two primary reasons. First,
failed. This does not mean that the progress the client came into therapy with a strong belief
made was unimportant or not real. Had this that the host of medications she was on were
“slippery spot over the abyss” been negotiated essential to her survival. Any attempt on the
safely, perhaps the client would have been able therapist’s part to manage her medications
to develop, finally, a life of quality. Risk is not would have been met by very strong resistance.
eliminated, however, just because an individual Although the drugs were dispensed in small
makes substantial progress. In this case, the doses, the only safe alternative would have
therapist did not believe during the last phone been to have the person living with her (her
call that the client was at higher than ordinary husband at first, then her roommate) manage
risk for imminent suicide. In contrast to many her medications, which the client also resisted.
previous phone calls and therapy sessions in In addition, the “no lethal drugs” protocol of
DBT is regularly criticized by some mental Adler, G. (1993). The psychotherapy of core borderline
health professionals, who believe that psycho- psychopathology. American Journal of Psychothera-
active medications are a treatment of choice for py, 47, 194–206.
suicidal individuals. In the face of professional Adler, G., & Buie, D. H. (1979). Aloneness and border-
line psychopathology: The possible relevance of child
and client resistance to the policy in this case
development issues. International Journal of Psycho-
the therapist relented. The second reason was analytic Psychotherapy, 60, 83–96.
that the lethal behavior of the client during American Psychiatric Association. (1987). Diagnostic
therapy consisted of cutting and slashing; thus, and statistical manual of mental disorders. (3rd ed.,
her using drugs to commit suicide did not seem rev.). Washington, DC: Author.
likely, and the therapist allowed herself a false American Psychiatric Association. (2000). Diagnostic
sense of safety with respect to them. Third, a and statistical manual of mental disorders (4th ed.,
group member’s suicide is extraordinarily text rev.). Washington, DC: Author.
stressful for clients with BPD who are in group Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Bor-
therapy. Although it is easy to believe that alli- derline personality disorder, stigma, and treatment
ances are not strong in a psychoeducational implications. Harvard Review of Psychiatry, 14,
249–256.
behavioral skills group, this has universally not
Bateman, A., & Fonagy, P. (1999). Effectiveness of par-
been our experience. The suicide of one mem-
tial hospitalization in the treatment of borderline per-
ber is a catastrophic event and can lead to con- sonality disorder: A randomized controlled trial.
tagious suicide and NSSI behavior, and therapy American Journal of Psychiatry, 156, 1563–1569.
dropouts. Thus, extreme care is needed in the Bateman, A., & Fonagy, P. (2001). Treatment of border-
conduct of group meetings for some time fol- line personality disorder with psychoanalytically ori-
lowing a suicide. Similar care is needed with ented partial hospitalization: An 18-month follow-
the treatment team, where the thread of hope up. American Journal of Psychiatry, 158, 36–42.
that maintains therapists in the face of a daunt- Bateman, A. W., & Fonagy, P. (2004). Mentalization-
ing task is also strained. It is important that the based treatment of BPD. Journal of Personality Dis-
personal reactions of therapists, as well as a pe- orders, 18, 36–51.
riod of mourning and grieving, be shared and Beck, A. T., Brown, G., Berchick, R. J., Stewart, B. L., &
Steer, R. A. (1990). Relationship between hopeless-
accepted. Fears of legal responsibility, never far
ness and ultimate suicide: A replication with psychi-
from the surface, must be confronted directly; atric outpatients. American Journal of Psychiatry,
legal counsel must be sought as necessary; and, 147, 190–195.
in time, a careful review of the case and the Beck, A. T., & Freeman, A. (1990). Cognitive therapy of
therapy must be conducted, if only to improve personality disorders. New York: Guilford Press.
treatment in the future. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G.
(1979). Cognitive therapy of depression. New York:
Guilford Press.
ACKNOWLEDGMENTS Benjamin, L. S. (1996). Interpersonal diagnosis and
treatment of personality disorders (2nd ed.). New
The writing of this chapter was supported by National York: Guilford Press.
Institute of Mental Health Grant No. MH34486 to Blum, N., Pfohl, B., St. John, D., Monahan, P., & Black,
Marsha M. Linehan. Parts of this chapter are drawn D. W. (2002). STEPPS: A cognitive-behavioral
from Linehan (1993b), Linehan and Koerner (1992), systems-based group treatment for outpatients with
Koerner and Linehan (1992), and Linehan (1997). The borderline personality disorder—a preliminary re-
quotations from Linehan (1997) in the section on vali- port. Comprehensive Psychiatry, 43, 301–310.
dation are reprinted with the permission of the Ameri- Bohus, M., Limberger, M. F., Frank, U., Sender, I.,
can Psychological Association. Finally, this chapter is a Gratwohl, T., & Stieglitz, R. D. (2001). [Develop-
revision of the same chapter in the previous edition of ment of the borderline symptom list]. Psychothera-
this book. Many contributions to this chapter were pies, Psychosomatik, Medizinische Psychologie, 51,
made by previous authors Bryan M. Cochran and Con- 201–211.
stance A. Kehrer. Bradley, R., Zittel, C. C., & Westen, D. (2005). The bor-
derline personality diagnosis in adolescents: Gender
differences and subtypes. Journal of Child Psychol-
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CHAPTER 9

Dialectical Behavior Therapy

intense emotional responses, and a slow return Invalidating Environments

Emotion Vulnerability/Self-Invalidation pressed through willful suppression, meaning

Modes of Treatment: problem, or if the behavior is currently not evi-

ENVIRONMENTAL INTERVENTION However, evidence supports the assumption

Therapist Variables “Treatment strategies” in DBT refer to the role

upset! We’ve got to do something immedi- Core Strategies

Two things are important to note here. First,

therapist maintains intermittent contact by enting a client to DBT as a whole and to

ties; following meditation retreats or extended THERAPIST: How so?

THERAPIST: Hmm. THERAPIST: That’s part of the reason we’re hav-

are. You don’t have to yell and scream or THERAPIST: Um hmm.

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