Linehan

Journal of Psychotherapy Integration, Vol. 4, No.
1, 1994
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Dialectical Behavior Therapy: An Integrative

This document is copyrighted by the American Psychological Association or one of its allied publishers.
Approach to the Treatment of Borderline

Personality Disorder
Heidi L. Heard1,2 and Marsha M. Linehan1
This article describes the integrative aspects of Dialectical Behavior Therapy

(DBT) designed to treat individuals diagnosed as borderline personality
disorder. We describe the dialectical philosophy, which provides the framework
for the synthesis of biological and environmental approaches to the etiology
and maintenance of borderline personality disorder, and for the integration of
Zen practice into behavior therapy. Next, we describe how DBT integrates
various therapy modes and how the integrative approach affects the selection
of treatment targets. Finally, we discuss how DBT therapists interweave and
balance opposing sets of treatment strategies.
KEY WORDS: psychotherapy integration; borderline personality disorder; dialectics; behavior
therapy; Zen.
INTRODUCTION
In psychotherapy integration, different theories and techniques are

examined and synthesized to achieve a more effective therapy. In several
ways, the process and goal of psychotherapy integration parallels the proc-
ess and goal of psychotherapy itself. Psychotherapies of various schools fos-
ter synthesis, whether they strive toward the integration of disparate aspects
of the self or the incorporation of new skills into the behavioral repertoire,
with the intent of enhancing the client's effectiveness in life. Despite the
abundance of theoretical writing on the topic of psychotherapy integration,
1
Department of Psychology, University of Washington, Seattle, Washington, USA.
2
Correspondence should be addressed to Heidi L. Heard, Department of Psychology, NI-25,
University of Washington, Seattle, Washington 98195, USA.
55
1053-0479/94/0300-0055$07.00/0 © 1994 Plenum Publishing Corporation
56 Heard and Linehan
few integrative psychotherapies have been described and published (Ark-

owitz, 1992).
Few therapies emphasize integration as explicitly or on as many dis-
parate levels as Dialectical Behavior Therapy (DBT; Linehan, 1993a,
1993b). DBT is integrative, in the "dialectical/developmental" sense of the
word (Stricker & Gold, 1993, referenced in Mahoney, 1993), meaning that
it emphasizes the "open-ended dialogical process in which differences are

examined and novel integrations are welcomed" (p. 7). While at any given
moment, DBT constitutes a single unified whole, the "whole" is in a con-
tinuous process of change, in which differences and polarities are accepted
rather than ignored and/or avoided. DBT was developed in a research pro-
gram aimed first at treating suicidal and parasuicidal individuals (Linehan,
1984) and subsequently at treating borderline personality disorder. As we
will discuss later, the development of DBT in this context was a very im-
portant factor in determining many of the decisions that were made during
its development. DBT is currently being adapted for the treatment of sub-
stance abuse (1993c, in press), and may also be effective with other disor-
ders. However, the only empirical investigations of the treatment have been
with chronically suicidal borderline clients (Barley et al., 1993; Linehan,
Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Heard, & Armstrong,
1993a; Linehan, Tutek, Heard, & Armstrong, 1993b), which have demon-
strated the effectiveness of DBT when compared to treatment as usual in
the community. DBT is the first psychotherapy for borderline personality
disorder and one of only a few integrative psychotherapies with published
empirical support based on a randomized experimental design.
This article aims at elaborating the many integrative aspects of DBT.
First, we will provide a context for our discussion by briefly describing the
treatment. We will then attempt to demonstrate DBT's balance of change
and acceptance and to trace the origins in behavior therapy and Zen prac-
tice of the many procedures employed in DBT. The article aims at pro-
viding a taste of integration in DBT, but will not attempt to construct a
genealogy of every literature or procedure that DBT has integrated, nor
will it attempt to catalog every similarity between DBT and other treat-
ments.
OVERVIEW OF DBT
The standard model for DBT is an outpatient treatment in which the

client commits to one year of treatment. At the end of the year, the client
and therapist(s) decide whether to renew their treatment contract. DBT is
defined by its philosophical base (dialectics), biosocial theory, treatment
Dialectical Behavior Therapy 57
strategies, and treatment targets. The overriding dialectic is the necessity

of acceptance of patients as they are within the context of trying to help
them change and be different than they are. The treatment is derived from
a biosocial model that suggests that borderline personality disorder is pri-
marily a dysfunction of emotional (in its broadest sense) dysregulation. The
developmental model is a biosocial transactional one that suggests that in-
itial emotional vulnerability plus an invalidating environment reciprocally

influence each other such that the vulnerable individual does not learn
emotional regulation. As a result, emotional dysregulation and dysfunc-
tional behavioral regulation patterns (e.g., substance abuse, suicidal behav-
iors) are reinforced.
The model synthesizes motivational and capability deficit models of
behavioral dysfunction and suggests that: (1) individuals with behavioral
dysfunctions lack important interpersonal, self-regulation (including emo-
tion regulation), and distress tolerance skills; and (2) personal and envi-
ronmental factors both inhibit the use of behavioral coping skills that the
individual does have and often reinforce dysfunctional behavioral patterns.
With severely dysfunctional patients, DBT assumes that, on the one hand,
necessary skill training is extraordinarily difficult if not impossible within
the context of a therapy oriented to reducing the motivation to continue
abusing drugs or engaging in other highly dysfunctional behaviors. On the
other hand, sufficient attention to motivational issues cannot be given in
a treatment with the rigorous control of therapy agenda needed for skill
training. To resolve this dilemma, the various therapeutic tasks (e.g., skills
acquisition, improving motivation and skills strengthening, skills generali-
zation) are broken apart and are accomplished in several separate modes
of treatment. Taken together, the various modes constitute the DBT treat-
ment program as a whole. Treatment mode refers to the form, shape or
structure in which the therapy is delivered and is defined in part by both
the setting and by who is involved, although all modes share the philo-
sophical bases and draw from the same set of treatment strategies. The
DBT program, as a whole, ordinarily includes one mode for each major
task. In standard outpatient DBT, the motivation/capability deficit model
is addressed by three treatment modes that run concurrently: individual
DBT (1 hour sessions/week) to address motivational issues, group skill
training (2.5 hours/week) to address capability deficits, and ad lib phone
calls to the individual psychotherapists to address generalization of skills
to everyday life. In addition, the dialectical model assumes that the thera-
pist may also need to pay attention to motivational issues and skills deficits.
With difficult clients, in particular, the transaction between client and
therapist may be such that therapeutic behaviors are punished and iatro-
genic behaviors are rewarded. Weekly supervision/consultation meetings
among therapists (1.5 hours/week) address these issues. The mode of treat-
ment (e.g., individual vs. group therapy) and task or function of therapy
(e.g., motivational work, skills acquisition) are largely independent. Thus,
although in standard DBT motivational work is done in individual psycho-
therapy, it could be done as well in group therapy. Skills acquisition could
also be done individually.
Behavioral targets in DBT are specific, clear, and hierarchical, and

guide the agenda of particular sessions. From most to least important, they
are as follows: (1) reducing suicidal and other life threatening behaviors;
(2) reducing therapy-interfering behaviors (of both client and therapist);
(3) reducing severe quality of life interfering behaviors (including serious
substance abuse, homelessness, inability to hold a job or maintain relation-
ships); (4) increasing skillful coping behaviors, including distress tolerance,
emotion regulation, interpersonal effectiveness, and mindfulness; (5) reduc-
ing post-traumatic stress responses; (6) enhancing self-respect; and (7)
other goals of the client. In standard DBT, the hierarchy for individual
psychotherapy is the same as for the treatment as a whole, and the agenda
of each individual psychotherapy session is set weekly depending on the
client's behavior since the last session. Target behaviors are focused on
according to the hierarchy and recursively as higher priority behaviors re-
appear. High-priority behaviors are never ignored in DBT. Information
about the client's behaviors since the last session can come from a number
of sources, including direct contact with the client, collateral reports or
phone calls, urinalyses or blood tests (when substance abuse is a problem),
verbal report by the client at the beginning of the session, and weekly diary
cards that the client brings to each session. Besides information about sui-
cidal ideation and deliberate self-injurious behaviors during the week, the
diary cards also elicit information about daily use of prescribed, over-the-
counter, and illicit drugs. Failure to complete or bring the cards to the
session, as well as dishonesty, are targeted directly as therapy-interfering
behaviors. Targets and their order are similarly defined for each DBT
mode.
Treatment strategies are divided into those most related to accep-
tance and those most related to change. The DBT therapist must balance
the use of these two types of strategies within each treatment interaction.
Strategies refers to the plan of action or method by which the therapist
reaches treatment goals. The strategies are divided into four basic sets: dia-
lectical strategies, core strategies (validation and problem solving), commu-
nication strategies (irreverent and reciprocal communication), and case
management strategies (consultation-to-the-patient, environmental inter-
vention, and supervision/consultation with therapists). Problem-solving
strategies (behavioral analysis, insight/interpretation, solution analysis, di-
dactic, orientation, commitment) may also include one or more basic

change procedures, such as contingency management, skills training, expo-
sure, and cognitive modification. In addition, there are two sets of integra-
tive strategies (integrating across the basic sets of strategies and
procedures) that are defined for typical problems that arise in the treatment
of borderline clients.
As the treatment's name suggests, the concept of synthesis and inte-

gration permeates DBT in a number of ways. First, Linehan proposed a

transactional theory of the etiology and maintenance of psychological dis-
orders that integrates both biological and environmental models as well as
developmental and learning perspectives. Second, the treatment evolved
out of a tension between an emphasis on change as the raison d'etre of
psychotherapy vs. an emphasis on radical acceptance of the client "in the
moment" as a requisite context for treating severely impaired individuals.
Third, in searching for experts on the art and science of acceptance at its
most radical level, Linehan drew from Eastern, particularly Zen, psychology
and practice. (Although the effects of Zen practice on the individual often
resemble the effects of psychotherapy, we must emphasize that Zen should
not be considered as another form of psychotherapy. It is a practice quite
distinct from psychotherapy.) The tensions between principles of behavior
therapy and principles of Zen practice required a framework that could
house opposing views. The dialectical philosophy, which includes the proc-
ess of synthesis as one of its defining characteristics, provides such a frame-
work. Thus, through the continual syntheses of theory and research vs.
clinical experience and of change vs. acceptance, DBT evolved in a manner
similar to the theoretical integration model described by psychotherapy in-
tegration researchers (Arkowitz 1989, 1992; Norcross & Newman, 1992).
Fourth, reflecting the complexity of resources needed to treat severe
dysfunction, the structure of DBT requires the continuous integration of
various therapy modes (e.g., individual, skills training, etc.). During the de-
velopment of the treatment, Linehan determined that it was also necessary
to integrate supervision of and consultation to the therapist by DBT peers
into the treatment. Fifth, because of the complexity and multiplicity of
problems presented within a session, DBT therapists interweave attention
to a range of different client behaviors, both in and out of sessions, using
a diverse sets of treatment strategies. While DBT therapists primarily em-
ploy strategies and techniques adapted from standard behavior therapy (in-
cluding cognitive and cognitive-behavior therapies), combined with
practices and an orientation to both clients and the therapy process itself
reflecting Zen practice, they also use techniques from other orientations,
such as crisis intervention, and areas of research, such as social psychology.
DBT modifies the technical eclecticism approach of psychotherapy integra-
tion (Arkowitz, 1992; Norcross & Newman, 1992) by requiring that all tech-
niques fit within a dialectical framework synthesizing a basically behavioral
approach on the one hand, and certain key ideas taken from Zen practice
on the other. The reliance on a coherent set of principles appears crucial
to treating the therapist, as well as the client. When treating difficult popu-
lations, therapists desperately require a coherent framework on which they
can depend.
DIALECTICAL PHILOSOPHY AS A FRAMEWORK FOR DBT
Dialectics is the underlying philosophy of DBT and provides a view

of the fundamental nature of reality that directs the synthesis of Zen prac-
tice into behavior therapy. The American Heritage Dictionary (Morris, 1979)
defines dialectics as "The Hegelian process of change whereby an idea-
tional entity (thesis) is transformed into its opposite (antithesis) and pre-
served and fulfilled by it, the combination of the two being resolved in a
higher form of truth (synthesis)" (p. 363). The application of dialectics in
Western culture first appears among the early Greek philosophers such as
Zeno the Elder, Socrates, and Plato. Modern Western philosophers have
also employed dialectics to explain their theories. Kuhn's discourse on the
nature of scientific paradigms (Kuhn, 1970) and Marx's theory of economic
evolution (Tucker, 1978) describe the dialectical process of change through
thesis, antithesis, and synthesis.
In her use of dialectics, Linehan (1993a) drew on Basseches' (1984)
work on the development of dialectical thinking in adults and the work of
evolutionary biologists (Levins & Lewontin, 1985). DBT emphasizes the
three primary characteristics of the dialectical philosophy: (1) interrelated-
ness or unity, (2) opposition or heterogeneity, and (3) continuous change.
As we discuss each of these characteristics, we will elaborate on how they
relate to the treatment in general and how they relate to behavior therapy
and Zen practice specifically. We will try to demonstrate how this one over-
arching set of assumptions organizes the sometimes quite disparate posi-
tions taken in DBT.
Interrelatedness
Dialectics stresses the fundamental interrelatedness and unity of re-

ality. The dialectical philosophy emphasizes relationships, the complexity
of causal connections, and the whole as opposed to the parts. Levins and
Lewontin (1985) describe this aspect of dialectics: "Parts and wholes evolve
in consequence of their relationship, and the relationship itself evolves.

These are the properties of things that we call dialectical: that one thing
cannot exist without the other, that one acquires its properties from its
relations to the other . . ." (p. 3).
Both behavior therapy and Zen recognize the importance of interre-
latedness. Although all behavior therapists are trained to include the ex-
ternal environment in their search for controlling stimuli and to evaluate

the effect of behavioral consequences as well as antecedents, the contex-

tualist position described by Hayes (1987) most clearly resembles the dia-
lectical emphasis on attention to interrelatedness and the whole. Zen
(Aitken, 1982) and other Eastern practices (Wilber, 1979) discuss the ex-
perience of connectedness to the universe and letting go of personal
boundaries. Of course, many other psychotherapies also share an emphasis
on interrelatedness and the whole. Gestalt therapy (Perls, 1976; Perls, Hef-
ferline, & Goodman, 1951; Yontef & Simkin, 1989), feminist therapy
(Miller, 1983) and family therapy (Bowen, 1978; Palazzoli, Boscolo, Cec-
chin, & Prata, 1978) also emphasize wholeness, relationships, and systems.
Within DBT, the therapist considers two basic levels at which the
client may be experiencing dysregulation or disruption of systems influenc-
ing behavior. The first level includes overlapping and mutually influential
systems within the individual, such as biochemical systems, affective regu-
lation systems, and information processing systems. Although such a com-
prehensive dysregulation may appear more difficult to treat, a systemic
approach forces the DBT therapist to consider how different treatment in-
terventions influence multiple systems. The second level of systemic dys-
regulation involves the many interpersonal systems, such as family, and
culture, and other environmental systems that influence behavior. To obtain
an accurate understanding of the client's behavior, the DBT therapist per-
forms "dialectical assessments," which attend to these larger influences. For
example, the therapist attends to the reinforcing effects of hospitalization,
the physical effects of homelessness, and the cultural value for inde-
pendence.
Opposition
Dialectics also focuses attention on the complexity of the whole. Re-

ality is not static but is comprised of opposing forces in tension, the thesis
and the antithesis, out of whose synthesis evolves a new set of opposing
forces. Balance occurs only temporarily. The philosophy suggests a hetero-
geneous world in which reality is neither black nor white. This view parallels
the psychodynamic therapies that highlight the role of conflict and ambiva-
lence within the individual. Conflict plays a leading role in Freud's (1923)
theory of psychopathology. The ego may be cast in the role of the synthe-
sizer of oppositional id and superego forces. This characteristic of dialectics
essentially describes the whole process of psychotherapy integration. A
similar view also appears in contextual theory and therapy (Hayes, 1987).
According to Linehan (1993a), the central opposition in all forms of
psychotherapy occurs between change and acceptance. The fundamental

relationship between change and acceptance forms the basic paradox and
context of treatment. Therapeutic change can occur only in the context of
acceptance of what is, and the act of acceptance itself is change. Linehan
(1993d) defines acceptance as "the fully open experience of what is without
distortion, adding judgment of good/bad, clinging or pushing away" and as
"the radical truth without the haze of what we want it to be or what we
don't want it to be. " Linehan (1993d) further defines radical acceptance
as "an act of the total person that is allowing of this one moment, this
reality, without discrimination." The key idea here is that radical accep-
tance applies to the totality and complexity of reality. Thus, acceptance of
a destructive act requires not only acceptance that the act has occurred,
but also that it is or was destructive, and that it may need repair. Accep-
tance does not imply approval or agreement. Moving rapidly, the therapist
balances acceptance strategies that acknowledge the client in the moment
and change strategies that attempt to alter the client's behavior. The ther-
apy strives to help the client understand that responses may prove both
appropriate or valid and dysfunctional or in need of change. For example,
the client who is afraid of having his/her therapist leave town for two weeks
because he/she does not believe he/she can cope without the therapist is
a valid response from a client who has few coping skills. On the other
hand, they must learn new skills to cope with the separation because the
therapist will be leaving town. The same policy also applies to therapists.
For example, that a therapist is terribly afraid that a suicidal client might
kill him/herself and, therefore, wants to hospitalize the client may be a
valid response to wanting to protect both the client and the therapist. To
continue hospitalizing the client in response to suicidal crises, however, may
need to change because the therapist may be reinforcing suicidal behavior
and increasing the long-term risk to both the client and therapist. The DBT
therapist would strive to neither catastrophize the situation by assuming
that the client will suicide, nor minimize it by denying the possibility that
the client might suicide. This balance point, however, continually changes
and requires that the therapist react flexibly and quickly in therapy.
The ability of the DBT therapist to balance change and acceptance
is enhanced through synthesizing aspects of Zen practice into behavior
therapy. This process of synthesis began in pilot work in which Linehan
applied standard behavior therapy procedures to chronically parasuicidal

clients. Compared to most clients who successfully complete behavioral pro-
grams, these clients had significantly more behaviors to target, poorer treat-
ment compliance, and higher treatment drop-out. The difficulties in
forming a collaborative relationship, maintaining safety, keeping a stable
set of goals and priorities from one session to the next, and unrelenting
crises made the application of behavior therapy in any straightforward or

systematic way fraught with difficulties.

The difficulty in applying standard behavior therapies suggested an
inherent poorness-of-fit between these therapies and borderline clients.
From Linehan's perspective, difficulties occurred because these therapies
stressed the dysfunctional aspects of client behaviors and emotions and
their need for change. Thus, the therapists focused on how clients' irra-
tional, inaccurate, or biased thoughts and assumptions contributed to dys-
functional negative emotions, how their inappropriate social behaviors
contributed to interpersonal problems, and how their overreactivity con-
tributed to their overall problems. Standard behavior therapies focused pri-
marily on changing client behavior.
According to Linehan, the focus on change invalidated the borderline
client. The therapist suggested that the client was the problem and needed
to change. Being told that one must change, however, is inherently invali-
dating to oneself, even if one agrees with the statement. In a sense, the
therapist validated the client's fears that he/she indeed could not trust
his/her own reactions, cognitive interpretations, or behavioral responses.
The practice of Zen offered an alternative to the often invalidating
insistence on change in traditional behavior therapies. In contrast to be-
havior therapies, Zen encourages radical acceptance of the moment without
change. Basic principles include focusing on the current moment, seeing
reality as it is without delusions, and accepting reality and observing without
judgment. Zen students learn that each moment is complete by itself and
that the world is perfect as it is (Aitken, 1982). Zen focuses on acceptance,
validation, and tolerance, instead of change. Other principles discussed at
greater length elsewhere in this article include the concept that all indi-
viduals have an inherent capacity for enlightenment and truth, that all in-
dividuals are one, that boundaries are only a delusion, and that experiences
are impermanent, ebbing and flowing like waves. Zen also encourages stu-
dents to let go of attachments that obstruct the path to enlightenment, to
use skillful means, and to find a middle way. Finally, in contrast to the
experimental evidence required in psychology, Zen emphasizes experiential
evidence as a means of understanding the world.
Unfortunately, as Linehan further noted, a therapeutic approach
based on unconditional acceptance and validation of the client's behaviors
proves equally problematic and, paradoxically, can also invalidate. If the

therapist only urges the client to accept and self-validate, it can appear
that the therapist does not regard the client's problems seriously. Zen, as
well as Western acceptance-based therapies such as Gestalt (Perls, 1976;
Perls et al., 1951; Yontef & Simkin, 1989) and client-centered (Raskin &
Rogers, 1989; Rogers, 1951, 1986), can appear to discount the desperation
of the borderline individual since they place little emphasis on change. The
client's personal experience of the current state of affairs as unacceptable

and unendurable is thereby invalidated. Of course, the categorization of
behavior therapy and Zen practice into change and acceptance is only rela-
tive, as each practice contains elements of both acceptance and change.
Behavior therapy, like all other therapies, includes at least some elements
of acceptance by acknowledging the client's behavior in a nonjudgmental
way. As we will discuss below, change or impermanence is a critical concept
in Zen.
To facilitate progress in therapy, the DBT therapist strives to inte-
grate the principles of Zen acceptance with behavior therapy change. In
this focus on change and acceptance, DBT resembles Hoffman's (Hoffman,
Kohener, & Shapira 1987; Hoffman & Segal, 1989) "dialectical psychother-
apy" in which one member of the therapist pair "challenges" the client
while the other "supports" the client. DBT, however, synthesizes the op-
posing roles by having one person play both roles, while Hoffman's therapy
retains the split. In recent years, a number of psychotherapists have become
increasingly interested in developing psychotherapies that balance accep-
tance and change. Marlatt and Gordon (1985) attend to acceptance and
change in their treatment of substance abuse, as does Jacobson (1991) in
his marital behavior therapy, and Hayes (1987) in his individual psycho-
therapy.
Change
Dialectics stresses change as a fundamental aspect of reality. Change

is the very essence of experience, and both the individual and the environ-
ment undergo continuous transition by a process of opposition resolving
through synthesis. In contrast to Darwinian theories of change, which as-
sociate evolution with progress, the dialectical philosophy described here
suggests that change or development need not occur along a positive tra-
jectory.
To some degree, all therapies foster change (few clients pay to remain
exactly the same), but they differ in what type of change they promote and
to what degree. Because of its assumption that clients' lives are currently
unbearable, DBT places a great emphasis on change. In addition to influ-

encing change in the client's behavior, DBT allows an extensive degree of
change to the therapeutic frame. In contrast to traditional psychoanalytic
approaches, which advise against changes in fees or appointment schedules
(Arlow, 1989), DBT assumes that such changes will occur and views these
changes as opportunities for the therapy to actively address deficits in the
client's ability to adapt to change. Although many other therapies allow

some degree of change in the therapeutic frame, DBT allows more change
and requires less consistency in the frame than most. For example, a thera-
pist is not required to maintain the same hours of phone availability for a
client throughout that client's treatment, nor is the therapist expected to
have the same hours of availability for all clients at any one time. Group
therapists may rotate in and out of an ongoing group every few months,
despite the fact that clients describe this as distressing. Indeed group thera-
pists view this as an opportunity for clients to practice the distress tolerance
skills that are taught in group. Therapists must remain consistent only with
respect to the therapeutic relationship, they must always be on the client's
side in the struggle to overcome the client's problems, and they must always
reinforce any behavior by the client that represents progress.
As noted above, both behavior therapy and Zen discuss change, al-
though in slightly different ways. Behavior therapy is designed to change
the client's behavior primarily by decreasing dysfunctional behaviors (in-
cluding emotions and thoughts) that precipitate overt dysfunctional behav-
iors and by enhancing functional behaviors. In behavior therapy, the client
and/or therapist becomes responsible for actively doing something to
change the feelings, thoughts, or overt behavior. In contrast, neither the
Zen student nor the master intentionally try to change anything. Whereas
the behavior therapist teaches the client how to actively decrease dysfunc-
tional behavior, the Zen master helps the student learn how to observe
simply observe how feelings, thoughts, and overt behavior, both pleasant
and aversive, naturally come and go without any attempts by the individual
to change them. According to Zen, everything is impermanent and comes
and goes like waves in the ocean. Behavior therapy and Zen practice thus
offer two approaches to change in therapy. For example, while behavioral
procedures can reduce suicidal behavior by teaching the client how to ac-
tively reduce suicidal urges, Zen practice can reduce suicidal behavior by
teaching the client how to allow and observe the urges without acting on
them. These behavioral and Zen approaches to parasuicide reciprocally en-
hance each other. On the one hand, an important step in reducing suicidal
urges is to increase awareness of those variables that control the urges. On
the other hand, if one observes the urges without reinforcing them through
action, the urges will naturally decrease over time.
DBT TREATMENT TARGETS AND STRATEGIES
Targets
Although the practice of behaviorally defining and hierarchically ar-

ranging treatment targets or goals comes from traditional behavior thera-
pies, the decision about which targets to include in the DBT hierarchy was
strongly influenced by the integration of Zen and other areas of psychology.
The definition of treatment targets highlights a tension between behavior
therapy and Zen and a paradox within Zen itself. While the behavior thera-
pist helps the client to define where he/she wants or needs to go, the Zen
master helps the student to realize that he/she is already there. The paradox
within Zen is that although one enters the practice to achieve enlighten-
ment, the more one focuses on enlightenment as a goal during practice,
the less likely one is to experience it. The DBT therapist balances requiring
the client to work on treatment targets with appreciating the strengths in-
herent within the client. Of course, the therapist must also attend to the
many ways in which attention to treatment targets can interfere with their
achievement. For example, the client's fears of not being able to stop drink-
ing may actually cause an increase in drinking to avoid the anxiety. Al-
though all of the targets have dialectical and integrative aspects, we will
discuss only two of the targets in detail: therapy-interfering behaviors, the
second target, and skills, the fourth target. We will also consider why DBT
does not include the achievement of an autonomous, independent self as
a treatment target.
Therapy- Interfering Behavior
Adhering to the dialectical principles of the treatment, the DBT

therapist attends to the system of the therapeutic relationship and to the
tensions or therapy-interfering behaviors that can arise. Therapy-interfering
behaviors refer to behaviors by either the client or the therapist that impede
the progress of therapy. Although all psychotherapies attend to the thera-
peutic relationship, they vary in terms of how they view the role and nature
of the relationship (Linehan, 1988). Dialectics specifically directs the thera-
pist's attention toward transactions that occur within the therapeutic con-
text and accepts that, despite attempts by the therapist to remain neutral,
the therapist is part of and therefore influenced by the therapeutic context.
The DBT therapist views therapy as a system in which the therapist and
client reciprocally influence each other. Thus, the client's experience of and
behavioral responses toward the therapist are examined for their validity
within the context of the present relationship and not only as transferences
from past relationships. Just as the therapist shapes the client's behavior,
so the client shapes the therapist's behavior. It is the borderline client's
tendency to shape the therapist's behavior in a direction detrimental to
therapy, that necessitates the integration of therapist supervision/consult-
ation into the treatment as a whole. Also, the therapist is considered as
likely a suspect as the client when the therapy ceases to progress. The thera-
pist attends to ways in which his/her behavior maintains the client's dys-
functional behavior. Although behavior therapy does not attend extensively
to the therapeutic relationship beyond the obvious need to establish a col-
laborative relationship, behavior therapists do address the issue of client
compliance (Meichenbaum & Turk, 1987; Shelton & Levy, 1981). Finally,
the primary essence of Zen is the practice of overcoming the delusions
that interfere with the practice of Zen or the attainment of enlightenment
(Aitken, 1992). Thus, in DBT, therapy-interfering behaviors are not con-
sidered to be obstacles to be avoided or simply solved so that therapy can
proceed, but instead are viewed as examples of the very behaviors that
occur in the client's life outside of therapy and are often the very patterns
that brought the client into therapy.
Skills
Generally taught in a group format and enhanced by the individual

therapist, skills training (Linehan, 1993b) is not considered a supplement
to individual therapy, but as a necessary part of addressing the motivation/
capability deficit model. The client first learns a wide variety of skills and
then works to integrate these skills into a repertoire. The client's job re-
sembles that of a technically eclectic psychotherapist who may select from
a variety of techniques to solve a therapeutic problem. For both individuals,
the key question is what is effective in this situation. The DBT skills trainer
teaches four modules or groups of skills which can be divided into two
sets: the acceptance set, consisting of the mindfulness and distress tolerance
modules, and the change set, consisting of the emotion regulation and in-
terpersonal effectiveness modules.
Mindfulness skills are a direct translation and breakdown of Zen
teachings. Linehan translated Zen instead of applying it directly because
of her clinical experience that severely disturbed individuals simply could
not do focused meditation for any length of time. Her experience closely
parallels the old Zen saying that the practice of Zen requires a strong mind
and a strong body (Kapleau, 1980). As conducted in DBT, mindfulness
practice consists of the skills of observing, describing, participating sponta-
neously, being nonjudgmental, being mindful or focusing attention com-

pletely and only on one thing at a time, and focusing on what is effective
in a given situation. Clients also learn to find "wise mind"—the synthesis
of emotion mind, which includes feelings, wishes, impressions, etc., and ra-
tional mind, which consists of thoughts, logic, facts, etc. These mindfulness
skills are inherently integrated into most aspects of the other skill modules.
For example, during the teaching of the interpersonal effectiveness and

emotion regulation modules, clients must practice observing and describing

interpersonal situations and single emotions, respectively.
Distress tolerance skills focus on learning to radically accept reality.
Radical acceptance is a blend of ideas and practices from Zen (Aitken,
1982) and of ideas of acceptance and willingness from Western contem-
plative practice (May, 1982). Accepting reality teaches clients to acknow-
ledge and radically accept their current emotions, thoughts, and
environments. In his description of Zen, Aitken comments on the nature
of reality and the effects of not accepting: "The first truth enunciated by
the Buddha is that life is suffering. Avoidance of suffering leads to worse
suffering. . . we drink alcohol excessively to avoid that pain, thus causing
more pain" (p. 49). Tolerating distress does not imply "giving up" or nec-
essarily approving of a situation, but it allows one to cope with pain in the
moment. Consequently, distress tolerance skills are primarily acceptance
oriented strategies.
In contrast to distress tolerance, emotion regulation skills teach the
client how to effectively prevent and modulate extreme emotional states.
Thus, emotion regulation skills are primarily change-oriented strategies and
are adapted primarily from traditional behavior therapy. The module in-
cludes didactically teaching clients about the function of emotions, about
ways to decrease emotional vulnerability and about ways to increase posi-
tive emotions. Like emotion regulation skills, interpersonal effectiveness
skills are primarily change skills adapted from behavior therapies, such as
assertiveness training (Linehan & Egan, 1983). Largely through such be-
havioral techniques as role playing, the module teaches clients how to maxi-
mize their probability of effecting and changing their interpersonal
environment.
Independent Self as a Target
One treatment target addressed by many traditional psychotherapies,

but not in the DBT hierarchy, is the promotion of an autonomous, inde-
pendent self as a treatment goal. For example, cognitive-behavior therapies
in particular (Spiegler & Guevremont, 1993) have developed detailed be-
havioral techniques designed to teach self-control and self-monitoring. In

contrast, dependency has been labeled as immature and pathological, or
at least inimical to good health and smooth societal functioning (Perloff,
1987), a labeling to which the flood of the codependency literature attests.
Linehan (Heard & Linehan, 1993; Linehan, 1993a) however, disagrees with
the tradition that automatically pathologizes dependence and questions in-
cluding the independent self as a treatment goal. A therapy that emphasizes

the development of an independent self, in whom behavior is controlled

almost exclusively by utilizing internal cues and resources and for whom
the definition of self explicitly excludes other individuals and the commu-
nity, may even prove iatrogenic for borderline clients.
Challenges to the autonomous, independent model come from Zen
and dialectics, as well as social psychology and feminist theory. Zen and
dialectics both emphasize unity and connection. Aitken (1992) quotes
Yamada Roshi, saying "The practice of Zen is forgetting the self in the
act of uniting with something" (p. 9). As discussed earlier, dialectics em-
phasizes that development and identity depend upon relationships within
the system.
Feminist theorists and social psychologists have also challenged the
assumption of the superiority of an independent self. Feminist theorists
such as Gilligan (1982) have argued for the importance of a relational or
social self among women. Lykes (1985) cogently argued the feminist posi-
tion when she defined "the self as an ensemble of social relations'' (p. 364).
A relational self refers to a self in which the self is defined and experienced
within the context of an individual's relationship with others. Feelings, be-
liefs, values, and goals are determined within the context of the relation-
ship. Within this conceptualization, experiencing the loss of a relationship
as a loss of part of the self would not be considered pathological. Triandis,
McKusker, and Hui (1990) have found that, in several cultures, relational
or "collective" selves, as opposed to "individualistic" selves, appear more
prevalent. No data yet suggests that a relational self is pathological, even
in an individualistic culture, and Pratt, Pancer, and Hunsberger (1990)
found a positive relationship between having "connected self-concepts" and
complex reasoning about relationships and self.
The contradictions between the self-control tradition of cognitive-be-
havior therapy and the no-self tradition of Zen offer an opportunity to
demonstrate how a dialectical framework can synthesize the tensions that
arise when one attempts to integrate to treatment approaches and develop
a more effective treatment. A dialectical stance requires one to attend to
the system as a whole, including both sides of any conflict. Thus the DBT
therapist cannot apply only Zen and the literature arguing for a relational
self, and simply ignore the self-control tradition in behavior therapies. In-
stead, the therapist searches for the relevance of the self-control therapies
in the client's life and realizes that such therapies mirror the values of the
culture at large. If DBT therapists ignored the cultural idealization of in-
dependence, the therapy could not prepare clients to live in their culture.
A synthesized approach to treating borderline clients may involve helping
the client find a different social network that would support a collective
or connected self, and/or learn to validate him/herself so that he/she can

experience greater comfort in an unsupportive environment. It seems logi-

cal that an individual with a collective or connected self must also have
sufficient interpersonal effectiveness to maintain relationships. The DBT
therapist attends directly to the deficit that many borderline clients have
with respect to interpersonal effectiveness. In a culture that insists upon
self-reliance and that provides increasingly fewer opportunities for reliable
support from others, however, the need to develop greater self-reliance re-
mains. Thus, DBT must also enhance self-reliance to the fullest of the cli-
ent's capabilities.
Strategies
It is among the DBT treatment strategies that the influence of inte-

gration and synthesis occurs most substantially. The dialectical strategies
provide the framework for balancing the other strategies. The core, stylistic,
and case management categories all contain paired sets of strategies, with
one member of the pair and the other representing most clearly acceptance.
The emphasis here is on the relationship between the change and accep-
tance members of a pair; each is the dialectical antithesis of the other. The
DBT therapist must tolerate the tension and search for a balance. The
point of balance is, of course, difficult to discover because the fulcrum on
which the polarity is balanced is the client's position, one that is constantly
changing. The DBT therapist moves quickly between the pairs of strategies
like a pianist's fingers on a keyboard. The relationship between the strate-
gies resembles a figure skating pair in a single rink. The members of the
pair have different steps, but the steps must flow together and balance each
other, with one member's moves enhancing, not competing with, the moves
of the other. Attaining balance is difficult, of course, particularly since the
balance point continuously changes across clients and across time for a sin-
gle client. That the session is no longer flowing (i.e., the therapist has en-
countered "resistance") is the primary indicator that one or more of the
pairs of strategies have become imbalanced. Unfortunately, the therapy
does not include any guidelines to help the therapist decide which way to
move when an imbalance occurs. At another level of integration, the sets
of strategies themselves contain many different procedures and techniques

adapted from a variety of areas in psychology.
Dialectical Strategies
The dialectical strategies define DBT and permeate the therapy struc-
ture and application. Dialectical strategies function both as a way of or-

ganizing the session and integrating other treatment strategies, and as a
specific set of procedures. As a method of organizing and integrating, dia-
lectics includes attending to the context as a whole and using the opposi-
tions that naturally develop in the therapeutic relationship. The therapist
both creates and responds to the dialectical tension in therapy by balancing
change strategies with acceptance strategies, e.g., persistence with flexibility.
The therapist also orchestrates and guides change by the art of persuasion
in the manner of ancient Greek philosophers who employed "dialectics as
a method of debate that involved refuting an opponent's argument by hy-
pothetically accepting it and then leading the opponent to admit that it
implies contradictory conclusions" (Linehan & Heard, 1991, p. 250). Fur-
thermore, dialectical strategies require a flexible approach to therapy in-
teractions, with fluid, continuous, and responsive movement by the
therapist, a nonrigid setting of boundaries around problems encountered,
and attention to the oppositions occurring in each moment of the interac-
tion. Therapy should feel a bit like dancing with a partner, albeit often
dancing by the side of a cliff.
Specific dialectical strategies, more so than any others in DBT, are
adaptations (and sometimes wholesale importations) of strategies from out-
side of standard behavior therapy. Dialectic strategies include entering the
paradox, playing devil's advocate, and extending, among many others. "En-
tering the paradox" (e.g., caring for yourself as a way to care for others)
requires the therapist to highlight the contradictions within the client's be-
haviors, the therapy process, or reality in general (caring for yourself is
important, caring for others is important), to tolerate the ambiguity and to
help the client to solve the paradox by finding a synthesis of the various
positions. The presentation of paradoxes in DBT somewhat resembles the
koans, or practices, presented to students in Zen (Suler, 1989). In both,
the solution must be experiential, not intellectual. The ultimate paradox in
Zen, for Westerners at least, may be the coupling of the proposition that
"the essential world of perfection is this very world . . ." (Aitken, 1982,
p.63) with the proposition that "life is suffering" (Aitken, 1982, p. 49).
Playing devil's advocate requires the therapist to present an extreme
form of a dysfunctional belief held by the client (e.g., "If my therapist ever
disagrees with me, she must hate me.") and to maintain that belief while
the client argues against it. Eventually the therapist and client move toward
a more balanced belief, synthesizing both sides of the argument. The pro-
cedure was developed by Goldfried (Goldfried, Linehan, & Smith, 1978)
and closely resembles the argumentative techniques of cognitive restruc-
turing therapies (Ellis, 1962, 1987) in that the therapist argues for the ir-
rational belief.
Extending is a translation of a technique used in Aikido, a Japanese

martial art (Saposnek, 1980; Windle & Samko, 1992). Extending is a strat-
egy whereby the therapist produces change by "extending" or taking more
seriously than the client a position taken by the client in an effort to pull
the client, slightly off balance so that movement or a shift in direction is
forced. The therapist joins with the client, allows the behavior to progress
naturally to the point intended by the client, and then extends the behavior
beyond the point intended by the client. The challenge for the therapist is
in deciding what to extend. For example, a client may say "You're a jerk,
I'm quitting therapy," with little intent of leaving therapy, but with the ex-
pectation that the therapist will resist the client leaving therapy and will
focus on the therapy relationship to keep the client. A therapist using ex-
tending, however, would join with the client about being a jerk, would ac-
cept the client wanting to leave therapy, and extending the client's threat,
would offer to give the client referrals.
Validation and Problem Solving: Core Strategies
Core strategies are the primary strategies employed in DBT and in-
clude a number of validation strategies balanced by a number of problem-
solving strategies and behavioral procedures. The therapist must interweave
these strategies in a way that prevents the therapy from becoming extremely
focused on change or on acceptance. This pair of strategies demonstrates
the primary dialectical tension in DBT between acceptance and change.
Linehan (1993a) describes validation as occurring when "the therapist
communicates to the patient that her responses make sense and are un-
derstandable within her current life context or situation" (pp. 222-223).
Validating the client requires an acceptance of the client in the moment
and an active search for the wisdom of the client's affective, cognitive or
overt behavioral response to or experience of a situation. Validation can
occur at any one of five levels: (1) accurately listening to the client's ex-
perience, (2) reflecting this experience back to the client (3) "reading" the
client's unstated experience back to the client, (4) indicating the validity
of the response or experience in terms of past learning experience, and (5)
validating the response in terms of present circumstances (Linehan, 1993e).

The fourth and fifth levels differentiate validation from ordinary (but also
essential) reflection and empathic responding. It is the fifth level, however,
that is essential to and defining of validation in DBT. To illustrate the
difference between levels four and five, imagine a new client in therapy
who indicates that he/she does not trust the therapist. Compare a level
four validation—"It makes sense that you have difficulty trusting me given
your previous experience with therapists who have not treated you
well"—to a level five validation difference—"It makes sense that you have
difficulty trusting me given that we have just met and that you don't know
me well." Although these validation procedures are not adapted from Zen,
the philosophy behind them does reflect the emphasis in Zen on the cur-
rent moment, on searching for truth or enlightenment, and on this truth
and the capability of discovering it being inherent within oneself. In his
discussion of Zen, Aitken (1982, p. 6) observes, "All beings are the truth,
just as they are." The validation strategies also include "cheerleading" the
client by focusing on the client's strengths and by communicating faith in
the client's abilities and motivation to develop. When using cheerleading,
the therapist essentially plays the role of a cheerleader on the sidelines
yelling to the tired players on the field that they have what it takes to win
the game. Although the validation procedures were not intentionally
adapted from Roger's (1951, 1986) humanistic therapy, his influence on
the first three levels of validation cannot be doubted.
Schaeffer's (1986) promotion of "affirmative interpretations" in the
psychoanalysis of borderline clients provides a fruitful comparison to DBT's
promotion of validation. Schaeffer defines affirmative interpretation as the
"idea that the therapist assumes that whatever a patient experiences or
does is necessary, given the adverse circumstances that prevail uncon-
sciously in the patient's psychic reality. The adverse circumstances are . . .
situations . . . that the patient transfers from the past into the present" (p.
149). The first part of the definition resembles the DBT therapist's search
for the wisdom in the response, but the second part differs sharply from
DBT. Schaeffer's definition could be as interpreted as "Behaviors make
sense, given patients' past and their current neuroses." In contrast, the DBT
therapist searches for and acknowledges the inherent, not conditional, va-
lidity of the behavior in the current context. This is not to say, of course,
that all behavior is valid in the present context. Much of the dysfunctional
behavior of clients is valid only in the sense of level four (i.e., in terms of
past learning and faulty generalization to the present). However, a char-
acteristic of DBT is that the therapist searches for and acknowledges those
responses that have validity in the moment (i.e., level five validations).
Schaeffer also outlines a three-component process for interpretations

in therapy. As in DBT, Schaeffer's first two components require the thera-
pist to explicitly empathize with the client and appreciate the adaptive value
of the behavior. In component three, however, "the therapist may also ex-
press appreciation for the ways the patient is unconsciously motivated to
maintain his [sic] life-style despite its problems" (p. 149). This component
directly conflicts with the DBT cheerleading strategy that requires the
therapist to express his/her faith that the client wants to improve. The syn-
thesis in DBT is that the client does want to improve but emotions such
as fear, shame, and anger may inhibit him/her.
Balancing the focus on acceptance inherent within validation strate-
gies, problem-solving strategies focus on change. Among the treatment
strategies, problem-solving strategies are the purest example of the influ-
ence of traditional behavior therapy on DBT. During the first part of prob-
lem solving, the DBT therapist involves the client in a behavioral analysis
of the client's dysfunctional behavior. The behavioral analysis itself is a syn-
thesis of acceptance and change. On the one hand, to complete a behav-
ioral analysis the client must first acknowledge that the behavior occurred
and then observe and describe that behavior in detail, but without judg-
ment. The success of the behavioral analysis is strongly affected by the cli-
ent's ability or willingness to accept both past behavior, as well as any
behavior that occurs during the behavioral analysis itself. In this way, be-
havioral analyses resemble the Zen practice of observing without "delusion"
(Aitken, 1982). On the other hand, the effects of a behavioral analysis can
also be explained by any of the four solution procedures described below.
For example, behavioral analyses (every single time in excruciating detail)
may decrease parasuicidal behavior by functioning as a contingency man-
agement procedure, because clients regard such analyses as moderately
aversive, or by functioning as an exposure procedure by requiring clients
to describe and reexperience feared emotions that lead to the dysfunctional
behavior.
Following the behavioral analysis, the therapist and client proceed to
the solution analysis (e.g., how can the client prevent hurting him/herself
again). In practice, the therapist continually interweaves the behavioral
analysis and solution analysis strategies. As part of the solution, the thera-
pist may employ one or more of four traditional behavior change proce-
dures: skills training, cognitive modification, contingency management, and
exposure. These are all behavioral procedures described in most basic be-
havior therapy textbooks (e.g., Spiegler & Guevremont, 1993). Although
formal use of each set of procedures in a separate package would not be
contraindicated in DBT, in usual practice the four procedures are woven
together informally. Skill training procedures are aimed at increasing cop-

ing capabilities. Cognitive modification procedures are used to modify rules,
expectancies, and beliefs interfering with adaptive coping. Contingency
management procedures are used to increase incentives for adaptive coping
and to reduce incentives for maladaptive coping. Essential to the contin-
gency strategies is the ability of the therapists to avoid appeasing the client,
even in the face of high risk or highly aversive behaviors, while simultane-
ously soothing and validating the client's difficulties. In practice, this bal-
ance is enormously difficult to achieve. In contrast to most behavior therapy
applications, relationship contingencies are emphasized heavily in DBT. Ex-
posure procedures are aimed at reducing emotional response patterns in-
hibiting adaptive coping. It is essential, of course, that exposure occurs in
an environment that does not further reinforce the targeted emotion. The
exposure is applied in conjunction with attention to the client's coping
strategies, such as relaxation, breathing, and observing, as well as therapist
soothing behaviors such as cheerleading and validating.
Before the therapist can implement solution procedures he/she must
have the client's commitment to work on solving the problematic behavior.
The attention to commitment and the techniques used to obtain this com-
mitment reflect an integration of traditional behavior therapy and social
psychology. As do most psychotherapies, DBT requires the therapist to ori-
ent the client to treatment and to obtain an agreement from the client on
treatment goals. Explicit commitment to treatment and to agreed upon
goals is emphasized in DBT based on social psychological research (e.g.,
Hall, Havassy, & Wasserman, 1990; Wang & Katzev, 1990), which indicates
that individuals are more likely to follow through with a plan or remain in
a situation if they have committed to that plan or situation. Two of the
social psychology commitment techniques that Linehan adapted are the
foot-in-the-door (Freedman & Fraser, 1966) and the door-in-the-face
(Cialdini, Vincent, Lewis, Catalan, Wheeler, & Darby, 1975) techniques.
In the foot-in-the-door technique, the therapist asks the client for an initial
commitment that the therapist believes the client can give. After receiving
an initial commitment, the therapist then asks for a little more and then,
after receiving another commitment, for a little more. The commitments
requested at each step are relatively small and seem more reasonable to
the client than an initial large commitment. The door-in-the-face technique
generally progresses in the opposite manner, with the therapist initially ask-
ing for more than the client will give, and then reducing the request until
the client commits. DBT interweaves these two techniques, as suggested
by Goldman (1986), to maximize movement in therapy.
Reciprocal Communication and Irreverent Communication:

Stylistic Strategies
The stylistic strategies refer to the manner in which the therapist in-
teracts with the client. These strategies attend to the how, as opposed to
the what, of the therapist's communications to the client. The therapist
balances and tolerates the tension between two opposite sets of strate-
gies—reciprocal communication and irreverent communication.
Linehan (1993a) defines the reciprocal communication style by "re-
sponsiveness, self-disclosure, warmth and genuineness" (p. 371). Part of re-
ciprocal communication is attending to the client in a mindful manner by
noticing even subtle responses by the client and by not allowing precon-
ceptions or judgments to interfere with the attention. This same philosophy
of responsiveness is reflected in the Zen approach to achieving a state of
the mind at rest: "Nothing carries over conceptually or emotionally . . . .
we do not react out of a self-centered position. We are free to apply our
humanity appropriately in the context of the moment according to the
needs of people . . . . (Aitken, 1982, p. 42). Mindfulness during the session
resembles Freud's (1959) emphasis on the need to maintain "evenly hov-
ering attention" and to work through countertransference issues that inter-
fere with such attention. As another aspect of reciprocal communication,
the therapist self-discloses personal information to the client to encourage
self-disclosure by the client, to model coping with problems, or to validate
the client's perception of the therapist. The emphasis on self-disclosure in
DBT is based on findings in social psychology literature (see Derlega &
Berg, 1987, for a review) suggesting that self-disclosure by one individual
facilitates self-disclosure by another. The emphasis on warmth and genu-
ineness was influenced, of course, by Roger's humanistic approach (1951,
1986). The reciprocal communication style most closely resembles the
therapies of Kohut (1977) and Adler (1985), among the psychoanalytic
therapies.
In contrast to reciprocal communication, Linehan (1993a) defines the
irreverent communication style as "unhallowed, impertinent and incongru-
ous" (p. 371). These strategies temporarily "unbalance" the client by shift-
ing attention or by introducing a new viewpoint. Procedures include a
prosaic reaction to maladaptive behaviors, direct confrontation of client's
"crazy" behavior, and unorthodox responses. Linehan emphasizes, however,
that the strategies must be applied upon a foundation of compassion and
caring. Zen masters employ this same style of unorthodox responses:
Bassui [the master]: "Don't covet the left-overs of others while losing the pre-
cious jewel which hangs around your own neck."
Questioner: "What is this precious jewel which hangs around one's neck?"
Bassui: "When the dragon calls, clouds appear. When the tiger roars, the wind
begins to blow." (Braverman, 1989, p. 17)
The irreverent communication strategies also integrated techniques from

Whitaker's (1975) irreverent style in family therapy. The direct confronta-
tional nature of irreverent communication also resembles Ellis' (1962, 1987)
style in his rational emotive therapy. The irreverent communication style
most closely resembles Kernberg (Kernberg, Selzer, Koenigsberg, Carr, &

Appelbaum, 1989) among the psychoanalytic therapies for borderline per-

sonality disorder.
It is important to note that within the context of DBT, irreverence
refers to behaving in an offbeat manner, not behaving disrespectfully or
sarcastically toward the client. The therapist must interweave warmth, vul-
nerability, and closeness with matter-of-factness and confrontation. As in
Zen practice, the therapist strives toward both compassion and detachment.
A primary function of balancing of these strategies is the preservation of
the therapeutic alliance as a context for client change. If the therapist main-
tains reciprocal vulnerability (to the extent of the client's vulnerability), he
or she is likely to feel overwhelmed or suffocated and to want to leave the
relationship, whereas if the therapist maintains extreme imperviousness, the
client is likely to feel ignored or abandoned and to want to leave the re-
lationship for a new therapist.
Case Management Strategies
The case management strategies refer to how the therapist responds

to the client's environment beyond the therapeutic relationship. Linehan
(1993a) defines case management as "helping the patient manage her physi-
cal and social environment so that her overall life functioning and well-be-
ing are enhanced . . ." (p. 399). The case management strategies consist
of three sets of strategies—environmental intervention, consultation-to-the-
patient, and therapist supervision/consultation—that balance each other.
Tolerating the tension between helping the client and helping the client
help him/herself, the DBT therapist balances the environmental interven-
tion and consultation-to-the-patient strategies to prevent the therapy from
becoming either too nurturing or too withholding. While the environmental
intervention strategies involve the therapist actively interacting with the cli-
ent's external (to therapy) environment, the consultation-to-the-patient
strategies involve the therapist activating the client to interact with the en-
vironment. The therapist's supervision/consultation addresses the tension
between caring for oneself and caring for the client. Without supervision,
therapists are more likely to become distracted from treatment targets, to
ignore their own therapy-interfering behavior, and to become demoralized

by the client. Together then, the three sets of case management strategies
attempt to synthesize treatment of the client with treatment of the thera-
pist.
The therapist uses environmental interventions in situations where im-
mediate outcomes are very important, but where the client alone does not
have the capability to influence the outcome. Such situations range from
interfering to save the client's life to sending mandatory progress reports

to insurance or welfare agencies. The environmental intervention strategies
are primarily a combination of operant reinforcement therapy procedures
(Spiegler & Guevremont, 1993) that require the therapist to alter environ-
mental contingencies, exposure therapy procedures (Spiegler & Guevre-
mont, 1993) that require the therapist to accompany to the client into the
environment, and crisis intervention procedures (Bongar, 1991; Roberts,
1990).
While the environmental intervention strategies require the therapist
to advocate for the client, the consultant-to-the-patient strategies encourage
the client to advocate for him/herself. The consultant-to-the-patient strategy
enhances the client's ability to request services and interact effectively with
other professionals. The DBT therapist consults with the client about how
to interact with other service providers such as physicians, case workers,
and lawyers. Although the role of the DBT therapist when using the con-
sultation-to-the-patient strategies resembles other therapies such as psycho-
analysis and self-management behavior therapy, in that the therapist does
not intervene directly in the client's environment, the DBT therapist plays
a fairly unique role by acting as a consultant to the client with respect to
other health professionals. Among all of the DBT strategies, this set of
strategies appears to be the most original contribution and to least involve
the integration of procedures from other psychotherapies. In itself, how-
ever, the strategy represents juxtaposition of acceptance and change. The
therapist validates the client's inherent capabilities to function in the en-
vironment and take care of him/herself, while simultaneously teaching and
reinforcing more effective coping strategies.
The treatment of the therapist by a supervision team is also consid-
ered an essential component of DBT. All therapeutic schools require su-
pervision for therapists new to that school, and many suggest some form
of supervision or consultation throughout the career as an adjunct to treat-
ing clients. DBT stresses supervision even more strongly by integrating it
into the treatment model; just as the client requires treatment by the thera-
pist, so the therapist requires treatment by the supervision team. Treating
the therapist in addition to the client provides a dialectical frame for the
treatment by attending to both major subsystems within the therapeutic
context. Of all of the definitions employed in psychoanalytic supervision

literature, DBT's attention to the therapist's issues most closely resembles
Lakovics' (1983) "total countertransference," which emphasizes the inter-
action between therapist and client and includes essentially all of the thera-
pist's responses to the client.
PSYCHOTHERAPY OUTCOME
DBT was the first psychotherapy to be evaluated in a randomized

clinical trial (Linehan et al., 1991; Linehan et al., 1993b, Linehan et al.,
1933a). In the one-year outpatient treatment trial, female clients meeting
criteria for borderline personality disorder and having a history of chronic
parasuicidal behavior were assigned either to DBT or to treatment-as-usual
in the community. At the end of one year, DBT subjects demonstrated
significantly better improvement in suicidal behavior (including reduced
frequency of parasuicide acts and less medically severe acts), treatment re-
tention, inpatient psychiatric days, anger, and social and global adjustments.
No treatment effects emerged, however, for depression, hopelessness, rea-
sons for living, or suicidal ideation. Results were generally maintained dur-
ing a one-year follow-up. An open comparison trial of DBT on an inpatient
psychiatric unit by Barley et al. (1993) also demonstrated the efficacy of
DBT in reducing parasuicidal behavior. An outpatient research study is just
beginning to evaluate the effectiveness of DBT when treating female bor-
derline clients who also meet criteria for drug addiction.
CONCLUSION
DBT is a comprehensively integrative psychotherapy. Theoretically, it

synthesizes principles of behavior therapy with principles of Zen practice.
It integrates several therapeutic modes in a manner that allows each mode
to promote development in another. Strategically, DBT balances accep-
tance and change. Technically, it draws from social psychology, crisis in-
tervention, and various psychotherapies, in addition to behavior therapy
and Zen practice. Research results foretell a positive future for this ap-
proach to treating borderline personality disorder. Due to its dialectical
foundation, DBT is a therapy that strives to constantly evolve by synthe-
sizing clinical and research data from new and multiple sources.
ACKNOWLEDGMENTS
The authors would like to thank Hal Arkowitz and Patrick Hawk
Roshi for their editorial suggestions.
The development of this treatment was supported by National Insti-
tutes of Mental Health Grant No. MH34486 to the second author.
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Journal of Psychotherapy Integration, Vol. 4, No.

Dialectical Behavior Therapy: An Integrative

Approach to the Treatment of Borderline

This article describes the integrative aspects of Dialectical Behavior Therapy

In psychotherapy integration, different theories and techniques are

few integrative psychotherapies have been described and published (Ark-

it emphasizes the "open-ended dialogical process in which differences are

The standard model for DBT is an outpatient treatment in which the

strategies, and treatment targets. The overriding dialectic is the necessity

itial emotional vulnerability plus an invalidating environment reciprocally

Behavioral targets in DBT are specific, clear, and hierarchical, and

dactic, orientation, commitment) may also include one or more basic

As the treatment's name suggests, the concept of synthesis and inte-

gration permeates DBT in a number of ways. First, Linehan proposed a

DIALECTICAL PHILOSOPHY AS A FRAMEWORK FOR DBT

Dialectics is the underlying philosophy of DBT and provides a view

Dialectics stresses the fundamental interrelatedness and unity of re-

in consequence of their relationship, and the relationship itself evolves.

ternal environment in their search for controlling stimuli and to evaluate

the effect of behavioral consequences as well as antecedents, the contex-

Dialectics also focuses attention on the complexity of the whole. Re-

psychotherapy occurs between change and acceptance. The fundamental

applied standard behavior therapy procedures to chronically parasuicidal

crises made the application of behavior therapy in any straightforward or

systematic way fraught with difficulties.

proves equally problematic and, paradoxically, can also invalidate. If the

client's personal experience of the current state of affairs as unacceptable

Dialectics stresses change as a fundamental aspect of reality. Change

unbearable, DBT places a great emphasis on change. In addition to influ-

client's ability to adapt to change. Although many other therapies allow

DBT TREATMENT TARGETS AND STRATEGIES

Although the practice of behaviorally defining and hierarchically ar-

Therapy- Interfering Behavior

Adhering to the dialectical principles of the treatment, the DBT

Generally taught in a group format and enhanced by the individual

neously, being nonjudgmental, being mindful or focusing attention com-

For example, during the teaching of the interpersonal effectiveness and

emotion regulation modules, clients must practice observing and describing

Independent Self as a Target

One treatment target addressed by many traditional psychotherapies,

havioral techniques designed to teach self-control and self-monitoring. In

cluding the independent self as a treatment goal. A therapy that emphasizes

the development of an independent self, in whom behavior is controlled

or connected self, and/or learn to validate him/herself so that he/she can

experience greater comfort in an unsupportive environment. It seems logi-

It is among the DBT treatment strategies that the influence of inte-

of strategies themselves contain many different procedures and techniques

ture and application. Dialectical strategies function both as a way of or-

Extending is a translation of a technique used in Aikido, a Japanese

Validation and Problem Solving: Core Strategies

validating the response in terms of present circumstances (Linehan, 1993e).

Schaeffer also outlines a three-component process for interpretations

together informally. Skill training procedures are aimed at increasing cop-

Reciprocal Communication and Irreverent Communication:

The irreverent communication strategies also integrated techniques from

most closely resembles Kernberg (Kernberg, Selzer, Koenigsberg, Carr, &

Appelbaum, 1989) among the psychoanalytic therapies for borderline per-

Case Management Strategies

The case management strategies refer to how the therapist responds

ignore their own therapy-interfering behavior, and to become demoralized