Dialectical Thinking – The Forgotten Part of DBT

January 7, 2010 —

Dialectical Thinking – The Forgotten Part of DBT

Dialects and DBT
Dialectical behavior therapy (DBT) is a therapeutic approach which combines elements of western cognitive behavior therapy (CBT) with mindfulness practice associated with Zen Buddhism. It has proven to be extremely useful in treating patients with Borderline Personality Disorder, depression, and other psychiatric conditions in which patients have difficulty managing strong emotional responses and intense interpersonal relationships. Among other areas of focus, DBT teaches specific skills for better managing emotional life in four modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Marsha Linehan developed DBT based on the paradoxical principle that patients need to be validated because they are doing the very best they can do with their lives and their therapy. At the very same time, they need to learn to do better. Therapists need to send the message that they accept their patients for who they are and, simultaneously, insist that they change.

Much of the excitement around the therapeutic effectiveness of DBT focuses on the skills training. Parasuicidal behaviors (e.g. – self cutting, threatening overdose, bingeing and purging, drinking to excess) and other ineffective methods of coping with emotional stress are carefully analyzed in order to understand the precipitants and decision making that goes on just beneath the patient’s awareness. Patients are taught how to be more mindful and less reactive, giving them opportunities to make better decisions that have more desirable consequences. Specific strategies are devised to help patients deal more effectively with emotional states (e.g. – rage, despair, hopelessness) and interpersonal situations (e.g. – asking to have a need met, arguing with a person one cares about) that have been problematic in their lives.

However, the attitude of the therapist is also critical for success. The therapist must hold contradictory positions in balance, with the understanding that both are true. This keeps the therapist and patient from prematurely going down a one-sided path, which likely has been tread before many times with a poor outcome. Staying with the “dialectical dilemma” gives both therapist and patient the psychological space to work together on problems that have been impossible to solve up to that point. For this to come about, the therapist must be able to guide and structure the therapy sessions. This may involve methodically completing a behavioral chain analysis through the guidance of the patient’s diary card. This provides a framework so that therapy is not swept up in a series of unrelenting crises. The focus stays on resolving the life threatening behaviors (and therapy interfering behaviors) before all others. Frequently, the therapist must switch between validating and irreverent styles of communication. This technique allows the therapist to keep both poles of the dialectic on the table – the patient is doing her best and she also needs to change. When the dialectical poles are held long enough in therapeutic tension, a synthetic solution can emerge.

For example, a patient with Borderline Personality Disorder finds the pain of rejection intolerable, leading to wishes to die and the behavior of cutting herself to “feel alive” again. In analyzing this with the patient, the therapist learns that she feels hopeless and powerless at the height of her misery. At other times, when she is not immersed in this emotional state, the patient is capable of creative and effective action to get things done in her life. The patient’s cutting can be seen as a move towards “effective action” that gets her out of the powerless position. The therapist needs to validate the experience of hopelessness AND the creative action (cutting) the patient has learned gets her out of it. She can then help the patient look at other strategies that have some of the same elements of turning a passive/powerless experience into one of action/empowerment, but this time with more desirable consequences. If the therapist does not acknowledge the patient’s despair and her best efforts to overcome it, she dismisses the patient’s experience (which likely has happened many times in her life.) On the other hand, if the therapist simply sits with the patient’s pain, she misses the opportunity to enlist the patient in coming up with a better solution.

There are many “dialectical dilemmas” that the therapist must engage if she is to help her patient face them. Many of these are familiar from more traditional psychodynamic psychotherapy practice, but may not be in full awareness. DBT frames them in dialectical format (thesis – antithesis – leading to synthesis), which is very helpful in keeping them in mind. In addition, the therapist and patient can learn to hold these dilemmas in balanced tension with the help of mindfulness training.

A New Look at Transference
One central dilemma that troubles many patients (and troubles therapists as they try to work with these patients) involves the search for the right emotional distance. Therapy needs to be intense enough to be emotionally meaningful, but with enough distance to make sense of what is going on. (In psychodynamic psychotherapy, this is the problem of dealing with the transference and countertransference.)

Some examples of how this shows up in DBT-informed work are listed below:

- Thesis: I need to be close in order to feel loved. If I am not close enough, I feel unloved and unlovable.
- Antithesis: When I am close, I feel terribly vulnerable to being hurt (e.g.-abandoned, suffocated, scorned.)

- Thesis: I want my therapist to love me in a special way (which may be maternal, paternal, sexual or in some other way.)
- Antithesis: I need my therapist to maintain objectivity so she can help me with the problems I came to therapy with.

- Thesis: My feelings for my therapist are real and deserve to be recognized as such.
- Antithesis: My feelings for my therapist are a repetition of past relationships that have not worked well for me in my adult life. I need to understand these patterns and master them.

The focus on dialectical thinking in therapy can be very useful in engaging these dilemmas in ways that eventually lead to productive work. Both thesis and antithesis are true, yet both need to be recognized in relationship to the other to get a more complete picture. Taking only one side is a pathway towards acting out, fleeing treatment, or stalemate. The work towards creative synthesis of these and similar dilemmas, along with the development of practical skills in managing emotional and interpersonal life, is the essence of all good therapy.

Don Ross, MD
Medical Director
Kelly Shannon, LCSW-C
Coordinator of DBT Programs

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