DIALECTICAL BEHAVIOUR

THERAPY
ASHKEEN SHAJAHAN
INTRODUCTION
● Dialectical behaviour therapy or DBT (Linehan 1993) is a broad-based cognitive
behavioral treatment originally developed for chronically suicidal individuals
diagnosed with borderline personality disorder (BPD).
● It consists of combinations of individual psychotherapy, group skills training,
telephone coaching and a therapist consultation team.
● It was the first psychotherapy shown through controlled trials to be effective with
BPD.
● The effectiveness of DBT is also seen in tackling a wide range of disorders and
problems including both undercontrol and overcontrol of emotions and associated
cognitive and behavioral pattern.
● When clients have complicated, severe, chronic problems and multiple treatment
providers, when misery makes suicide seem the only option, DBT helps therapist
to find order amid the chaos.
● DBT structures the treatment environment into weekly individual therapy, weekly
group skills training, telephone coaching, and a peer consultation team of DBT
therapists.
● Within that environment, DBT consists of a hierarchy of treatment priorities and core
strategies for addressing those priorities. These features offer systematic guidelines
for clinical decision making that help therapists treat life-threatening and
therapy-interfering behaviors as well as their own emotional reactions.
● Understanding DBT starts with understanding this core problem—pervasive emotion
dysregulation.
WHAT ARE DIALECTIC?
Pervasive emotion dysregulation

● Linehan explained the etiology and maintenance of BPD with a biosocial theory of emotion
dysregulation.
● Emotion dysregulation is the inability, despite one’s best efforts, to change or regulate
emotional cues, experiences, actions, verbal responses, and/or nonverbal expressions under
normative conditions.
● Pervasive emotion dysregulation is when this inability to regulate emotions occurs across a
wide range of emotions, problems, and situational contexts. (Linehan,Bohus, & Lynch, 2007).
● Such difficulties with dysregulation lead to maladaptive behaviors (e.g., suicidal behavior,
purging, abusing substances),because these behaviors function to regulate emotions or are a
consequence of failed emotion regulation.
Biosocial theory

The impact of vulnerable biology and invalidating social environment

Vulnerable biology and its consequences -

Linehan hypothesized that three biologically based characteristics contribute to an

individual’s vulnerability.People prone to emotion dysregulation react immediately and
at low thresholds (high sensitivity)They experience and express emotion intensely
(high reactivity) and this high arousal dysregulates cognitive processes They
experience a long lasting arousal (slow return to baseline) Due to biological
vulnerability - emotions tend to vary wildly (eg: social situations - shy or outgoing?)
Invalidating social environment and its consequences -

Emotional development in an optimally validating environment - In healthy emotional development,

caregivers respond to a child in ways that strengthen the links between environmental cues, primary
emotions, and socially appropriate emotional expression while weakening the links for socially
inappropriate expression. When caregivers consistently and persistently fail to respond as needed to
primary emotion and its expression - pervasive invalidation occurs when, more often than not, caregivers
treat our valid primary responses as not to be taken seriously.The person thus learns to avoid,interrupt,
and control his or her own natural inclinations and primary emotional responses. He or she learns to avoid
any step that results in pain and invalidation.In Linehan’s theory, different combinations of biological
vulnerability and social invalidation can result in fairly similar experiences. People may also travel different
developmental routes yet end up with the same difficulties. For those with a high biological vulnerability to
emotion dysregulation, even a “normal” level of invalidation may be sufficient to create serious problems.
Like those with attention deficits, they face enormous but often hard-to-perceive difficulties.
The first key component of DBT is the biosocial theory of disorder. It proposes that:
1) problematic or disordered behavior, particularly extremely dysfunctional behaviors,
may be a consequence of emotion dysregulation or an effort to re-regulate emotion
(2) invalidation plays a role in maintenance of current difficulties regulating emotion;
(3) common patterns subsequently develop as a person struggles to regulate emotion
and deal with invalidation; these patterns become problems that themselves must be
treated.
DBT’s overarching treatment rationale therefore is to teach and support emotion
regulation and to reinstate the natural organizing and communicative functions of
emotion.
DIALECTICAL DILEMMAS
● Secondary behavioral patterns
● Managing emotion vulnerability and ongoing invalidation often strands the client in a
dilemma between overregulating and underegulating emotional experience and expression.
● Linehan called this - dialectical dilemma - as the essential idea of “dialectics” is that any one
position contains its own antithesis or opposite position.
● The client’s inevitable failures to regulate emotion lead to increased invalidation

(“Why are you so sensitive?,” “You’re crazy!,” or “Get over it!”), which in turn leads to redoubled
efforts to self-regulate in order to avoid further invalidation. At the other extreme, clients may
escalate expression as they try to communicate why their responses are valid (“I’m not crazy!
You don’t understand!”).

Over time, common behavioral patterns develop as clients attempt to resolve the dilemmas
inherent in pervasive emotion dysregulation.
Emotional vulnerability and self invalidation

● Biological vulnerability and a history of pervasive invalidation create sensitivity.

● Because the individual cannot control the onset and offset of events that trigger emotional
responses,the person can become desperate for anything that will make the pain end.
● “Emotion vulnerability” refers not only to the exquisite sensitivity but also to the
consequences of living as a person who is exquisitely sensitive. Unavoidable day-to-day
experiences trigger intense emotional pain to the point where having emotions can become
traumatic: people in this situation cannot tell when they will be undone by emotions.
● Performance becomes unpredictable - foils personal and interpersonal expectations -
create frustration - they despair as their emotional sensitivity feels like biological and never
changing - feels trapped - suicide may seem the only wat to prevent suffering.
Active passivity and apparent competence

Active passivity is the tendency to respond to problems passively in the face of insufficient help while
communicating distress in ways that activate others.

Apparent competence is deadly. At one moment the client appears able to cope and then (unexpectedly to
the observer) at other times it’s as if the competency did not exist. Clients have learned to “appear
competent” that is, to hide emotion and vulnerability so that observers see very little expressed emotion.

Unrelenting crisis and inhibited grieving-

Unrelenting crisis refers to a self-perpetuating pattern in which a person both creates and is controlled by
incessant aversive events. An emotionally vulnerable person may impulsively act to decrease distress; this
can inadvertently increase problems that quickly snowball into worse problems.

Inhibited grieving is an involuntary, automatic avoidance of painful emotional experiences, an inhibition of

the natural unfolding of emotional responding. The tragedies that some of our clients have endured have
been shattering. They may inhibit grief associated with childhood trauma or revictimization as an adult, or
grief evoked by current losses that are the consequence of maladaptive coping or inordinately bad luck
STRUCTURING THE TREATMENT ENVIRONMENT
Comprehensive treatment for highly disordered clients, from this viewpoint,
requires that treatment accomplish five functions:
1. Enhance client capabilities.
2. Improve client motivation to change.
3. Ensure that new client capabilities generalize to the natural environment.
4. Enhance therapist capabilities and motivation to treat clients effectively.
5. Structure the environment in the ways essential to support client and therapist
capabilities
HIERARCHY OF TREATMENT AND GOALS
● Treatment goals are the overarching desired end point for a stage of work.
● Targets in DBT are behaviors identified as needing change, whether to be
increased or decreased.
● DBT stages treatment using a commonsense notion:
● “Prioritize problems according to the threat they pose to a reasonable quality
of life.”
● Therapy tasks are organized hierarchically so that the most important tasks
take priority over the less important.
STAGES
Linehan describes 5 stages -
● Stage 1 and 2 are secondary treatment targets addressing behavioral
patterns and dialectical dilemmas.
● Stage 3 to help client synthesize what was learned in earlier stages,
increasing self respect and a sense of abiding connection.
● Stage 4 focuses on sense of incompleteness that client experience even after
problems are essentially resolved.
PRIMARY BEHAVIOURAL TARGETS

Pretreatment : agreement and commitment

● Agreement on goals and methods

● Commitment to complete agreed-upon plan
Stage 1: Severe behavioral dyscontrol → behavioral control
1. Decrease life-threatening behaviors
● Suicidal or homicidal crisis behaviors
● Nonsuicidal self-injurious behaviors
● Suicidal ideation and communications
● Suicide-related expectancies and beliefs
● Suicide-related affect
2. Decrease therapy-interfering behaviors
3. Decrease quality-of-life-interfering behaviors
4. Increase behavioral skills
● Core mindfulness
● Distress tolerance
● Interpersonal effectiveness
● Emotion regulation
● Self-management
Stage 2: Quiet desperation → emotional experiencing
Not a priori hierarchy; instead, prioritized based on individual case formulation
Decrease:
● Intrusive symptoms (e.g., PTSD intrusive symptoms)
● Avoidance of emotions (and behaviors that function as avoidance)
● Avoidance of situations and experiences (i.e., avoidance that includes what is seen
in PTSD but that is not specifically limited to avoidance of trauma-related cues)
● Emotion dysregulation (both heightened and inhibited emotional
experiencing,specifically related to anxiety/fear, anger, sadness, or shame/guilt)
● Self-invalidation
SECONDARY BEHAVIOURAL TARGET (ACROSS ALL
STAGES)
● Increase emotion modulation
● Decrease emotional reactivity
● Increase self-validation
● Decrease self-invalidation
● Increase realistic decision making and judgment
● Decrease crisis-generating behaviors
● Increase emotional experiencing
● Decrease inhibited grieving
● Increase active problem solving
● Decrease active passivity
● Increase accurate communication of emotions and competencies
● Decrease mood dependency of behavior
SKILLS TRAINING
● Individual therapy sessions are typically crowded with high-priority tasks and
crises making it difficult to sustain a step-by-step skills training focus.
Consequently, skills training is taught in a group format as a class.
● Linehan (1993b) has taken various evidence-based protocols and distilled
them into four categories of skills that clients can learn and practice:
1. Mindfulness
2. Emotion regulation
3. Distress tolerance
4. Interpersonal effectiveness
● Mindfulness and distress tolerance skills are acceptance oriented. By
practicing mindfulness skills, clients become increasingly able to willingly and
nonjudgmentally engage with their immediate experience.
● Emotion regulation and interpersonal effectiveness, on the other hand, are
change oriented skills. Clients learn the natural and adaptive functions of the
major emotions and learn practical techniques for preventing emotion
dysregulation, for changing or reducing negative emotions, and for increasing
positive emotions.
HOW DBT TREATS

With a combination of core treatment strategies—

● Change,
● Acceptance, and
● Dialectical strategies
1. Change strategies
● Orienting and micro-orienting - In DBT you not only orient at the beginning
of treatment but also provide what could be called “microorienting.
Consequently explaining why a particular treatment task is necessary to reach
the client’s goals and, also need to instruct the client specifically on how to do
the therapy task despite or in the face of emotion dysregulation.
● For eg, a client and therapist are assessing what led to the occurrence of a
instance of target behavior that week. When the therapist asks for details, the
client suddenly curls into her chair, head down and mute (behavior signals
emotion dysregulation). In order for assessment of the target behavior to
continue, the client needs to be helped to re-regulate her emotion as well as
oriented to the original task
● "something just happened and you have curled up and become silent. My
guess is you’ve had a huge wave of emotion— maybe fear? Maybe shame?”
● Didactic strategies - DBT uses didactic or teaching interventions such as
psychoeducation.
● In DBT you discuss diagnostic criteria, relevant research, and provide other
information that helps the client understand his or her difficulties and the
therapy process almost as if the client were a graduate student or therapist in
training
● This is done because the client must not only know how to manage the contingencies
that affect his or her own behavior, but also must educate others about how to do so.
● For example, some clients come to overrely on punishment as a means to regulate
their behavior. They have never learned the self-management skills needed to learn,
maintain, and generalize new behaviors and to inhibit or extinguish undesirable

Commitment strategies - Many clients who come to DBT find it difficult to generate and
sustain their motivation to change.

● Ambivalence about change and lack of motivation to change are expected.

● They are viewed as problems that the therapy should treat, not ones the client should
resolve before being ready to begin therapy.
● Whenever initiating change, especially during initial sessions, DBT emphasizes use of
strategies that help clients strengthen their own commitment to change
COMMITMENT STRATEGIES
● Pros and cons - The therapist takes a genuinely balanced stance to help the
client consider the reasons for and against change, and the reasons for and
against maintaining the status quo
● Foot-in-the-door – this is when the therapist presents the contemplated change
in a vague enough way that anyone would say “Yes”.For example, a client
describes how her romantic relationships repeatedly fail, in large part, because
she responds to relationship problems by cutting herself. Using foot-in-the-door,
the therapist might say, “We could use this therapy to help develop the skills to
make and keep better relationships. Would that be of interest to you?”
● Door -in-the-face - Here the therapist asks for the exact or ultimate change
needed in the situation without qualification or reservation. Opposite of foot in the
door
● Freedom to Choose, Absence of Alternatives- therapist highlights that the
client is free to choose whether to make or not to make a change, yet
simultaneously highlights highly undesirable consequences of not changing.
● Linking Prior Commitments to Current Commitments- therapist helps the
client notice the similarity of past successful changes and highlights that
because the client made one change (e.g., successful past commitments to
stop smoking or get off heroin) he has the capability to make another change
(stop intentional self-injury).
● Devil’s Advocate- when the therapist takes the position of arguing for the
status quo, stating the doubts, concerns, or drawbacks of change.
● Shaping- The therapist helps the client experience more frequent, intense, or
sustained behaviors of wanting, acknowledging and acting in line with the
commitment to change
SELF MONITORING - THE DBT DIARY CARD
● Each day the client uses a standard DBT diary card to monitor and record all
primary treatment targets
● Double sided - One side monitors practice of DBT skills.
● Other side monitors occurrence of other primary targets (suicidal urges and
actions, urges and actions to self-harm), associated emotions, and drug use.
● The client brings the completed diary card to each session and sessions begin
with reviewing the diary card together.
● The therapist and client develop a shared operational definition of target
behaviors to be monitored and discuss how changes in these behaviors link to
the client’s goals.
● Behavioral chain analysis—a form of functional analysis—is used to identify the variables that
control specific instances of targeted problems such as self-injury.It is an in-depth analysis of
events and contextual factors before and after an instance (or set of instances) of the targeted
behavior.
● DBT case formulation is based on the functional patterns that emerge from these chain
analyses.
● Treatment plans address what needs to go differently in the behavioral chain so that the client
does not engage in the problem behavior.
● DBT’s change strategies include not only skills training but also three other groups of
cognitive-behavioral procedures: exposure therapy, contingency management, and cognitive
modification.
● However,because pervasive dysregulation leads to mood-dependent behavior and crises, the
DBT therapist must often modify these standard cognitive-behavioral therapy (CBT)
interventions to be successful.
● Begin the chain analysis by clearly defining the problem behavior and picking one instance to analyze
● Next, the therapist and client identify two important types of controlling variables: precipitating events
and vulnerability factors.
● Precipitating events are the immediate events that began the chain that led to the problem behavior.
● Vulnerability factors create a context in which precipitating events have more influence, for example,
physical illness, sleep deprivation, or other conditions that influence emotional reactivity
● Next, the therapist and client identify each link between the precipitating event and the problematic
behavior to yield a detailed account of each thought, feeling, and action that moved the client from point
A to point B
● Close attention is paid to reciprocal interactions between environmental events and the client’s
● Finally, the therapist and client identify the consequences associated with the problem behavior—those
immediate and delayed reactions of the client and others that followed
FOUR CBT CHANGE PROCEDURES AS USED IN DBT
1. Skills deficits, - are addressed with skills training procedures
2. Problematic emotional responding -problems with conditioned emotions are
addressed with exposure procedures
3. Problematic contingencies - faulty contingencies are addressed with
contingency management procedures
4. Problematic cognitive processes - are addressed with cognitive modification
procedure
CONTINGENCY MANAGEMENT PROCEDURES
● 24-hour rule - if the client deliberately self-harms, then the therapist will not
increase therapeutic contact during the subsequent 24 hours (although he or she
does keep any previously scheduled session). This is meant to strengthen the
client’s motivation to seek contact when he or she needs help refraining from the old
solution of self-harm and replacing it with a new solution
● The Four-Miss Rule- to preemptively address attendance problems. If a client
misses four consecutive sessions of individual therapy or group skills training, then
the client is discharged from the program for the remainder of the contracted
treatment period.The clarity and non-negotiable nature of this rule motivates the
therapist to actively assess and address whatever interferes with attendance
● Natural Contingencies of the Therapeutic Relationship - Self-involving
self-disclosure
VALIDATION STRATEGIES
● Validation emphasizes acceptance.
● DBT defines validation as empathy plus the communication that the client’s
perspective is valid in some way.
● With empathy, you accurately understand the world from the client’s
perspective; and also actively communicate that the client’s perspective
makes sense.
● Validation, in itself, can produce powerful change when it is active, disciplined,
and precise.
● Used genuinely and with skill, it reduces physiological arousal that is a normal
effect of invalidation and it can cue more adaptive emotions to fire.
● Validation in itself reduces physiological arousal that is validation directly
downregulates emotion. Validation in itself cues adaptive responding that
regulates emotion
What to validate?
● The client’s primary emotional responses and expressions
● The client’s behaviors: observe and label
● The client’s cognitions: reflect his or her thoughts, assumptions, and values
● The client’s ability to attain his or her ultimate goals
When a client is dysregulated, validate:
● The problem’s importance
● The task’s difficulty
● The client’s emotional pain
● The client’s reasons for feeling out of control
● Wisdom in the client’s ultimate goals (if not the means selected)
● The client’s location perspective
When it’s hard to see what to validate, validate:
● Past learning history,
● Whatever is justifiable in terms of facts, logical inferences, or accepted authority
● Whatever is an appropriate or effective means to an end
How to validate

● Search for the Valid- “The therapist observes, experiences and affirms but does not create validity. That
which is valid pre-exists the therapeutic action” (Linehan, 1997b, p. 356)
● Know Thy Client (and the Psychopathology and Normal Psychology Literatures) -Constantly be aware
of the client’s current emotional arousal and how it affects the ability to process new information, then
balance change and validation accordingly
● Validate the Valid; Invalidate the Invalid - Be precise about what you are validating

Validate at the Highest Possible Level; Actions Speak Louder Than Words

Linehan (1997b) distinguishes six levels of validation -

● Level 1: Listen with Complete Awareness, Be Awake

Listen and observe in an unbiased manner, and communicate that the client’s responses are valid by listening
without prejudice

● Level 2: Accurately Reflect the Client’s Communication

Communicate understanding by repeating or rephrasing, using words close to the client’s own without added
interpretation. Remain nonjudgmental, that is, not focused on improvement or encouragement or evaluating
effectiveness or merit, but instead on the simple “is-ness.” “This is how it is for you right now”
● Level 3: Articulate Non Verbalized Emotions, Thoughts, or Behavior
Patterns
Perceptively understand what is not stated but meant without the client having to
explain things. Clients with a pervasive history of invalidation are so sensitized that
often they disclose a tiny bit but feel they have told you everything; or so habitually
mask or control expression that you need to intuit the rest from small signals
● Level 4: Describe How the Client’s Behavior Makes Sense in Terms of
Past Learning History or Biology
Identify the probable factors that caused the client’s response.For example, to a
client who constantly seeks reassurance that therapy “is going okay,” the therapist
might validate by saying, “given the unpredictability of your parents, it makes
sense to have the feeling of waiting for the other shoe to drop and seek
reassurance.”
● Level 5: Actively Search for the Ways That the Client’s Behavior Makes Sense
in the Current Circumstances, and Communicate This
Find the ways a response is currently valid, whenever possible, and remember not to rely
only on verbal validation. For example, say you were walking to a movie theater with a
friend who’d been raped in an alley, and you proposed that you take a shortcut through
an alley so that you wouldn’t be late for the movie and your friend said she did not want
to because she was afraid. Saying, “Of course you’re afraid, you were raped in an alley,
how insensitive of me” would be a Level 4 validation. Saying, “Of course you are afraid,
alleys are dangerous, let’s walk around” would be a Level 5 validation. When you can
find a Level 5 validation (and search like a fiend for it), use it rather than a Level 4.
● Level 6: Be Radically Genuine
Act in a manner that communicates respect for the client as a person and an equal,
rather than as “client” or “disorder.”This is clear-eyed and unflinching—you are what you
are and I can handle it and you can handle it. The therapist validates the individual rather
than any particular response or behavioral pattern.
DIALECTICAL STRATEGIES
● The tension between the need to accept clients’ true vulnerabilities and yet
encourage them to make necessary change is a constant dilemma for the
therapist and often the root of therapeutic impasse.
● To navigate, therapists take a dialectical stance and use dialectical strategies.
● Dialectical strategies provide the practical means for both the therapist and
the client to retain flexibility amid conflicting and even contradictory “truths.”
Dialectical stance
● Taking a dialectical stance is the psychological equivalent of taking a
physically centered stance. Your stance determines what moves are possible
● A dialectical stance means adopting a set of assumptions that create a center
of psychological flexibility
● Three assumptions define DBT’s dialectical stance:
(1) reality is whole and interrelated;
(2) reality is complex and in polarity; and
(3) change is continual and transactional.
● Maintaining a dialectical stance can be hard for therapists because the pull is
to become locked into a concept at either end of the pole rather than directly
experience how two truths stand side by side as part of a larger synthesis

This can be particularly difficult for two of DBT’s main goals—

● Enhancing client emotion regulation and

● Decreasing priority targets (such as self-injury)

Thus, DBT therapists view both these goals in dialectical terms.

● Dialectics of Emotion Regulation

● Dialectical Abstinence
DIALECTICALLY BALANCING STRATEGIES
Important strategy sets are used dialectically to prevent rigid polarization:

1. Stylistic strategies,
2. Case Management strategies
3. Specific Dialectical strategies

The aim is to create the appropriate mix of acceptance of the client’s vulnerability
and change that recognizes the client’s strengths.
STYLISTICS STRATEGIES:RECIPROCAL AND
IRREVERENT
● Offer a practical dialectic in how the therapist communicates, balancing being
warmly reciprocal and irreverently confrontive. In DBT, the therapist balances
two communication styles:
1. Reciprocal
2. Irreverent
● A reciprocal communication style emphasizes acceptance.
● The therapist is sensitive to the nuance in the client’s behavior, takes the client’s
agenda seriously and directly responds to it rather than interpreting any latent
meaning.
● If a client asks something personal about the therapist, the therapist, responding in
a reciprocal style, is likely to use self disclosure, warm engagement and
genuineness to answer the question.
● Such strategic disclosures can enhance the therapeutic relationship, normalize
clients’ experiences, model adaptive and intimacy building behavior, demonstrate
genuineness, equalize power in the therapeutic relationship, enhance the
therapeutic relationship, and establish it as more similar to outside relationships,
thus facilitating generalization
● A reciprocal communication style alone or an imbalance toward this style can lead to
impasse.
● When the glum client who has told the same story of grievance many times has a
therapist who simply paraphrases in the same monotone as the client, the
probability is that the client’s mood will stay the same or worsen.
Irreverent communication includes using humor or reframing a client’s
communication in an unorthodox or offbeat manner.
Irreverent communication also includes:
1. Plunging in where angels fear to tread
2. Oscillating the intensity of emotional tone or language
3. Expressing impotence or omnipotence
4. Using a confrontational tone
5. Calling the client’s bluff.
CASE MANAGEMENT STRATEGIES
● People in the client’s social and professional network often don’t know what the
client can and cannot do without help. Treat client as fragile and step in to
control when client is capable, or they expect performance beyond the client’s
true capability and fail to offer needed help.
● Case management strategies concern how the therapist helps the client to
navigate his or her social environment, balancing consulting to the client with
direct intervention on the client’s behalf in some limited cases.
● When multiple treatment providers as well as family or friends are actively
involved in clients’ lives and treatment, conflict becomes more likely as these
“important others” have strong opinions about what should and should not be
done in therapy and want to discuss with the therapist what can be done
about the identified patient.
● In DBT these common problems are addressed by balancing the
change-oriented intervention of “consultation to the client” with
acceptance-oriented “environmental intervention”.
● Consultation to the client helps the client become more skillful in personal and
professional relationships.
● In environmental intervention, the therapist accepts the client’s true
vulnerability and so directly and actively intervenes on the client’s behalf
SPECIFIC DIALECTICAL STRATEGIES
● Specific Dialectical Strategies directly target polarization.
● The therapist reaches for dialectical strategies when he or she is stuck.
However, when we’re stuck, we may feel frustrated or despairing and be
prone to problematic use of dialectical strategies
● Linehan’s cautionary note - : dialectical strategies can be easily confused with
gimmicks and game playing.
● Therapist needs to show the utmost care, honesty, and commitment to what is
actually said and done, so that dialectical strategies are used with humility,
and not from a superior position of “I know and am tricking you into seeing it
my way.”
● Entering the Paradox - ” Rather than convince the client that things will eventually get better or that in
fact she can do it, the therapist enters the paradox, but not in a rational way. Instead, the therapist
highlights the paradoxical or contradictory elements without pulling the client out of the struggle and
encourages the client to solve the dilemma experientially, to find how things can be true and not true,
and that the answer can be both yes and noLinehan (1993a) has highlighted common examples of
these paradoxes in DBT. They include that the client is free to choose her own behavior but cannot stay
in DBT if she does not choose to reduce intentional self-injury
● Metaphor - Because metaphors often have multiple meanings, the client can use it in his or her own
way, feel more open, less overwhelmed, and less likely to stop listening.“It’s hard to confidently lead the
climb here when you keep unclipping the rope and jumping off the mountain.”
● Devil’s Advocate- the therapist holds down the maladaptive end of the continuum, freeing the client to
advocate for the more adaptive end of the continuum. This technique is used to strengthen the client’s
position once he has moved toward adaptive responding
● Extending - the therapist takes one aspect of the client’s communication more seriously than the client
anticipated, sometimes taking the client more seriously than she takes herself.The client, for example,
may have been reinforced for making threats in past therapies and offer a threat or challenge when
unhappy with the therapist’s or program’s limits “If you don’t act differently, this therapy isn’t going to
help me (the challenge).” To extend, the therapist might say, “If this therapy isn’t helping, then we need
to do something about that. Do you think you should fire me? This is very serious.”
● Activating Wise Mind - “What would wise mind say?” the therapist assumes
that the client has the capacity for wisdom, a way of knowing that integrates
emotion and reason, grasping meaning or truth intuitively.Even in the heat of
a very intense moment, a client can often access the wisdom to know of
what’s needed.
● Making Lemonade - the therapist helps the client transform something
problematic into an asset The therapist may view a discouraging event as an
opportunity to practice distress tolerance
● Allow Natural Change - The therapist does not artificially create stability and
consistency. Instead, the therapist allows change to occur naturally to help the
client develop comfort with change, ambiguity, unpredictability, and
inconsistency, knowing that this too is an opportunity to practice acceptance
of reality as it is.
THANKYOU