Clinical Interventions Therapeutic Approaches

Dialectics, DBT and the Therapeutic Process

DBT is explicitly based on dialectical notions, but dialectics is implicit in other therapies. Therapists can be more helpful if they can identify the dialectics inherent in the therapeutic process.

By Mental Health Academy 2023-11-27 07:11:23

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DBT is explicitly based on dialectical notions, but dialectics is implicit in  other therapies. Therapists can be more helpful if they can identify the dialectics inherent in the therapeutic process.

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Introduction

Dr. Marsha Linehan developed Dialectical Behaviour Therapy (DBT) in response to what she called the “woefully inadequate” therapies available at the time she began working with clients diagnosed with borderline personality disorder (BPD) (Linehan, 1993). These clients with serious psychological wounds felt invalidated when Linehan challenged their thoughts in the pursuit of typical cognitive behavioural reframes, trying to help them understand how their thoughts and interpretations were unhelpful or irrational. She further realised that many of the clients with the BPD diagnosis – typically coming from an invalidating environment – seemed to have a high degree of emotional vulnerability, and would react intensely to stressors, taking longer than normal to return to baseline levels of calmness. Emotional dysregulation was constant, threatening their lives, the therapy, and certainly their relationships. 

Thus, a new therapy was needed for this population, one which would: (1) be highly supportive; (2) show acceptance of the client while still suggesting that change might improve the client’s quality of life; and (3) help clients to live more in the present moment, not over-reacting to every stimulus.  The therapy, most importantly, needed to keep clients engaged in therapy while teaching them how to regulate their emotions.  Thus DBT – an incorporation of behavioural science, dialectical philosophy, and Zen practice – was born (Miller, Rathus, & Linehan, 2017; MacPherson, Cheavens, & Fristad, 2013). In this article and two companion pieces, we shine the spotlight on aspects of it.

BPD symptoms, regrouped dialectically

As a serious personality disorder, BPD symptoms appear in the DSM-5-TR. But in our quest to understand the dialectics of the therapy designed specifically for BPD, let us look at its symptoms according to Linehan’s way of grouping them, which highlights their dialectical nature and strengthens the rationale for her DBT theoretical framework. Notice how each pair of features forms a dialectical dilemma, between the poles of which the BPD client swings; we use “she” to refer to the client because the overwhelming majority of people diagnosed with BPD are female.

1a) The client shows emotional vulnerability, having difficulty coping with stress and, often, blaming others for having “unrealistic expectations” and making “unrealistic demands”.

1b) Having internalised the invalidating environment, the BPD tends toward “self-invalidation”, disqualifying her own responses, having unrealistic goals and expectations, and then feeling ashamed and angry when she fails to achieve the goals. Note how the first key feature and this one form a dialectical pair: that is, a continuum with two poles between which the BPD vacillates, because both poles are experienced as distressing.

2a) Unrelenting crisis becomes the modus operandi of the BPD, because the person experiences a much higher-than-normal incidence of traumatic events: partly related to her own dysfunctional lifestyle and made worse by her extreme emotional reactions, with a slower-than-normal return to baseline levels of emotionality. Being constantly in crisis mode results in experiencing new crises before old ones are resolved. But, on the other hand…

2b) Because the BPD has difficulties with emotional modulation, facing negative affect is hard. A tendency to inhibit feelings, especially of loss or grief, becomes a pattern. We now see the second dialectical dilemma: the high emotionality of crisis (2a) combined with the felt need to inhibit affective expression altogether.

3a) The BPD exhibits active passivity: that is, she is highly active at seeking out others to sort out her problems but is passive at solving her own problems.

3b) The BPD shows apparent competence, especially in response to the invalidating environment. The word “apparent” is used because the skills that show competence do not generalise across all situations in the person’s life, and being able to use them is dependent on her mood of the moment. These final two symptoms form the third dialectical pair: while looking competent, the BPD only feels able to solve problems passively: that is, through other people helping her (Grohol, 2018 and 2019; Miller et al, 2017; Buford, 2021; Ferguson; 2021).

Many BPD clients’ way of coping with such intense, opposites is to engage in self-harm, suicide attempts, or other extreme behaviours which result in frequent admissions to psychiatric units (Harvey & Rathbone, 2013; Miller et al, 2017). Let us now examine what dialectics is, with an eye to seeing how it works in DBT and other therapies to embrace – and transcend – the dialectical tension already present for most clients.

Dialectics: what it is, how it was embraced, and examples

A long history

Dialectics – the mind’s way of understanding things by comprehending their opposites – is not a new concept in philosophy. From the ancient Greek philosophers through Hegel and Marx and into the present day, we have understood that when we allow the tension between two opposites, a greater truth can emerge from their interplay and integration. When philosophers in the time of Socrates found holes in each other’s arguments, they recognised the emergent insights, discovered by this Socratic dialogue, to be greater than either individual position. In the nineteenth century, the universal dialectic was stated by Georg W. F. Hegel as thesis, antithesis, synthesis (Reidbord, 2019).

The duality of life

We perceive most core concepts in this way; for instance, we know light because we have experienced darkness, happiness because we have experienced sorrow, and fidelity because we have experienced betrayal. Dialectics is based on the notion that we fully comprehend things when we perceive not only the pair of opposites, but also, the integration of the two at a higher level. Not only concepts, but all of existence relies on the fact that the world is constructed and perceived around seeming opposites. The problem is that the word “opposite” implies something antagonistic and irreconcilable. Yet Eastern mystic traditions and even modern physics have been showing us that what often seem like totally opposite ideas are in fact, two sides of the same coin, each representing a side of the truth. The same holds true for views of our self and others (Elliott, 2010).  

Linehan embraces synthesis

We noted above how Linehan’s use of cognitive-behavioural strategies early on implicitly pathologised her clients, who tended to think, when challenged, “If I need to change, there must be something wrong with me.” To avoid re-traumatising them, she engaged Zen Buddhism’s self-acceptance and focused on clients’ strengths. The problem with that course of action, however, was that – to achieve a higher quality of life – the clients had a real need to change. Thus, Linehan came to realise that she must integrate change (thesis) and acceptance (antithesis) into a larger truth that incorporates both (synthesis) (Reidbord, 2019).

Dialectical examples in therapy

This is the fundamental dialectic of DBT, although there are others. DBT therapists help their clients to see, for example, that both people who feel ultra-dependent on others and also those who must be always independent often fail to get useful help when it would come in handy, or that both people who feel unworthy of having their needs met and also those who feel excessively entitled tend to cause people to avoid meeting their needs. Another dialectic is that the client is doing his or her best but wants to do better. Similarly, the therapist is trustworthy and reliable, but also makes mistakes. Although we use “but” for clarity here, DBT teaches clients to use “and” instead (e.g., “The therapist is reliable and makes mistakes.”). In doing so, the therapeutic task is to embrace the truth of both propositions at once, not to choose one over the other. In Psychosynthesis therapy, this is referred to as embracing the “both and”, a concept Carl Jung also incorporated into his work (Reidbord, 2019; Elliott, 2010; H. Palmer to author, 1997).

Basic dialectical characteristics of DBT and other therapies

Dialectical Behaviour Therapy combines standard CBT (cognitive-behavioural therapy) techniques for regulating emotion and testing reality with concepts of distress tolerance, acceptance, and mindfulness chiefly originating with Buddhist and other Eastern meditative practices. Thus, its theoretical orientation to treatment is a blending of behavioural science, dialectical philosophy, and Zen practice (Miller et al, 2017). Here are the chief features which illustrate dialectics.

Characteristics

DBT is support-oriented. Rather than merely examine what is wrong, the processes help a person to identify her strengths and build on them so that she can feel better about herself and her life.

DBT is cognitive-based. In true CBT fashion, DBT helps clients identify thoughts, beliefs, and assumptions that are making life harder for them. Examples of these could be: “I have to be perfect or I’m worthless”, “I got angry, so I must be a terrible person”. DBT helps clients to replace these with more helpful thoughts and beliefs, ones which make life easier to bear: for example, “I’m quite competent at tennis, but I am still a beginner at negotiation skills” or “Anger is a natural, protective emotion, and most people experience it at some time.”

DBT is collaborative. The goal is to have the therapist as an ally rather than an adversary as the issues are worked through. Thus, the therapist aims to accept and validate the client’s feelings at any given time, BUT – and here is one of the dialectical aspects – the therapist does not shy away from showing the client how some feelings and behaviours are maladaptive and pointing out better alternatives. Thus, through such a tough-love stance, the therapist achieves the synthesis of two opposites, e.g.: “I accept you as you are” and “Changing some things can bring you higher quality of life.” Clients are encouraged to work out problems in their relationships with their therapist, and therapists are encouraged to do the same with them. Moreover, therapists are encouraged to support one another in supporting the BPD clients (Harvey & Rathbone, 2013; Miller et al, 2017).

High-quality therapeutic relationships are key. Along with (3), collaboration, a high-quality therapeutic alliance between the therapist and the client is key. The emphasis in DBT is on this being a genuinely human relationship, one in which the needs of both therapist and client are considered. Due to the nature of the BPD client population, burnout is a real risk for the therapist, and thus Linehan was keen to set up a team approach, where support was not an optional extra. So, clients get DBT from the therapist and therapists give DBT to each other. There are several assumptions that DBT therapists are asked to make in undertaking DBT work; these are crucial for success: 

  • That the client wants to change and is doing her best at any time to achieve this.
  • That her behaviour pattern is understandable given her background and present circumstances.
  • Despite (b), however, she needs to try harder if she wants life to improve. How her life has come about is not entirely her fault, but she is responsible for making things different.
  • Clients do not fail in DBT. If a client finds things are not improving, it is the treatment that is failing.
  • The therapist must avoid viewing or talking about the client in pejorative terms. Linehan stressed that the word “manipulative” needed to be avoided. While BPD clients can easily evoke in people a sense of being manipulated, Linehan stressed that this was not arguably the case, as “manipulation” connotes conscious control of circumstances, whereas BPD clients are more commonly simply unskilled at managing situations and asking directly for their needs to be met. 
  • There is an acknowledgement that an unconditional relationship between therapist and client is not humanly possible; if the client tries hard enough, she can make the therapist reject her. Thus, the therapist strives to make the limits as clear as possible from the outset, and it is therefore in the client’s interest to learn to treat the therapist in a way that encourages him or her to want to continue helping. It is not in her interests to burn out the therapist. This issue is confronted openly. 
  • The therapist is asked to take up a non-defensive stance regarding the therapy; “perfect” therapy isn’t possible, and therapists are fallible human beings, too. Mistakes will be made, and this must be accepted (Miller et al, 2017; Harvey & Rathbone, 2017). 

Dialectics in other therapies

Support and strength-finding

Most therapies would say that they support a client to find their strengths, but it may be a matter of emphasis, in that therapies such as positive psychology, narrative therapy, and solution-focused therapy actively seek out a person’s strengths, identifying them and basing action plans on them. For those therapies that place a strong emphasis on looking into the past as the key to the future, the option is change the emphasis, offering strengths-identifying and -developing a greater role in the total treatment.

Collaborative

Therapies such as motivational interviewing and some culturally based approaches fully comprehend that the client is the expert on their own life, yet the therapist has some expert insights and strategies that may be helpful. Thus, a jointly generated plan of action for both the sessions and the time in between them is most likely to be “owned” by the client and thus successful at creating change. The dialectical nature that emerges in collaboration can be seen as therapist knowledge (thesis) and client lived experience (antithesis) may produce greater insight and adaptive action (synthesis).

High-quality relationships

In the current era, we see few therapies that don’t claim relational quality as one of the highest priorities for treatment! But here, we stress the dialectical nature of assumptions made by DBT therapists. As noted above, these are constituted by stances such as that (1) the client is doing their best and they need to make changes if they want their quality of life to improve; (2) the client is very difficult, and they deserve to be spoken about respectfully; (3) Rogerian unconditional positive regard is a nice idea and it is possible for the client to behave in such as way as that the therapist cannot take it, and rejects the client; (4) the therapist is experienced and competent and they are human; they will make mistakes.

Perhaps the overall takeaway message we can glean from the amply-validated therapy of DBT is that we are our best selves as therapists and can bring out the best in our clients, no matter which theoretical approach we work with, if we can embrace the many opposites which naturally occur in the therapeutic process and find the “both-and”: the synthesis that brings all the work to a higher level of integration and effectiveness.

Key takeaways

  • Dialectics, a key foundational philosophy of dialectical behaviour therapy, proposes that the highest understandings of phenomena come about when both valences of opposites are considered, and new insights emerge from their synthesis.
  • Many BPD symptoms can be grouped dialectically, illustrating the need for a therapy for BPD and similar clients which takes into account their experience of swinging between emotionally-charged opposites; DBT was developed to do that, recognising the opposites and seeking their synthesis.
  • Many current therapies have elements of dialectics and therapists can be even more effective when those elements are explicitly recognised and emphasised.

References

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