An Illustration of Dialectical Behavior Therapy

MARSHA M. LINEHAN University of Washington

This article describes a form of behavior therapy called Dialectical Behavior Therapy (DBT), developed by Linehan for treatment of the seriously and chronically suicidal patient. The author describes the following characteristics of DBT: 1 theoretical perspective (dialectics, biosocial/behavior), 2 treatment stages and targets, and 3 treatment strategies, including dialectical strategies, core strategies (validation and problem-solving), change procedures (use of operant learning principles, skills training, and exposure/response prevention techniques from behavior therapy and cognitive modification techniques taken

primarily from rational-emotive therapy), communication strategies (irreverent and reciprocal communication), and casemanagement strategies (consultation to the patient, environmental intervention, supervision/consultation with therapists). Some aspects of DBT are represented in a case presentation together with transcripts of several sessions. © 1998 John Wiley & Sons, Inc. • borderline personality disorder • behavior therapy • suicide attempts • parasuicide • Zen IN SESSION: PSYCHOTHERAPY IN PRACTICE 4/2:21–44, 1998

Writing of this manuscript was partially supported by grant MH34486 from the National Institute on Mental Health, Bethesda, MD. The author thanks Kelly Koerner and Milton Brown for their editorial assistance. The commentary on the transcript is adapted from Linehan, M. M. & Kehrer, C. A. (1993). Borderline personality disorder. In D. H. Barlow (Ed.), Clinical Handbook of Psychological Disorders (2nd ed.). New York: Guilford Press, 396–441.

• Correspondence and requests for reprints should be sent to Marsha M. Linehan, Department of Psychology, Box 351525, University of Washington, Seattle, WA 98195-1525. In Session: Psychotherapy in Practice, Vol. 4, No. 2, pp. 21–44 (1998) © 1998 John Wiley & Sons, Inc. CCC 1077-2413/98/020021-24

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LINEHAN

Most psychotherapists and other mental health practitioners can expect to encounter clients meeting criteria for Borderline Personality Disorder (BPD) during the course of their professional careers. For a number of reasons, many practitioners approach this circumstance with trepidation and concern. Behavioral patterns that define BPD are particularly problematic and stressful for both clients and therapists (Gutheil, 1985a; Linehan, 1993a). From 70% to 75% of BPD clients have a history of at least one suicide attempt or other nonfatal self-injurious act (Clarkin et al., 1983; Cowdry et al., 1985). Parasuicide, defined as any intentional, acute, self-injurious behavior with or without suicidal intent, including both suicide attempts and self-mutilative behaviors, represents one of the most difficult and intractable problems faced by practicing clinicians. Suicide threats and crises are also frequent even among those who never engage in any overt suicidal behaviors. Besides nonfatal suicidal behaviors, BPD clients also pose a serious risk for fatal behavior; lifetime suicide rates are estimated at close to 10% (Frances et al., 1986; Paris et al., 1987; Stone et al., 1987). Difficulties with emotion regulation not infrequently lead to intense and out-ofcontrol emotional displays, often accompanied by impulsive and dysfunctional behaviors, including angry outbursts at the therapist or stopping activities important for progress (for example, dropping out of school, quitting work, refusing to selfmonitor or complete other homeworks assigned by the therapist), creating even more stress for the therapist. The activity frequently discontinued is therapy itself, often without warning. Even when clients remain in treatment, outcomes are unpredictable (Gunderson, 1984; McGlashan, 1987; McGlashan, 1986). In the face of such clinical stress, it is understandable that there is an enormous clinical and research literature on BPD. It is interesting, however, that with the exception of the approach discussed here, no psychotherapy approaches to date have demonstrated effectiveness in randomized clinical trials. Dialectical behavior therapy (DBT) attempts to resolve many of the problems associated with treating borderline clients by presenting a systematic, coherent approach to the understanding of the disorder and a treatment regime that is programmatic and comprehensive.

THEORETICAL PERSPECTIVE

DBT is based on a social behavioral conception of behavior best exemplified by Staats (1975). Behavior from this position and in the remainder of this article refers to any and all private and public, implicit and explicit, activities and responses of the individual, including emotional, physiological, cognitive, and overt-motor responses. The treatment draws from models of borderline behavior patterns that theorizes (1) BPD individuals lack important interpersonal, self-regulation (including emotional regulation), and distress-tolerance skills and capabilities; and (2) characteristics of the person and of the environment inhibit and/or block the use of capabilities the individual does have, interfere with the development of new skills and capacities, and often reinforce inappropriate and ineffective behaviors. DBT assumes that it is essential for the therapist to attend both to teaching new skills and enhancing capabilities as well as to improving motivation to use the skills and capabilities the client does have. A number of difficulties quickly emerge in applying standard treatments with the severely disordered BPD client: (1) Focusing on client change, either by im-

brief. for regulating emotions. and (5) borderline individuals’ behaviors often unwittingly reinforce therapists for iatrogenic treatment (for instance. it can be extremely useful to split therapy into several different components including ones that focus primarily on learning new skills (for example group or individual structured skills training). telephone contact with the individual therapist (addressing application of coping skills). quit trying. in community mental health settings it might be done by afterhours teams or crisis phone workers. (3) sufficient attention to motivational issues cannot be given in a treatment with the rigorous control of therapy agenda needed for skills training. . a hostile attack on the therapist. is often experienced as self invalidating by individuals meeting criteria for BPD and often precipitates either withdrawal from the therapist and therapy.g. including. a client may be silent in sessions if the therapist confronts their ineffective behavior or may respond with a drug overdose when the therapist refuses to recommend hospitalization stays that have been determined to be reinforcing suicide threats)—a state of affairs that can reduce the competency of an otherwise competent therapist. and peer consultation/supervision meetings (to treat the therapist). on motivational issues and coaching and reinforcing new skills (individual psychotherapy).Illustrations of DBT • 23 proving motivation or by enhancing skills. On a psychiatric inpatient or day treatment unit. First. are extraordinarily difficult to remember and apply when one is in a state of crisis. a client may stop attacking the therapist if the therapist changes the subject away from topics the client is afraid to discuss or if the therapist accedes to an unreasonable or demanding request) and punish them for effective treatment strategies (for example. strategies that more clearly reflect radical acceptance and validation of clients’ current capacities and behavioral functioning must be added to the treatment. Third. at times. individual psychotherapy (addressing motivational and skills strengthening). This dialectical emphasis brings together in DBT the “technologies of change” based both on principles of learning and crises theory and the “technologies of acceptance” (so to speak) drawn from principles of eastern Zen and western contemplative practices. or vacillation between the two modes of responding. and on application of skills to everyday life outside the treatment context (via phone and in vivo consultations). and experiencing rather than avoiding the moment) to the extent believed necessary is extraordinarily difficult if not impossible within the context of a therapy oriented to reducing the motivation to die.. and/or act in an out-of-control fashion. tolerating distress. the coaching might be done by the milieu. Three modifications in standard behavior therapy are useful to take these factors into account. Second. The dialectical emphasis in DBT ensures the balance of acceptance and change within the treatment as a whole and within each treatment interaction. (2) teaching and strengthening new skills (e. individual skills coaching session (in person or by phone) with one of the skills trainers may be added. The four modes in standard outpatient DBT are highly structured individual or group therapy (for skills training). early drop-out from treatment. such as mindfulness to the moment. (4) new behavioral coping skills. In DBT for substance abusers (and with other populations with a high incidence of social phobia and/or treatment avoidance). a consultation/team meeting focused specifically on keeping therapist motivated and within an effective treatment frame is important. making actual application of these skills to situations associated with high stress and negative emotions extraordinarily difficult without additional help. interacting with other people.

invalidating the other. especially neglect and physical and sexual assaults. Reducing high-risk suicidal behaviors (parasuicide acts. are comorbid for many disorders and the major goal is to simply get them in control of themselves and their lives. Reducing behavioral patterns serious enough to substantially interfere with any chance of a reasonable quality of life. phoning at unreasonable hours or otherwise pushing a therapist’s limits. In Stage I the hierarchy is as follows: 1. Although self-respect and self-trust are important throughout treatment. Many individuals are content with Stage III functioning. chronically losing relationships or jobs). missing or coming late to sessions. In Stage III. and the movement into flow or peak experiencing (cf. places. interpersonal effectiveness. Learning sufficient life skills to meet client goals (skills in emotion regulation. 1970). distress tolerance. Individuals in Stage I have multiple problems. 4. connection to helping individuals. and participate in a manner that is nonjudgmental. it doesn’t make much difference how potentially effective the treatment is. blocking suicide). they become central at this point. or activities associated with childhood traumatic events. discussion topics. In Stage I. including a reasonable immediate life expectancy (for example. are hierarchically arranged in order of importance. (that is. or in vivo activities) to events. places. imagery. the therapist can move to focused exposure (via recall. the clients have mostly done the work necessary in earlier stages and are now at the stage of addressing residual problematic patterns that interfere with achieving their other important goals. including suicide attempt. An important focus of treatment in this stage is to understand and reduce the sequelae of early trauma. Treatment goals and session agenda in DBT depend on stage of treatment and. effective. 3. Here the tasks are expanded awareness. With behavior under control. and experiential of the present moment). then . however. the clients have action under reasonable control. If you can’t keep the client alive. role plays. self-management. high-risk suicidal ideation. within stage. noncompliance. With respect to each goal. Maslow. In Stage II. Treatment needs and capabilities here are different than in Stage I. including patterns that put clients in a high-risk group for suicidal behaviors (severe depression and other Axis I disorders would qualify here. and activities (such as work). All of the research to date has been on Stage I and the case illustration described below is also Stage I. 1997). plans and threats). the tasks of treatment are to achieve reasonable self-control. not returning phone calls or otherwise pushing a client’s limits). or avoiding topics during sessions. have a residual sense of incompleteness.24 • LINEHAN TREATMENT STAGES AND TARGETS Treatment in DBT is conceptualized as occurring in stages. stability and control of action. Reducing both client and therapist behaviors that interfere with the therapy (for instance. and basic capabilities needed to achieve these tasks. with each stage having its own outcome goals (Linehan. as well as mindfulness. Most. are connected to treatment and are focusing on their ability to experience emotions without trauma and to form and maintain connections to people. the ability to observe. persons. the task of the therapist is first—and many times thereafter—to elicit the client’s collaboration in working on the relevant behavior. also homelessness. its resolution and achievement of a capacity for sustained joy are the goals of Stage IV. describe. spiritual fulfillment. 2.

it is the relationship itself that may hold the client in this life. when all else fails. 1993a. including psychotropic medication management. In times of crisis. formulating hypotheses about possible factors influencing the problem. especially as they relate to the individual’s vulnerabilities and sense of desperation. as well. It also shares elements in common with psychodynamic. progress through the hierarchy of goals is an iterative process over time. the . Dialectical Strategies Dialectical strategies are woven throughout all treatment interactions. Treatment strategies are divided into five sets: 1. supervision/consultation with therapists). TREATMENT STRATEGIES DBT addresses all problematic client behaviors and therapy situations in a systematic. and urges taking precedence over all other topics. case management strategies (consultation to the patient. treatment is oriented to current behaviors. a number of specific behavioral treatment protocols covering suicidal behavior. and trying out and evaluating the solutions. Linehan. environmental intervention. 1987). planning. core strategies (validation and problem solving). relationship problem solving.. crisis management.Illustrations of DBT • 25 to apply the appropriate treatment strategies described below. from the rapid juxtaposition of change and acceptance techniques to the therapist’s use of both irreverent and warmly responsive communication styles. The treatment itself integrates cognitive-behavioral interventions with eastern Zen and western contemplative practices and teaching techniques. generating possible changes (behavioral solutions). ordinarily involving direct and focused work on the behaviors relevant to the goals. client-centered. and exposure/response prevention techniques from behavior therapy and cognitive modification techniques taken primarily from rational-emotive therapy). Attention to each goal within individual therapy. with parasuicidal acts and life-threatening suicidal ideation. The context for these analyses and this solution-oriented approach is that of validation of each client’s experiences. In contrast to many behavioral approaches. dialectical strategies. These are more fully described in the treatment manuals (Linehan. 4. 2. The primary dialectical strategy is the balanced therapeutic stance described above. problem-solving manner that interweaves conducting a collaborative behavioral analysis. is jointly determined by the hierarchical list above and by the behaviors and problems that have surfaced since the last session and/or during the current session. skills training. Treatment strategies are divided into those most related to acceptance and those most related to change. DBT places great emphasis on the therapeutic relationship. There are. Thus. and ancillary treatment issues. paradoxical and strategic approaches (cf. 5. at least as described in print. 1993b). gestalt. change procedures (use of operant learning principles. Thus. therapy-interfering behavior and compliance issues. communication strategies (irreverent and reciprocal communication). Soloff et al. Because therapeutic change is usually not linear. DBT requires that the therapist balance use of these two types of strategies within each treatment interaction. 3.

and then assisting the client to create new orderings that embrace and include what was previously excluded. it is reasonable to not completely trust someone you have just met. Articulating or “mind-reading” that which is unstated. evaluate.26 • LINEHAN constant attention to combining acceptance with change is the very essence of the dialectical strategy. and believing in the individual no matter what. 1967. recognize. As can be seen. and implement alternative solutions that might have been made or could be made in the future in similar problematic situations. Validating the client in terms of present and normal functioning (for instance. and reflect the current validity. both in therapy and the client’s life. experiential knowledge bases. The therapist helps the client move from “either-or” to “both-and. sexual abuse. the therapist does not treat clients as fragile or unable to solve problems. Validation is required in every interaction and is used at any one of six levels: Level 1.” This aspect of validation is best described by Rogers in his discussion of genuineness in the therapeutic relationship (see Rogers & Truax. and so forth) or in terms of a disease or brain-disorder model. Problem-solving is a two-stage process involving. The goal is to bring out the opposites. Thus. are important parts of validation. emotions. and paradox. focusing on the strengths of the individual. Radical genuineness with clients. metaphor. physiological responses. being one’s genuine self within the therapeutic relationship. and reinforcement for use of intuitive.. Reflection. an attempt to generate. and seeing the person as an equal individual rather than through the guise of “client. myth. meeting the client on a person-to-person basis. the therapeutic use of ambiguity. 101). Level 5. paraphrasing. Level 2. i.” Strategies include extensive use of stories. drawing of the client’s attention to the fact of reality as constant change as well as the embracing of change in the therapeutic conditions. thoughts and . second. an analysis and acceptance of the problem at hand and. Analyses of the client’s problem behaviors. summarizing.e. Validating the client’s experience in terms of past experiences (for example. Level 3. p. validating is not simply building up self-esteem—although cheerleading. Level 6. maladaptive modeling. Validation requires the therapist to search for. Listening to the client with interest. The key idea guiding the therapist’s behavior is that for any point. and to provide conditions for syntheses. but without pushing the interpretation on the client. including dysfunctional actions. cognitive challenging and restructuring techniques. and so on). high emotional arousal disorganizes cognitive functioning in all people. In line with this latter prescription of the treatment. Level 4. first. invalidating families. an opposite position can be held. such as fears of admitting emotions or thoughts. Core Strategies Core strategies consist of the balanced application of validation and problem-solving strategies. or sensibility. of the individual’s response. synthesis and growth require a continuous search for what is being left out in both the therapist’s and client’s current ordering of reality.

serious suicide threats. The idea here is that severely suicidal individuals should not be treated alone. Communication Strategies In DBT. interpretation and implicit assumptions. from the client’s current pattern of response. or advising) and/or work on motivation and strengthening of skills the individual already has via both reinforcing more adaptive functioning (and extinguishing or responding aversively to dysfunctional responses). The modal style is the reciprocal strategy. At each link in the chain of events leading from a precipitating situation to a suicidal response. and changing thoughts and implicit assumptions and beliefs that lead to dysfunctional behaviors. The strategy is the application of the principle that the DBT therapist teaches the client how to interact effectively with the client’s environment. emotions. which is characterized by a matter-of-fact attitude. which is actually interwoven with the first. The consultation/supervision strategy requires that each DBT therapist meet regularly with a supervisor or consultation team. or emotion. thoughts. Case Management Strategies There are three Case Management Strategies designed to guide each therapist during interactions with individuals outside the therapy dyad. as well as an analysis of the individual’s response capabilities. requires the generation of alternate responses (that is. which includes responsiveness to the client’s agenda and wishes. suggesting. more adaptive response that might have been made. sensations. parasuicide. This process often leads into brief teaching of new coping skills (for example. The second stage. rather than teaching the environment how to interact with the client. The consultant-to-the-client strategy is a simple concept but very hard to carry out. and self-disclosure of both personal information that might be useful to the client as well as immediate reactions to the client’s behavior. adaptive solutions to the problem). Also involved is the highlighting of consequences in the natural environment for both effective and ineffective behaviors. increase in suicidal ideation) until both therapist and client achieves an understanding of the response patterns involved. warmth. The essence of the strategy is that it “jumps track. and feelings. the chains of events (both responses of the individual and events in the environment) are examined for patterns and clues to information about factors that influence the problematic responses. The strategy of examining in extremely fine and sequential detail the individual’s reactions to events and their effects and transactions with the environment over time is repeated for every instance of targeted problem behaviors (for example. thought. This strategy represents a point of view that looks at adversity and “bad” treatment of the client . Over time. the therapist balances two communication strategies that represent rather different interpersonal styles.” so to speak. modeling. actions and action urges that follow each other linkby-link leading up to and following the particular problematic response at hand. where the therapist takes the client’s underlying assumptions or unnoticed implications of the client’s behavior and maximizes or minimizes them. Reciprocity is balanced by an irreverent communication style.Illustrations of DBT • 27 ways of processing information requires a very detailed chain analysis of the specific environmental events. therapeutic exposure to reduce emotions inhibiting more adaptive behavior. in either an unemotional or overemotional manner to make a point the client might not have considered before. the therapist engages the client in looking for an alternate.

that’s understandable. THERAPIST : So. . I guess I am. So what I’d like to do is talk a little bit about the program and how you got here. the dialectical technique of devil’s advocate can be effective when used as a commitment strategy. Obtaining the client’s commitment is a crucial first step in this endeavor. I begin by orienting the client to the purpose of this initial session. with all its problems and inequities. the therapist actively intervenes in the environment to protect the client or to modify situations that the client does not have the power to influence. problem solving (insight. When absolutely necessary. For the next fifty minutes or so we have this opportunity to get to know each other and see if we want to work together. Session goal: Orienting and commitment Strategies: Validation. These particular dialogues are chosen to provide the reader with examples of the application of a range of DBT treatment strategies for dealing with such issues as orienting clients to the therapy and getting their commitment. I don’t know. In the first therapy session with a suicidal client. however. In each dialogue I note the specific goals of the interaction and then list the specific DBT strategies illustrated in the dialogue that attempt to achieve these goals. it views the role of the therapist as teaching the client to live in the world as it is. .28 • LINEHAN by the environment (including other professional helpers) as an opportunity for practice and learning. orienting and commitment). THERAPIST : Well. The following is a first session with a client following a referral from her pharmacotherapist and an initial meeting with the client and her family following her discharge from an inpatient psychiatric unit. dealing with suicidal behavior. integrated (relationship enhancement). I’m just a mess. From another perspective. (pause) So tell me. what do you want out of therapy with me and what are you doing here? CLIENT : I want to get better. are you a little nervous about me? CLIENT : Yeah. I don’t know how to deal with anything. THERAPIST : Well. dialectical (devil’s advocate). and helping clients regulate their emotions and improve their interpersonal effectiveness. what’s wrong with you? CLIENT : I’m a mess (laughs). As illustrated in the following transcript. the most important therapy focus is to keep the client alive until the next session and to stop intentional self-injury and suicide attempts. And I can’t even . THERAPIST : How so? CLIENT : Um. . ILLUSTRATIVE TRANSCRIPTS The following three (composite) transcripts represent actual examples of the process of therapy that transpired over several sessions with different clients. I just can’t even cope with everyday life right now.

But. and you know. I use my lighter or cigarettes. You know. well. I’m sick of it. I still have a tendency toward that. Maybe. I haven’t thought about it that way. though. you know. So what is it exactly that you want out of therapy with me? To quit harming yourself. Sometimes I take pills.Illustrations of DBT THERAPIST : CLIENT : • 29 So. or I know I shouldn’t eat something and I do it anyway. And is there anything else you want help with? CLIENT : THERAPIST : CLIENT : Um. So it sounds like part of the problem is you actually know how to do things. everything I try these days just seems overwhelming. I’m a former alcoholic and a recovering anorexic/bulemic. by all means. or both? Both. I’m not the greatest guesser. I just feel that I don’t know how to handle myself. Hmmm. And I think my psychiatrist wants to send me away because of all my self-harming and trying to kill myself. it’s like sometimes I know it. How often do you self-harm? Maybe once or twice a month. and a lot of it is I do know how but for some reason I don’t do it anyway. Do you think maybe some of what is going on with you is that you’ve replaced your alcoholic and anorexic behaviors with self-harm behaviors? I don’t know. Exactly. I mean I know I need to save money and I know that I need to budget myself and I do every single month but every single month I get in debt. I couldn’t keep up on my job and now I’m on medical leave. you just don’t know how to get yourself to do the things you know how to do. well. and that is obviously getting to me because if it wasn’t I wouldn’t be trying to kill myself. Do things just not enter your mind very often? So maybe with you I’m going to have to be a very good guesser. I don’t really know. So we’ll have to teach you how to have things come to mind. it’s really hard for me. THERAPIST : CLIENT : THERAPIST : CLIENT : THERAPIST : CLIENT : THERAPIST : CLIENT : THERAPIST : Unfortunately. Uh huh. what does that mean exactly? Um. I don’t know how to handle money and I don’t know how to handle relationships. quit trying to kill yourself. I don’t have friends. sometimes a razor blade. Your psychiatrist tells me you’ve also drunk Clorox. um. Yeah. Plus everyone’s sick of me being in the hospital so much. A lot of things. they don’t connect with me very often. THERAPIST : CLIENT : THERAPIST : CLIENT : THERAPIST : CLIENT : THERAPIST : CLIENT : . from your perspective one problem is that you don’t know how to do things. So. you know. Why didn’t you mention that? I guess it didn’t enter my mind. and I guess work through stuff.

and then when I’m in the mood I go back to being a mess again. Because I can’t survive that way if I don’t. the fact that it makes horrible things happen in your life so far hasn’t been enough of a motivation to get you to do things against your mood. because it’s not happening. right? Well. THERAPIST : That of course is going to be hell to do. I then in the next section begin to shape a commitment using the dialectical strategy of devil’s advocate. that you are a person who does things when you’re in the mood? Yes. this is going to be a big problem. But it still doesn’t seem to matter because if I’m not in the mood to clean it. Doesn’t that tell you though. I mean. I mean just immaculate. I can’t deal with all this. because when I’m. like with budgeting money. So one of the tasks for you and me would be to figure out a way to get your behavior and what you do less hooked up with how you feel. And now I’ve got collection agencies on my back. magic wand. . I know I need to do it and then when I don’t do it makes me even more upset. So you’re a moody person.” and then all of a sudden you’re going to want to do things that you’re not in the mood for. Right. THERAPIST : CLIENT : In the above dialogue. I want to do it because it’s so inconsistent. Yeah. but I can’t afford to live if I just spend money on fun and stupid frivolous things that I . It’s not like you’re going to walk in here and I’m going to say. I won’t clean the house for two months and then I’ll get in the mood to clean and then I’ll clean it immaculately and keep it that way for three weeks. Everything’s done by the mood. And then I just want to end it all. and I end up self-harming and going into the hospital. I know that. don’t you think? Why would you want to do that? It sounds so painful. you know. like I’ve lost bills before and then I end up not paying them. Well. Because I’ve got to. or whatever. The use of devil’s advocate in this case is to get the client to construct arguments against her own dysfunctional urges and behavior. why clean the house if you’re not in the mood? Because it pisses me off when it’s a mess. obviously not (laughs). So. I won’t. “OK. The approach is based on the effectiveness of counterattitudinal writing and speaking as a method of attitude change. . CLIENT : THERAPIST : CLIENT : Yes. Well. but in general. It’s worse. CLIENT : THERAPIST : CLIENT : THERAPIST : CLIENT : Yeah. And I can’t find things. I guess maybe you should have some limits and not be too off the wall. Why would you ever want to do something you’re not in the mood for? Sounds like a pretty easy life to me.30 • LINEHAN THERAPIST : Does it seem like maybe your emotions are in control. I use insight to highlight observed interrelationship between the client’s emotions and her behavior. THERAPIST : CLIENT : THERAPIST : CLIENT : THERAPIST : CLIENT : . don’t you think? This isn’t going to be something simple.

but I really am. as problem-solving behavior. THERAPIST : Well. giving up self-harm behavior is usually very hard. burning. the question is. Now I figure that’s the question. in my experience. yeah. that’s good. THERAPIST : Are you sure? CLIENT : Yeah. The way we look at it. in other words. But it only works in the short term. but you will have to work harder. THERAPIST : Well. I think of alcoholism the same way. THERAPIST : So you’ve agreed to not drop out of therapy for a year. but why not now? CLIENT : Because. THERAPIST : OK. including drinking Clorox. yeah. That’s why I’m here. not the long term. But we are a life-enhancement program. As illustrated by the foregoing segment. And like I told you when we talked last week. all things being equal. So quitting cutting. Individual therapy with me once a week. that’s a very tough thing to crack. this is my last hope. right? . I’ve been going through this since I was eleven years old. and I’m backed up against the wall. living a miserable life is no achievement. that’s going to be your strength. THERAPIST : Uh huh. if you’re kind of mood dependent. So. are you willing to commit for one year? CLIENT : I said I’m sick of this stuff. if you commit to this it’s for one year. I think it’s one of the hardest problems there is to deal with. the most important thing to understand is that we are not a suicide-prevention program. You’re going to have to remember that when it gets tough. why not die? CLIENT : Well. Those are my two choices. if it’s going to make me happier. CLIENT : Well. and group-skills training once a week. CLIENT : Yeah. that’s not our job. THERAPIST : Now. If it didn’t work. I then “up the ante” with a brief explanation of the program and its goals. excuse my language. great. CLIENT : If I can pull it off.) THERAPIST : I think we could deal with it but I think it’s going to be hell. (Looks down and slumps. Either I need to do this or I need to die. nobody would do it more than once. use of devil’s advocate has achieved “the foot in the door” and an initial client commitment. so it seems to me that if you’re not in the mood for things. If we decide to work together I’m going to help you try to improve your life so that it’s so good that you don’t want to die or hurt yourself. We’re going to play to that. I’m sick of this shit. Because if I’ve got one last hope left. why not take it? THERAPIST : So. if you can pull this off. Do you think this is going to be hard? CLIENT : Stopping drinking wasn’t all that hard. I mean. it works. It will require both of us working. But now I want to tell you about this program and how I feel about you harming yourself and then we’ll see if you still want to do this. is going to be exactly like quitting alcohol. The only difference is that cutting.Illustrations of DBT THERAPIST : • 31 Yeah. The real question is whether you’re willing to go through hell to get where you want to get or not. trying to hurt yourself. As a matter of fact. if it comes down to it I will. unfortunately. You should also know that I look at suicidal behavior. you’d rather live than die.

not really. meaningfully of course. whether you agree to that. THERAPIST : So . yeah. THERAPIST : So that’s what I see as our number-one priority. . you won’t kill yourself. I agree to that. Sensing when the client has been pushed to her limits is an important validation strategy. I mean. At this point. CLIENT : All right. you could? CLIENT : I don’t know. I just . And getting you to agree. CLIENT : Yes. that really does. because this therapy won’t work if you knock yourself off. just now? CLIENT : (Pause) . by me? CLIENT : No. I have obtained the client’s commitment to work on suicidal behavior. I want to be able to get to the point where I could feel like I’m not being forced into living. To have her enhance the strength of the commitment. Consequently I step back and move in with validation. I mean. I don’t think I really want to kill myself. rule out suicide for a year? CLIENT : Logically. that we will work on that. . are you agreeing with me because you’re feeling forced into agreeing? CLIENT : You keep asking me all these questions. I again employ the strategy of devil’s advocate. THERAPIST : I mean. no matter what your mood is. (Client starts to cry) THERAPIST : What just happened . if you think about it. Stepping back and at least temporarily refraining from further pressuring is an example of a response that. Now the question is.32 • LINEHAN Right. THERAPIST : So. . THERAPIST : Hmmm. THERAPIST : Why would you agree to that? CLIENT : I don’t know (laughs). although it may not verbally validate. not our only one but our number one. continued pressure is likely to boomerang and have the opposite effect of what I intend. Here I notice the client’s confusion. or try to. In instances such as this. . I think I just feel like I have to. THERAPIST : What do you think? CLIENT : I don’t know what I think right now. The most fundamental mood related goal we have to work on is that. wouldn’t you rather be in a therapy where if you wanted to kill yourself. THERAPIST : And you do realize that if you don’t drop out for a year. I never really thought about it that way. . honestly. we need to be absolutely clear about this. CLIENT : I don’t want to . and actually following through on staying alive and not harming yourself and not attempting suicide no matter what your mood is. . THERAPIST : CLIENT : So you’re feeling pushed up against the wall a little bit.I don’t know. functions to communicate that the client’s response or communication is valid. I don’t think it’s really even a mood thing.

you know there’s no other choice. I mean. CLIENT : Just overwhelmed.” CLIENT : I don’t want to back out. I mean I know it’s good. a new program. I think we can be successful working together. trying to kill yourself doesn’t usually solve problems. session goal: Reduce suicidal behavior strategies: Validation. making lemonade out of lemons). THERAPIST : And so. I have reviewed the client’s diary card and note a recent parasuicide in which the client opened up a previously self-inflicted tendon tear following her physician’s refusal to provide pain medication. And so. “Well. I end this part of the session by preparing the client for the difficulties she is likely to experience in keeping her commitment and working in therapy. it actually did do one thing for you. But we’re going to work on how to make it keep sounding like a good idea. OK? CLIENT : Uh huh. but I don’t see anything any better than it was the day I tried to kill myself. I just want to say that this seems like a good idea right now. Although. Good. dialectical (metaphor. But in five hours it might not seem like such a good idea. “Yes. skills training (distress tolerance). I just say. behavioral and solution analysis). that’s probably true. getting started. so do it. Cheerleading. THERAPIST : OK. Following getting a description of exactly what further harm the client . Maybe it isn’t any better. which I guess is good. Because I’m going to take you seriously if you say. I guess the word is. So my asking you all these questions makes you start to cry. to try to structure our relationship so that it’s very clear for both of us. but I have confidence. a validation strategy. THERAPIST : That’s part of the reason we’re having this conversation. and how hard this is because if you want to back out. THERAPIST : Well. and relationship enhancement lay the foundation for a strong therapeutic alliance. I just want to be clear on what our number one goal is. at least.” You know. right now I don’t see any ray of hope. I’m going to therapy. And that way. I want to do it. A standard assessment of imminent suicide risk is done before ending the session. stylistic (irreverent communication). we’ll try to cut down on how much you get overwhelmed by not knowing what’s going on with me. problem solving (clarifying consequences of behavior. You look like you must be feeling pretty bad.Illustrations of DBT • 33 think it’s when I feel like there’s no other choice. The following session occurs approximately four months into therapy with a woman who has made approximately five almost-lethal suicide attempts as well as many medically serious but not suicidal self-mutilations. Now. didactic. It’s kind of like it’s easy to commit to a diet after a big meal. You’re in kind of an energized mood today. CLIENT : It got me in therapy. It’ll be hell. but much harder when you’re hungry. now’s the time. THERAPIST : Yeah.

I begin with a detailed analysis of the factors influencing the client’s self-harm. The specification of an initial prompting environment event is always the first step in conducting an analysis of the chain of events that lead to the problematic behavior. THERAPIST : They just come at the identical moment? CLIENT : Just about. Here I begin by directly inquiring when the urges to parasuicide began. they would actually give you the pain killers? CLIENT : Yes. So is it that you’re assuming that if someone believed it hurt as bad as you said it does. Now. So let’s figure out how that broke down on Sunday so we can learn something from it. So when did you start having urges to hurt yourself? CLIENT : My foot began to hurt on Wednesday. and I got madder and madder and madder. Here it has become apparent that maladaptive thinking has been instrumental in the client’s decision to self-harm. and I even wrote it in my journal. So I felt like I had to show somebody that it hurts because they didn’t believe me. . THERAPIST : OK. You were in here last week telling me you were never going to hurt yourself again because this was so ridiculous. I’m in a lot of pain you know. But no! So I kept asking. maybe it wasn’t till Thursday. when did you start having the pain and when did the urge to harm yourself come? CLIENT : At the same time. THERAPIST : So the nerves were dead before that or something. And the nurse tried. Now. look. That’s where the faulty thinking is. I’m throwing up my food because the pain is so bad. and asked if he’d give me some painkillers. You see.34 • LINEHAN had done to her leg. THERAPIST : So let’s figure this out. I have proceeded by beginning to obtain a description of the events concurrent with the onset of the problem. but I asked my nurse. In the following segment I use the dialectical strategy of metaphor to highlight for the client her faculty thinking. THERAPIST : So how is it that feeling pain sets off an urge to parasuicide? Do you know how that goes? How you get from one to the other? CLIENT : I don’t know. THERAPIST : OK. She called the doctor and told him I was in a lot of pain. and the answer kept being no. huh? So you started having a lot of pain. you couldn’t stand it. That’s the problem. OK. I started to have a lot of pain THERAPIST : It hadn’t hurt before that? CLIENT : No. it’s entirely possible that people know how bad the pain is. you couldn’t hurt yourself any more. that if I’d gotten pain medication when I really needed it I wouldn’t have even thought of self-harming. I go. CLIENT : I believe firmly. but still aren’t giving you medication.

It’s someone not giving you something to help. if there’s no one in the room you eventually quit trying to talk to them. becoming also slightly irreverent. CLIENT : Why? THERAPIST : Because if you were sitting over here I think you would see that. I clarified the factors precipitating urges to harm by pointing out to the client the effects of other’s responses on the client’s own behavior. THERAPIST : I’m considering switching chairs with you. OK? So what we have to do is figure out a way for the communication behavior to quit working. And we’re on this raft together and your leg really hurts and you ask me for pain medicine and I say no. The pain is not what’s setting off the desire to self-harm. you quit talking. You’ve got to imagine this. CLIENT : I tried three nights in a row in a perfectly assertive way and just clearly stated I was in a lot of pain. And when the boat sunk your leg got cut really badly.Illustrations of DBT THERAPIST : • 35 Now. “Here. OK? Let’s imagine that you and I are on a raft together out in the middle of the ocean. But we don’t have any pain medicine. THERAPIST : You know. “No. no matter how bad the pain is. It’s like when a phone goes dead. Our boat has sunk and we’re on the raft. now can you tell that it hurts a lot?” THERAPIST : I’m thinking of switching chairs with you. hurting yourself is communication behavior. so in other words. Let me ask you something. THERAPIST : OK. THERAPIST : What if I said no because I didn’t want you to be a drug addict? CLIENT : I’d want to hurt myself. when you feel they could if they wanted to. Do you think you would then have an urge to hurt yourself and make it worse? CLIENT : No. CLIENT : Why? THERAPIST: Because you’re not going to stop doing it until it quits working. THERAPIST : OK. it would be a different situation. what do you think? CLIENT : If that were logical to me I’d go along with it and wouldn’t want to hurt myself. So we’ve got this clear. but if I did have the pain medication and I said no because we have to save it. THERAPIST : OK. CLIENT : Yes. You’re not hearing what I’m saying. I think I’ll switch chairs with you. The hospital staff may not have been reasonable either.” and then some little light came on in my head. It may be that they should have given you pain medicine. And together we’ve wrapped it up as well as we can. It’s like trying to talk to someone. CLIENT : And it was like. But we don’t have to say . In the following segment. I continue to highlight the communication function of parasuicide. CLIENT : And they kept saying. hurting yourself to get pain medication is not a reasonable response.

Did the urges start building after Wednesday and get worse over time? CLIENT : Yeah. borderline clients often want to remain focused on the crisis at hand. OK. THERAPIST : With the pain. So you were thinking that if you hurt yourself they would somehow give you pain medicine? CLIENT : Yeah. I know you did. This segment also illustrates how validation does not necessarily imply agreement. we’ve got to figure out how you could have gotten through without hurting yourself. I want to know everything you tried. CLIENT : I tried some of those distress-tolerance things and they didn’t work. no matter what’s going on. Cause if they wouldn’t listen to me then I could show them.36 • LINEHAN they were wrong in order to say that hurting yourself was not the appropriate response. This poses a formidable challenge for the therapist. CLIENT : Yes we are. And of course it would be good to get other things to work. CLIENT : A lady down the hallway from me was getting treatment for her diabetes and it got real bad and they gave her pain medication. even if you don’t get pain medicine. I know you did. who must necessarily engage in a back-and-forth dance between validating the client’s pain and pushing for behavioral change. CLIENT : No. As illustrated by the foregoing exchange. OK. What you’re arguing is “Well. she remains steadfast in maintaining the inappropriateness of the client’s response. we’ll figure out a way. hurting yourself is something we don’t want to happen. I’m not talking about that.” CLIENT : I tried this time! THERAPIST : Yes. I don’t think it was the appropriate response. But first I want to be sure I have the picture clear. . THERAPIST : Good. so you were thinking. we’re not on the same wavelength in this conversation. So far it has worked very effectively as communication.” And when did that idea first hit? Was that on Wednesday? THERAPIST : CLIENT : Yeah. Don’t worry. So what we’ve got to do is figure out a way to get it so that the response doesn’t come in. Although the therapist validates the client’s perception that the refusal to provide pain medication may have been unreasonable. “If they won’t listen to me I’ll show them. And the only way to stop it is to get it to not work anymore. Even if they should have. if I’m not going to get it this way then I should be able to get it another way. CLIENT : Hmmm? THERAPIST : You’re talking about whether they should have given you pain medication or not. But also they started growing with their continued refusal to give you pain medicine. What wavelength are you on? THERAPIST : I’m on the wavelength that it may have been reasonable for you to get pain medicine. You’re functioning like if I agreed with you that you should get pain medication I would think this was OK. THERAPIST : Now. THERAPIST : OK. and I certainly understand your wanting it. OK. They started growing with the pain. But I’m also saying that.

attempted to use some coping skills. THERAPIST : Um hmmm. Well. and it would normally be premature to move to the stage of solution analysis. OK.Illustrations of DBT THERAPIST : • 37 OK. THERAPIST : And what did they have to say? CLIENT : They said I should get pain medication. THERAPIST : That’s good thinking. So let’s figure out all the things you tried. And you just give yourself up to that situation. that you’re going to have to cope in some other way. use coping skills. So what was the first thing you tried? At this juncture the understanding of the factors that contributed to the client’s problematic behavior remains incomplete. So you keep up the good fight here. CLIENT : I thought that if I just continued to be assertive about it that the appropriate measures would be taken. Now what else did you try? CLIENT : I tried talking about it with other patients. in fact. However. we’ve got to figure out a way to tolerate bad things without harming yourself. I needed a little Ativan to get me there but I got there. THERAPIST : Right. CLIENT : Which I did yesterday. And I tried to get my mind off my pain by playing music and using mindfulness. But did they say you should cut yourself or hurt yourself if you didn’t get it? CLIENT : No. in my judgment it is more critical at this point to reinforce the client’s attempts at distress tolerance by responding to the client’s communication that she. Note in the following response how I immediately reinforce the client’s efforts with praise. that if I make it worse I’ll feel worse? CLIENT : Yeah. . One aspect of DBT skills training stresses the usefulness of evaluating the pros and cons of tolerating distress as a crisis-survival strategy. That’s when you’re thinking about the advantages and disadvantages of doing it. and then we have to figure out some other things because those didn’t work. in fact. So why didn’t you harm yourself right then? CLIENT : I didn’t want to. Here I use the dialectical strategy of turning lemons into lemonade by highlighting for the client how she did. I tried to read and do crossword puzzles. but that didn’t work. THERAPIST : OK. THERAPIST : Why didn’t you want to? CLIENT : I didn’t want to make it worse. OK. Did you try radical acceptance? CLIENT : What’s that? THERAPIST : It’s where you sort of let go and accept the fact that you’re not going to get the pain medication. THERAPIST : So you were thinking about pros and cons. so at that point the advantages of making it worse were outweighed by the disadvantages. You just accept that it ain’t going to happen.

or unacceptable. that’s like a suicide threat. a great thing to practice. THERAPIST : That’s good. When push comes to shove. they’re not going to change. So let’s figure out Sunday and see if there wasn’t an interpersonal situation on that day that made you feel criticized. radical acceptance is the skill to practice. Usually with you we can assume that something else happened. THERAPIST : OK. I’m still very angry about that. That’s a great skill. when you’re really at the limit. so you’ve just got to deal with this the best that you can.” THERAPIST : And did that acceptance help some? CLIENT : I’m still quite angry about what I believe is discrimination against borderline personalities. During a solution analysis it is often necessary to facilitate the process by helping the client brainstorm or by making direct suggestions for handling future crises. that’s better than a suicide threat because that means you had moved your threats down. Did it help though. THERAPIST : So you figured that should have done it? CLIENT : Yeah. I want you to know. Here I suggest a solution that is also taught in the DBT skills-training module on distress tolerance. you were in a lot of pain. I went looking all around the neighborhood for an open store. When I woke up I basically said. THERAPIST : OK. That’s great. THERAPIST : So you got the idea of getting alcohol to cure it. which may temporarily loosen a client’s maladaptive beliefs and assumptions and open up the client to the possibility of other response solutions. CLIENT : And I just told her how I was feeling about it. that’s how bad my pain is. I took a nap. And that wasn’t listened to.38 • LINEHAN THERAPIST : Yesterday? CLIENT : Yeah. The above response is very irreverent in that most clients would not expect their therapist to view making a threat as a sign of therapeutic progress. right? OK. The notion of radical acceptance stresses the idea that acceptance of one’s pain is a necessary prerequisite for ending emotional suffering. And it got on my brain how alcohol would steal away my pain. Because you really managed to battle all the way till then. CLIENT : Well. CLIENT : That’s AA [Alcoholics Anonymous]. unloved. to accept. That’s fine. and then what happened? CLIENT : I told the nurse I’ve been sober almost ten years and this is the first urge I’ve had to drink. The therapeutic utility of irreverence is often in its shock value. when it’s the worst it can be. and you couldn’t find any so you went back to the hospital. CLIENT : Um hmmm. But I couldn’t find a store that was open so I went back to the hospital. I was going to go get drunk. “Hey. . And the doctor still wouldn’t budge. on Saturday I was so pissed off and I went to an AA meeting. Now let’s go back to how did you give in to the urge. That’s how much my pain was influencing me. Very good though. Cause that’s a high level communication. THERAPIST : Yeah. and I thought that would do it.

instead of like going to sleep? . So how did you get from crying. THERAPIST : They don’t? Do you think that would have helped? CLIENT : I don’t know. Makes complete sense. CLIENT : Because I ended up hugging my teddy bear and just crying for a while. So you must have been ruminating while you were lying there.” THERAPIST : Then did you feel anger? CLIENT : I don’t know if I was really angry. notated with possible alternative pathways. THERAPIST : Before or after you decided to hurt yourself? CLIENT : Before. THERAPIST : OK. You were thinking about it. Here I am searching for junctures in the map where possible alternative responses are available to the client. . THERAPIST : OK. OK. But when did you decide to do it? CLIENT : Later on Saturday. hold your hand? An overall goal of this very detailed analysis is the construction of a general roadmap of how the client arrives at dysfunctional responses. and unlovable. abandoned probably. What would have happened if you had asked the nurse to come in and talk to you. or did getting angry make you stop crying? CLIENT : I think getting angry made me stop crying. feeling uncared about and hurt. That would have been a caring thing to do.Illustrations of DBT THERAPIST : • 39 So what did she do? Did she say she would call? CLIENT : She called. . THERAPIST : Oh really? Oh. So you were hurt . she was really sweet and she just said. but the doctor said no. THERAPIST : That’s a really adaptive response. CLIENT : Because then I got angry. but I was hurt. What were you thinking about? CLIENT : For a long time I was just wanting somebody to come care about me. Except that you’ve already done it without my teaching it to you. And then what happened? CLIENT : She came back. Now maybe there you could have done something different. “I’m really sorry. THERAPIST : When? CLIENT : After I got sick of crying. . I’ll show him. THERAPIST : Uh huh. That’s what I’m going to try to teach you. “Fuck this shit. CLIENT : They don’t have time to do that.” THERAPIST : Now did you quit crying before you got angry. Perfectly reasonable feelings. THERAPIST : She could have made you feel cared about. like you weren’t worth helping? CLIENT : Yes. . So you didn’t decide right away to hurt yourself. that’s pretty interesting. And I said. feeling unloved and not cared about and you cry and sob? How did you get from there to deciding to hurt yourself. THERAPIST : So you lay in bed and cried. THERAPIST : So you kind of got more energized. . She couldn’t help me. thinking.

or a feeling that other people don’t respect you. a feeling that has something to do with anger. Do you think that’s correct? CLIENT : Yes. a feeling of being invalidated. And. however. it’s the feeling of not being cared about. There’s got to be more than one way to get everywhere. THERAPIST : Does that mean you’re not even open to learning another way? CLIENT : Like what? THERAPIST : I don’t know. It’s got to be that there are other paths to places. probably. That’s my guess. We have to figure it out. As clients increasingly acquire new coping skills. and also want to die. Life is like walking on a path. You have a one-track mind. THERAPIST : See. The problem that we have to solve is how to be in a situation that you feel is unjust without having to harm yourself to solve it. like. Now listen. That’s what sets you up to hurt yourself. With repeated analyses. CLIENT : Yes. which may be likened to trying to find a pair of footprints hidden beneath layers of fallen leaves. and we all run into boulders. THERAPIST : I thought you’d say that. because we all run into boulders on the path. Such persistence will eventually undermine a client’s refusal to attempt new and adaptive problem-solving behaviors. Because if you were out on that raft with me you would have been able to handle the pain if I hadn’t had any medicine. interpersonal effectiveness .” or is it more open. more adaptive attempts at problem resolution will eventually become discernible. THERAPIST : Now is this a definite. it’s the sense of being invalidated and the sense of not being cared about. “I can’t think of another way but I’m open to the possibility?” CLIENT : I don’t think there’s another way. invalidated. the footprints are there. Are you open to that? CLIENT : Yeah. See what I think’s happening is that when you’re in a lot of pain and you feel either not cared about or not taken seriously. because it can’t be that nothing else can help. right? So it’s really not the pain. we’ve got to figure out something else to help you. like. And for you. clients learn that their therapist will not back down.40 • LINEHAN CLIENT : Yeah. That can’t be the way the world works for you. this fine-grained analysis is often an excruciating and laborious process for client and therapist alike. but I don’t think it would have helped. “I’m not going to let there be any other way. As illustrated above. is there any other way for you to feel validated and cared about other than them giving it to you? CLIENT : No. THERAPIST : What would have helped? CLIENT : Getting pain medication. but it may take much raking and gathering of leaves before they are uncovered. you know. Therapists often feel demoralized and tempted to abandon the effort. Session goal: Emotion regulation. THERAPIST : So I think it’s not actually the pain in your ankle that’s the problem. it really isn’t the pain in your ankle that’s the problem. the question is.

and we just have to deal with that. problem solving (clarification of consequences of behavior. That’s a big step. And when you do. . you’re a really strong woman . I’m willing to help you but I can’t do it alone. it’s not the worst thing any one ever did. There’s nothing freakish about that. Something has happened in your life that has made it so that you’re afraid to be angry. and cheerleading (“ . you should take off your sunglasses and then we should problem solve on how to cope when you can’t get angry. stylistic (reciprocal communication. I think. guarded. you can handle this. I think you do better when you’re not wearing those sunglasses. we’re a problemsolving team. But you’ve got to do it. you and me. . and it’s not a catastrophe to be mad at the collector. validation (cheerleading). clarifying the contingent consequences of her behavior.”). by taking off your sunglasses. we solve problems. irreverent communication). you feel better. but you can handle this. validating the client (“It’s made your life a lot harder . . and somewhat tortured telling me of her week’s problems. I’ve noticed that. . you have to work with me. This first segment follows a long. you’ve got to use it.”). THERAPIST : Thank you. . How? Well. And I figure they make it harder for you. I then move to clarify the contingent consequences of the client’s behavior by pointing out that provision of my assistance is contingent on her willingness to work. You’re a really strong woman. this is not more than you can cope with. and then try to shape her behavior so that she removes her sunglasses and works on expressing her anger. . you’ve got it inside you. I know. and that’s what you and I do. you always do better when you go forward. THERAPIST : And I knew you knew I’d say that. . . . for you. It’s like a step. In the following session (approximately ten months into therapy with a client who was mostly mute the first six moths) the client has arrived wearing mirrored sunglasses (again) and is angry because collection agencies have been persistent in pressuring her for payment on delinquent accounts. CLIENT : THERAPIST : I have begun the exchange by attempting to normalize the issue (“It’s not a catastrophe . you can cope with this. integrated (relationship enhancement). CLIENT : Sunglasses are your biggest bitch. how would you like to look at yourself talking to someone else? (long pause) They make it difficult for me. It’s just a problem to be solved. It’s made your life a lot harder. it’s not a catastrophe. use of reinforcement procedures). THERAPIST : It’s not a catastrophe that the collector did this to you. . you can cope . . CLIENT : I knew you’d say that.Illustrations of DBT • 41 Strategies: Dialectical (metaphor). THERAPIST : Well.”). I use cheerleading. for starters. (pause) CLIENT : (Removes sunglasses) All right. I immediately follow this by requesting a response the client is capable of making. (long pause) So that’s what you should do. It’s just a problem that you have.

THERAPIST : Listen. I just want you to express it. and you need to say it with some energy. you can be angry. Keep going.“I’m angry!” (long pause) You can scream of course if you want. Somewhat later in the session I move to elicit new behavior. wasn’t it? Now say it with a little vigor. THERAPIST : Good. you have to take the risk. CLIENT : (long pause) I can’t do any of it. I have a good feel for what your strengths are. And I know you can do it and you need to do it. Also note the framing of the issue as a problem to be solved. That you’re angry at yourself. we can be angry sometimes and it isn’t going to kill either one of us.”). I figure the only thing today you have to do is say. You can’t give up. Cheerleading and metaphor have been unsuccessful in moving the client to express her anger more forcefully. I know you’ve got it in you. just express directly to me how you feel. you don’t have to yell and scream or throw things. Can’t you say it with a little energy? CLIENT : (Shakes her head no) THERAPIST : Yes you can. by the way. I don’t think I will be.” CLIENT : That’s it. . Consequently I switch to irreverent communica- .” in a voice that sounds angry. Tell me how mad you are. I think you already are angry.42 • LINEHAN My use of reciprocal communication informs the client of her feelings regarding the sunglasses. as well as my use of the relationship strategy to enhance the therapeutic alliance. You’re not going to get past this or through this. (Long pause) CLIENT : (Barely audible) I’m angry at you. but I might. that you’re angry at the collection agency and that you’re damn angry with me. don’t you? THERAPIST: I don’t care who you get angry at. I don’t know how I’ve got this good feel. I want you to find it inside yourself. You have to take the risk. but I do. THERAPIST : That is bullshit. “There’s nothing freakish about that . And I might be angry if you don’t do it. . I know you’ve got it. and I figure you’re capable of that. That’s all I can do. Note my matter-of-fact attitude and my continued attempt to normalize the issue (that is. you can say. . Just say it aloud . at myself. You are like a person mountain climbing and we’ve come to this crevasse and it’s very deep. CLIENT : You want me to get angry at you. I can be angry. and the collection agency. It’s not the worst thing any one ever did. THERAPIST : Now c’mon. I continue to rely on cheerleading and praise as I continue the process of slowly shaping the client’s behavior in the direction of directly expressing her anger. Is that hard? (Long pause) It was. “I’m Angry! . I know you can do it. I also make a point of validating the client by letting her know that I realize this was difficult for her. in a way that I can understand how you really feel. . “I’m angry. I’m not going to ask you to do anything more today. that kill you? (Long pause) That’s great. you can’t let your feet slip. Express how angry you are. but we can’t go back because there’s an avalanche and the only way to go forward is for you to jump over this crevasse. That’s okay. You’ve got to do it.

so how angry are you? On a scale of one to a hundred. a primary difficulty in working with borderline clients is their not-uncommon tendency to refuse to engage in tasks recommended by the therapist. has described DBT as the process of playing jazz. and difficulty. Also note how I have communicated to the client the potential negative consequences of her continued refusal to express her anger (that is. (pause) Who’s the safest to be angry at? Yourself. the use of irreverent communication and dialectical strategies such as story telling and metaphor often succeed in producing a breakthrough and gaining the client’s working alliance. Piss me off too! CLINICAL ISSUES AND SUMMARY As illustrated by the foregoing exchanges. In situations like these. I might be angry . then. moving then to the next moment and the next problem without losing rhythm or relationship to the client. acceptance. to keep the focus on the client rather than on the procedure or on the therapist. THERAPIST : Um hum. the therapist has to have expertise in a wide range of behavioral. A colleague. “. the client’s sense of place. . THERAPIST : OK. the sense of being out-of-control and the fact of dysregulation in order to balance the behavior-change strategies and dialectical strategies that move both therapist and client away from verbal constructs toward experiencing the moment. THERAPIST : Um hum. You don’t have to make it sound like a hundred. Thus it is absolutely necessary that the therapist maintain persistence and not give up in the face of their client’s “I can’t” or “I won’t” statements. and play within and in response to a relationship with others playing in the moment. The therapist validates the importance of the client’s problem. In this manner. I am both using the relationship as a contingency and am also modeling comfort with anger. The therapist must also be able to put them together flexibly and spontaneously to address the problems presented in the moment with the client. damn right. The therapist must be .Illustrations of DBT • 43 tion in an attempt to get the client to jump track. THERAPIST : OK. This process is indispensable to maintain therapeutic movement and flow. be able to play with flexibility and spontaneity. The procedures that make up DBT have to be overlearned. try to make it sound like a fifty.”). In DBT. The role of validation is central to this alliance. me. angry voice) THERAPIST: Well. how angry would you say you are? CLIENT : (Barely audible) Maybe one hundred. Bruce Rounsaville. or the collection agency? CLIENT : Collection agency. pain. and dialectical procedures and have an overall “frame” of dialectics and of radical genuineness. CLIENT : They’re persistent. THERAPIST : Really? CLIENT : They know my situation. . . CLIENT : They really pissed me off! (Said in a loud. The therapist must have a firm grounding in both theory and technique. . tell me how angry you are.

C. W. McGlashan... M. H. T. J Abnormal Psych.. J.. H. W. W. 487. It is the flexibility and spontaneity in applying principles of classical behavior therapy blended with acceptance and nonjudgmentalness at every moment—fingers flying over the keys rapidly in response to the notes just played by the client and therapist.. R. T. J. (1987). Brown. and so on. Stone. select and implement the procedure most likely to be effective for the problem presented—and then move to the next problem being presented in the moment. R. J. (1985). J. & Davies. Borderline personality disorder and unipolar affective disorder. Pickar. 281–293. McGlashan. The therapeutic milieu: Changing themes and theories. 36. A. and stages of treatment research. 1279–1285. K. 28(6).).: American Psychiatric. DBT requires a very focused attention. Hurt. Development. T. M. Washington. M. D. Int J Psychiatry Med. Skills training manual for treating borderline personality disorder. The PI 500: Long-term follow-up of borderline inpatients meeting DSM-III criteria. modifying a sentence before it is even finished in response to how it sounds to the client’s ear. Fyer. Gutheil. (1984). A.. Frances. 92(3). George. Hospital and Community Psychiatry. The Chestnut Lodge follow-up study. F. Frances. Washington. Hurt. 291–298. Glantz & C. and dissemination of effective psychosocial treatments: Stages of disorder. Long-term follow-up of borderline patients in a general hospital. S. M. 15. M. G. Arch Gen Psychiatry. New York: Guilford Press. 43.. (1993b). Staats. (1987). T. Gunderson.. Annals of the New York Academy of Sciences.. Nathan. & Clarkin. H. G. Homewood. Linehan. SELECT REFERENCES/RECOMMENDED READINGS Clarkin. (1993a). (1987). New York: Harper & Row. Drug Abuse: Origins and Interventions. Linehan. Social behaviorism. R. W. Hartel (eds. M. (1975). M. Soloff. (1986). F. Linehan. 175. & Stone. A. evaluation. J Nerv Ment Dis. F.. Widiger.44 • LINEHAN able to quickly hear the problem being presented in the moment. J. M. Motivation and personality. D. R. IL: Dorsey Press. I: Global outcome. J Clin Psychiat. A. 155–157. (1986). Characterizing depression in borderline patients. D. Cowdry. A. M. Prototypic typology and the borderline personality disorder.. (1985). DC: American Psychological Association. D. (1983). III: Long-term outcome of borderline personality disorder. an ability to be in one’s own shoes while simultaneously being in the client’s shoes. 48. R. W. M. J Personality Disorders. New York: Guilford Press. 1. Comprehensive Psychiatry. P. G. . Cognitive behavioral therapy of borderline personality disorder. J. 263–275. select and implement the next procedure. R. In M. & Gilmore.. 20–30. Personality and suicide. Maslow. 467–473. Paris. H. (1987). levels of care. 530–535.. P. (in press). H... (1970). 201–211. Symptoms and EEG findings in the borderline syndrome. Borderline personality disorder. & Schulz. & Nowlis. A. S.