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Dialectical Behavior Therapy for Managing Interpersonal Relationships

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DOI: 10.1007/s12646-011-0132-8

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Dialectical Behavior Therapy for Managing
Interpersonal Relationships

Shalini Choudhary & Komilla Thapa

Psychological Studies

ISSN 0033-2968

Psychol Stud
DOI 10.1007/s12646-011-0132-8

1 23
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 Author's personal copy
Psychol Stud
DOI 10.1007/s12646-011-0132-8
REVIEW ARTICLE
Dialectical Behavior Therapy for Managing
Interpersonal Relationships
Shalini Choudhary & Komilla Thapa
Received: 14 July 2011 / Accepted: 24 October 2011
# National Academy of Psychology (NAOP) India 2011
Abstract Dialectical Behavior Therapy (DBT) is a treat-
ment designed for individuals having borderline personality
disorder (BPD), patients having binge eating disorder, co-
morbid substance dependence and BPD, and depressed
older adults. This paper aims to explore the use of DBT and
to ascertain the status of DBT education in treating
difficulties in handling interpersonal relationships among
clients seeking counseling and psychotherapy. The skills
training mode can be employed for teaching skills to solve
relationship problems. Validation and acceptance strategies
can lessen rejection sensitivity and negative feelings that
make interpersonal situations chaotic. Black and white
thinking can be resolved by finding a middle path through
acceptance and change. This paper suggests the possible
utility of DBT for enhancing psychological well-being in
clients.
Keywords Dialectical behavior therapy . Interpersonal
relationships . Managing relationship problems
Healthy relationships are a crucial part of human develop-
ment and individual growth. Through close relationships
(e.g. friendships), people are able to empathize with others,
experience both feelings of independence and dependence
within a relationship, trust others, and communicate more
easily in times of conflict. Jourard and Landsman (1980)
said that a healthy relationship has (1) open, honest
communication, (2) reasonable expectations or demands
S. Choudhary (*) : K. Thapa
Centre for Advance Studies in Psychology,
Department of Psychology, University of Allahabad,
Allahabad 211002, India
e-mail: shalini.3011@gmail.com
of each other, (3) concern about the other’s well being and
(4) freedom for both to be themselves. Individuals generally
have needs, feelings and boundaries, but many people
become confused when they come in contact with others or
form close relationships and these relationships have needs
and paths that are in competition with individual needs and
goals. Relationship researchers have identified a variety of
needs and goals that are often unique to the type of
relationship addressed (Berscheid 1994). Hamachek (1982)
says about things that interfere with healthy relationships
(1) we underestimate the changes we need to make but push
too hard for other people to change, (2) not liking ourselves
is usually associated with not liking other people, (3)
shyness inhibits closeness and intimacy with others and (4)
playing deceptive, self-serving “games” and being jealous
will drive others away. Brown (1995 cf, Jourard and
Landsman 1980) describes the decline of true intimacy in
American culture and tries to explain why Americans are
becoming more and more unable to sustain meaningful
relationships. Most people also accept that individuals
change in various ways over time, but are not able to
accept that relationships change, grow and decline in their
own ways as well. Somehow, relationship or group needs
must be considered and balanced with individual needs.
Unfortunately, many people do not see the forces and
elements involved to be able to create this balance. This
leads to common interpersonal difficulties or problems
raised by persons seeking counseling. Interpersonal prob-
lems are recurrent difficulties in relating to others, in
clinical as well as nonclinical sample (Reeves et al. 2010)
and are a common reason why people seek psychotherapy
(Horowitz et al. 1993).
People having Borderline Personality Disorder (BPD)
usually have disturbed relationships as a core characteristic.
The relational style of borderline personality disorder
 Author's personal copy
patient is characterized as intense and unstable relation-
ships, marked further by abandonment fears and by
vacillating between idealization and devaluation (Gunderson
2007). Many interventions and therapeutic strategies are
available for dealing with such interpersonal problems.
Dialectical Behavior Therapy (DBT) is a treatment designed
specifically for individuals who meet criteria for BPD and a
host of co-occurring problems (e.g., depression, anxiety,
substance abuse & eating disorders). DBT (Linehan 1993)
was initially developed to treat the problems of emotion
dysregulation and interpersonal deficits in BPD patients; thus,
modifying DBT to treat people having chaotic relationships is
a logical step and can be suggested to a nonclinical group.
There are several levels of adapting DBT that are
possible. First, one could simply apply DBT essentially
intact to new populations (for example, to battering men;
Fruzzetti et al. 1998 cf; Fruzzetti 2006). Or, one could use
the existing treatment to augment outcomes with borderline
clients (like teaching the original DBT skills to family
members or partners of borderline clients; Fruzzetti 2006).
Finally, one could also develop new interventions (skill
modules and/or treatment strategies), consistent with the
transactional model, to intervene specifically at the level of
the environment (a family; Fruzzetti 2006). Thus effective-
ness and success of DBT techniques can also be tried on
other populations seeking therapy. Many clients seeking
counseling and psychotherapy report interpersonal problems
or difficulties in relating to others. Over the last few decades,
research has shown that satisfying close relationships and
active social support networks have important implications
for health outcomes and behaviors (Berkman et al. 2000;
Uchino et al. 1996 cf, Uchino 2004). DBT balances
acceptance and change, with the overall goal of helping
patients not only to survive, but also to build a life worth
living.
The “personality-event congruence hypothesis,” which
posits that people who have an insecure relational pheno-
type experience stressful interpersonal events more drasti-
cally, has been confirmed that interpersonally preoccupied
or needy people are more disposed to respond to interper-
sonal stressors by becoming stressed (Little and Garber
2005). The interpersonal situation becomes a kind of
stressor to them thereby leading them to seek counseling.
The nonclinical sample can also be treated through
psychotherapeutic methods such as DBT.
Dialectical Behavior Therapy is a branch or modification
of cognitive-behavioral therapy (CBT) that includes an
eclectic mix of methods common to several other
approaches and biosocial theory. It uses standard CBT
interventions (e.g., self-monitoring, behavioral analysis and
solution analysis, didactic and orienting strategies, contin-
gency management, cognitive restructuring, skills training,
and exposure procedures).
Psychol Stud
Although the intervention resembles cognitive behavior
therapy there are several important distinctions. First, it is
an intervention designed for non clinical sample. Second, it
augments and reinforces the client’s individual treatment
since it teaches many of the same skills (in addition to
others) taught in the cognitive therapy. DBT for relationship
management is viewed as an “additional” treatment to the
individual. Third, it teaches emotion regulation techniques
for specific negative emotions experienced in interpersonal
situations. Fourth, the “Consultation Hour” (where clients
bring up relationship issues like rejection sensitivity and
interpersonal conflicts for consultation, with the goals of
skill application/generalization and problem solving) is
introduced. Finally, the program can be adapted for
synthesizing dialectical dilemmas as in black and white
thinking.
Interpersonal conflict is a situation in which one or both
persons in a relationship experience difficulty in working or
living with each other. This usually occurs due to different
or incompatible needs, goals or styles. The existence of
conflict is usually signaled by negative feelings such as
anger, jealousy, confusion, hostility, etc. A social cognitive
approach to understanding interpersonal problems assumes
that people who react differently to social situations think
differently about those situations (Andersen and Chen
2002; Baldwin 1992 cf, Anderson and Chen 2002).
DBT therapists take every opportunity to strengthen
clients’ valid responses, which alone and in combination
with CBT interventions facilitate change (Linehan et al.
2002 cf, Linehan et al. 2006a).
Comprehensive DBT involves addressing five different
functions in treatment: (a) enhancing client skills and
capabilities (mindfulness, emotion regulation, distress tol-
erance, and interpersonal effectiveness skills); (b) general-
izing those skills to everyday life; (c) increasing client
motivation to use these skillful alternatives to reduce
previous problematic behaviors and distress; (d) ensuring
that the family and social environment do not impede
treatment (and, ideally, facilitate it); and (e) enhancing
therapist skills and motivation to provide treatment effec-
tively (Linehan 1993).
The Dialectical Approach
& Dialectics stresses the basic interconnectedness of
reality: to fully understand a person you have to
understand his/her context.
& Reality is composed of opposing forces (thesis and
antithesis): there can be no function without dysfunc-
tion; distortion without accuracy.
& The fundamental nature of reality is change. Resolution
of the tension between polarities produces a “new”
 Author's personal copy
Psychol Stud
reality which, in turn, creates another set of polarities,
and so on.
DBT explores contradictory emotions, cognitions, and
behavior patterns and attempts to find the middle ground.
An implication of this premise is that people and their
environment are in constant transition and need to adapt to
inconsistency and change. Relationships serve as the
primary source of affection and support (Levinger and
Huston 1990). Difficulties with intimacy are frequently
implicated in decisions to seek counseling for interpersonal
problems whereas increasing or enhancing intimacy is often
one of the goals of using dialectical behavior therapy.
The significance of understanding adaptive interpersonal
processes, such as intimacy, for well-being and optimal
living is becoming increasingly recognized as a necessary
area of study (Ryff and Singer 2000). Moreover, a greater
understanding of the process that underlies intimacy can
assist in identifying what is going awry when people
complain of loss of intimate and loving feelings (Huston et
al. 2001). With its increase in popularity there have
emerged not only different methods of interpersonal
interventions (e.g., interpersonal psychotherapy) but also
DBT treatments are distinctly targeted for particular
populations.
Despite the considerable amount of data supporting the
effectiveness of DBT for a variety of problems related to
emotion regulation (e.g., Chapman 2006 cf, Lynch et al.
2006), DBT has not been evaluated as a treatment for
people (nonclinical sample) having interpersonal problems.
Considering the above mentioned viewpoint the purpose
of this theoretical paper is to explore the use of dialectical
behavior therapy (DBT) techniques in treating relationship
problems or difficulties in handling relationships among
clients seeking counseling and guidance. Another aim is to
justify a more rigorous examination of the feasibility,
efficacy and effectiveness of DBT as a treatment adapted
for relationship conflicts. The DBT method used by the
psychotherapists can be modified according to the needs of
general population seeking counseling for difficulties in
managing relationships or having unstable or chaotic
relationships. The challenge in adapting and extending
DBT to treat non clinical sample lies in its theoretical
foundations.
Principle of Dialectics in Relationships
The need to establish and maintain close relationships and
connections with others has been identified as a central and
fundamental human motivation (Baumeister and Leary
1995). Relationship issues can be understood in terms of
Interpersonal Systems Theory (Connors 2007). Relation-
ship systems of Interpersonal Systems Theory constantly
interact and change both within and between themselves
and cope with a stormy sea of changes inside and outside
these systems. The systems concepts of growth cycles and
life cycles helps to understand the pain, chaos, awkward-
ness and risk that are inevitable and necessary for
relationship health and productivity over time. Interpersonal
Systems Theory reveals the commonalities and connections
between relationships with all life forms. This theory strives
to understand the complicated world of relationships
through systems thinking. Systems Theory sees the uni-
verse as composed completely of living systems which
connect, work together and evolve over time. The proper-
ties of Interpersonal Systems Theory like systems are
holistic and that systems constantly involve in change
cycles and are changed by the life-cycles, can be under-
stood by a dialectical worldview. A dialectical worldview
permeates DBT. A dialectical perspective holds that one
can’t make sense of the parts without considering the whole
that the nature of reality is holistic even if it appears that
one can talk meaningfully about an element or part
independently. Interpersonal systems self regulate for
balance in order to stay healthy.
Applying a dialectical perspective implies that it is
natural and to be expected for these differing and partial
perspectives to be radically in opposition. The existence of
“yes” gives rise to “no,” “all” to “nothing.” From this point
of view, polarized divergent opinions should be expected
when a client has complex problems that generate strong
emotional reactions in his/her helpers.
Dialectical means that 2 ideas can both be true at the
same time.
& There is always more than one TRUE way to see a
situation and more than one TRUE option, thought, or
dream.
& Two things that seem like (or are) opposites can both be
true.
& All people have something unique, different, and
worthy to teach us.
& A life worth living has both comfortable and uncom-
fortable aspects (happiness AND sadness; anger AND
peace; hope AND discouragement; fear AND ease,
etc.).
& All points of view have both TRUE and FALSE within
them.
Unlike prior approaches that stressed “personal insecu-
rity” or “distorted thinking,” the current approach incorpo-
rates meta-cognitive, meta-emotional, and acceptance,
change and mindfulness techniques. These techniques
allow the client to accept discomfort, emotion, and
uncertainty which may be an inevitable part of any
relationship.
 Author's personal copy
The concept of the “invalidating environment,” central to
DBT, maintains that invalidation occurs when valid (true,
effective, and real) individual behaviors (esp. private
behaviors such as thoughts, self-concept, emotional and
sensory experiences) are delegitimized, punished, criticized,
or pathologized. A validating environment (or validation),
on the other hand, confirms what another is thinking,
feeling, or experiencing. Validation is not necessarily
positive (it may involve acknowledging anger or jealousy),
does not necessarily involve agreement with another, and is
possible at multiple levels (Linehan 1997 cf, Koerner and
Dimeff 2007).
Therapist uses dialectics in two ways:
1) Attempts to maintain a collaborative therapeutic rela-
tionship by balancing:
– Change & acceptance
– Flexibility & stability
– Challenging & nurturing
2) Teaches and models dialectical thinking and behavior
by:
– Highlighting contradictions in behavior and
thinking.
– By offering opposite or alternative positions.
– By maintaining that truth is not absolute but is
constructed and evolves over time.
– Attempts to find synthesis of oppositions (Hegel:
Thesis, Antithesis, Synthesis)
Dialectical Approach for Relationship Management
Exquisite emotional sensitivity, proneness to emotional
dysregulation, and a long history of failed attempts to
change either this intense emotionality or the problem
behaviors associated with it make supportive treatment
elements important.
The Dialectical approach specifically skills training
mode can be employed for teaching mindfulness, distress
tolerance, emotion regulation and interpersonal effective-
ness skills.
Mindfulness primarily has to do with the quality of
awareness that an individual brings to the present experi-
ence. Mindfulness practice often involves letting go of
attachments and becoming one with current experience,
without judgment or any effort to change. At the same time,
mindfulness involves the use of skillful means and the
finding of a middle path between extremes or polarities.
Skills to help clients discriminate between black and white
thinking and negative feelings (e.g., mindfulness) are
necessary in treatment. Skills taught in this module include
observing, describing, fully participating, being nonjudg-
Psychol Stud
mental, focusing on one thing in the present moment, and
being effective over being right. Clients are likely to have
difficulty labeling and expressing their emotional experi-
ences accurately (and assertively) as a consequence of in-
validation. Therefore, accurate expression is self-validating.
Invalidation may be a core component of the many
forms of interpersonal conflicts because it communicates
non-acceptance (or rejection), criticism, disrespect, con-
tempt, and/or disregard for other’s personal worth and often
results in increased emotional arousal and distrust of others
and one’s own feelings (Fruzzetti and Iverson 2004 cf,
Iverson et al. 2009).
Distress-tolerance training attempts to equip clients with
a range of specific methods aimed at improving the client’s
capacity to tolerate aversive situations, feelings, or
thoughts; to survive crises; and to radically accept that
which cannot be changed.
Emotional regulation difficulties may lead to dysfunc-
tional coping responses, such as problematic interpersonal
behaviors, and may negatively affect emotional well-being
(Gross et al. 2006). Emotion-regulation training tends to be
more change focused and includes specific methods
designed to identify what emotion is being experienced, to
decide whether the emotion is justified or fits the current
circumstances, and then to learn ways to modulate the
emotion if the client decides he or she would like to change
his or her emotional experience. Emotion intolerance and
over-control of emotion can be replaced by self-validation,
acceptance, and emotion regulation skills. The multiple
emotional problems like anger and jealousy that result for
many people in interpersonal situations, emotion regulation
may be an important treatment target for this population.
In response to intense emotional reactions during
therapeutic tasks (e.g., talking about an event from the
previous week), the therapist validates the uncontrollable,
helpless experience of emotional arousal, and teaches the
individual to modulate emotion in session, balancing,
moment to moment, the use of supportive acceptance and
confrontive change strategies.
Finally, interpersonal effectiveness training is designed
to help clients interact with others in ways that allow them
to improve relationships while simultaneously maintaining
their own personal values, self-respect and well being.
Resolving Interpersonal Issues Through DBT
DBT validation strategies are meant not only to communi-
cate empathic understanding but also to communicate the
validity of the client’s emotions, thoughts, and actions. In
addition, validation and acceptance strategies are taught to
lessen rejection sensitivity or abandonment fears and
negative feelings in interpersonal situations.
 Author's personal copy
Psychol Stud
Certain individuals are very sensitive to environmental
circumstances. They experience intense abandonment fears
and inappropriate anger even when faced with a realistic
time-limited separation or when there are unavoidable
changes in plans (e.g., sudden despair in reaction to a
friend’s or partner’s announcing the end of the meeting;
distress when there are certain changes in preplanned
schedules; panic or fury when someone important to them
is just a few minutes late or must cancel an appointment).
Rejection sensitivity is a trait closely related to abandon-
ment fears and intolerance of aloneness. They may believe
that this “abandonment” implies they are “bad.” These
abandonment fears are related to an intolerance of being
alone and a need to have other people with them. Brennan
et al. (1998 cf DiTommaso 2003) indicated that adult
attachments could be described in terms of two orthogonal
dimensions: attachment anxiety and attachment avoidance.
Adult attachment anxiety is defined as the fear of rejection
and abandonment. Adult attachment avoidance is charac-
terized as the fear of intimacy and discomfort with
closeness and dependence. This characterizes dependency
on others for social, emotional, informational or psycho-
logical support.
Attachment theory (Bowlby 1988 cf Brennan et al.
1998) represents an important theoretical perspective for
understanding an individual’s experience of negative mood
and interpersonal problems. The basic premise of attach-
ment theory is that individuals’ emotional experiences with
primary caregivers lead to the development of attachment
security or insecurity. Attachment security or insecurity is
then associated with the individuals’ ability to connect with
others and cope with affective or stressful problems (Kobak
and Sceery 1988 cf. Brennan et al. 1998). If individuals
have caregivers who are consistent in their emotional
availability, they are likely to develop attachment security
and can effectively cope with negative events that arise in
their life (e.g., seek support from a friend). If individuals do
not have caregivers who are emotionally available, indi-
viduals are likely to develop attachment insecurity and
subsequently be less able to cope with stressful events in
their lives (e.g., withdraw from others). It has been
proposed that rejection leads to self-regulation failure,
which in turn can lead individuals to make unhealthy
behavior choices.
Validation is also used to balance the pathologizing to
which both clients and therapists are prone. Clients often
have learned to treat their own valid responses as invalid
(as “stupid,” “weak,” “defective,” “bad”). Similarly, thera-
pists also have learned to view normal responses as
pathological. Validation strategies balance this viewpoint
by requiring the therapist to search for the strengths,
normality, or effectiveness inherent in the client’s responses
whenever possible and by teaching the client to self-
validate. The same behavior can be both valid and invalid
at the same time. From this perspective, all behavior is valid
in some way. The DBT therapist strives to identify and
communicate what is valid with the client.
“Feelings are potentially highly constructive since it is
through experiencing and expressing feelings that close
friendships are built and maintained” (David Johnson in
Reaching Out, p, 87). Quality of life can greatly be
improved through the experience and expression of feel-
ings. So a search for quality of life is really a search for a
greater range and wider variety of emotions and a desire to
build relationships in which emotions are aroused, allowed
positive expression and yet controlled, allowing joy for all
involved. Negative feelings like anger and jealousy lead to
barriers, increased conflicts, and the deterioration of the
relationship. People who aren’t aware of feelings, and can’t
accept and express them skillfully, have difficulty in
interpersonal relationships. These feelings generate certain
negative emotions in clients which need to be tolerated and
regulated by effective skills training Modules. These
negative emotions as a result of negative feelings in
relationships can be emptiness, hostility, loneliness, con-
tempt, guilt, etc. Emptiness, an inner experience associated
with feeling the lack of the presence of a caring other, arises
due to chaotic or deteriorating relationships. The negative
feelings, like anger and jealousy, can also be dealt with
DBT strategies. Clients seeking therapy raise anger and
jealousy as the most common negative feelings that hamper
healthy relationships.
Intense feelings of frustration and anger weaken an
individual’s patience. People need patience to understand
and solve complex problems, such as relationship problems.
In terms of human relationships and psychotherapy
anger is one of the most important emotions. Anger is “a
strong feeling of displeasure and antagonism....synonyms
are, rage, fury, indignation, wrath, all these mean an intense
emotional state induced by displeasure. Anger, the most
general term, names the reaction but in itself conveys
nothing about the intensity or justification…of the emo-
tional state” (Webster 1996 cf. Fehr & Harasymchuk 2005).
Easily angered individuals typically experience consider-
able distress or have significant impairment in their social
relationships or as a wage earner, homemaker, or student.
High levels of anger usually lead to limited problem
solving ability, impulsive decisions, and foolish actions. It
makes one less perceptive of the feelings and thoughts of
others. Anger largely results from our irrational beliefs,
expectations, and self-talk. Other people can trigger our
anger only by activating or stimulating our irrational
beliefs.
Sometimes there is an immediate and pleasant, but brief,
release of tension following a strong expression of anger.
Anger provides us with a temporary feeling of strength,
 Author's personal copy
power, and control and covers up our feelings of hurt,
rejection, helplessness, or insecurity or inadequacy. We feel
that we are handling a practical problem (for example,
getting a person who is behaving wrongfully to improve his
behavior) when we express our anger. An individual’s only
two choices regarding one’s anger is to express it or to hold
it in.
Two common sources of anger are low frustration
tolerance and threats to one’s self-worth. Believing that
one absolutely must get what he or she wants and if they
don’t, it’s awful and they can’t-stand-it causes impatience,
low frustration tolerance, heightened frustration, and anger.
Distress tolerance strategies can be effective here by
replacing the belief that a situation is awful or horrible
with the belief that it’s inconvenient or a hassle.
Individuals often respond with anger when they perceive
that others are attempting to lower their self-worth, self-
acceptance, or self-esteem, (Dryden 1990 cf. Finkel &
Campbell 2001). The extent of their anger is usually
proportional to the extent to which they doubt their own
self-worth. Acceptance and Change strategies can be taught
to hamper anger and clients can work on accepting
themselves, and recognizing that their rising anger may be
due to their feelings of self-worth being threatened.
Acceptance is “the unqualified and nonjudgmental
attitude to self and others, as well as an acknowledgment
that what exists is bound to exist given the conditions that
are present at the moment (Dryden and Neenan 1994 cf.
Finkel and Campbell 2001).” Clients can be taught to strive
for improvements, at the same time accepting themselves,
others, and the world as fallible.
Jealousy is often a destructive and refractory problem in
relationships, sometimes resulting in the feared consequen-
ces it attempts to prevent. Jealousy is a multidimensional
cognitive, emotional, behavioral and interpersonal phenom-
enon. It can be a destructive and often dangerous emotional
and interpersonal response to threats to a valued relation-
ship. Jealousy is a form of angry, agitated worry, whose
goal is to anticipate and avoid surprise and betrayal.
Personal Core Beliefs about jealousy—Jealousy is often
related to core beliefs about the self and others. Problematic
core beliefs include thoughts that one is unlovable, flawed,
doomed, or entitled to special treatment. Beliefs about
others may include thoughts that others are not trustworthy,
rejecting, abandoning, manipulative, or inferior. Thus, the
individual with a core belief that he is sexually undesirable
would be more likely to be jealous (Dolan and Bishay 1996
cf. Vohs and Ciarocco 2004).
DBT Strategies for dealing with Jealousy:-
1. Validate and Inquire: The therapist empathizes and
validates the emotion of jealousy while questioning the
degree, persistence, and the impact on pathological coping:
Psychol Stud
It is one thing to feel jealous, but another thing to punish
your partner. Validation can link jealousy to evolutionary
theory (“natural instincts to protect yourself”), the value of
commitment and honesty in relationships, and the desire to
feel understood (Gilbert 1998; Leahy 2005a cf. Leahy
and Tirch 2008). Validation is an essential component
because the jealous person is often dismissed and
criticized for his jealousy. Inquiry can examine the
extremity of the response, while validating the right to
have the emotion of jealousy. This sets up a dialectic
—“You have feelings of jealousy, but the response may
or may not be extreme” (Leahy 2001 cf. Leahy and Tirch
2008; Linehan 1993 cf).
2. Assess Motivation to Change: The therapist helps the
patient evaluate the costs and benefits of jealousy—for
example, the benefits may include not being surprised,
avoiding the dissolution of the relationship and devel-
oping the motivation to either improve or leave the
relationship. Costs may include anxiety, anger, help-
lessness and relationship conflict. Resistance to modi-
fying jealousy may include the belief that feeling less
jealous is “granting permission” to being hurt or may
reduce one’s effective self-defense against betrayal and
humiliation (Leahy 2005; Wells and Carter 2001).
3. Distress tolerance by diffusing thoughts and feelings:
Metacognitive and acceptance-based interventions can
assist the client in distancing from and de-literalizing
thoughts and emotions that escalate the jealousy.
Similar to worry and rumination, the patient may have
heightened cognitive self-consciousness, believe that
his jealousy protects him, view jealous thoughts as
potentially out of control and requiring suppression,
and believe that he will suffer negative consequences
because of these thoughts. These beliefs are similar to
metacognitive beliefs and strategies for worry, rumina-
tion and anger (Papageorgiou 2006; Papageorgiou and
Wells 2001; Simpson and Papageorgiou 2003 cf, Segrin
and Taylor 2007). Defusion techniques can serve to
change the context in which these thoughts are
experienced, thereby changing the function of the
angry and agitated worries involved in problematic
jealousy (Hayes et al. 2003).
4. Use Mindful Awareness: The therapist assists the
patient in employing a mindful “observing” stance
towards their experience of jealousy in the present
moment. Such a strategy would involve the suspension
of control-based strategies, urges to act upon emotions,
and attempts at interpersonal manipulation. Rather than
coercing or protesting, the patient can practice an
intentional, non-judgmental, and accepting awareness
of their internal responses to each participant’s behav-
ior, and of events independent of the relationship (Segal
et al. 2002). In such away, the client may learn to let go
 Author's personal copy
Psychol Stud
of habitual patterns of responding to perceived threats,
and may begin to have the space and time to make
more informed and reality based decisions regarding
the relationship to jealousy and partner.
5. Practice Acceptance: This phase of treatment recog-
nizes that uncertainty is part of any relationship and
accepting uncertainty as inevitable does not mean
giving up one’s rights. Furthermore, struggling to
suppress the experience of jealousy and jealousy based
predictions may paradoxically increase their frequency
(Wenzlaff and Wegner 2000). The therapist assists the
patient in recognizing that you cannot control the
partner’s thoughts and actions and that you may not
even be able to prevent the experience of jealous
feelings or thoughts, but that you can choose ways to
respond to jealousy (Hayes et al. 2003; Linehan 1993).
6. Teach Emotion Regulation Skills: Dialectical Behavior
Therapy skills can assist the patient in managing the
intensity of the emotion. This can include examining
emotional myths, improving the moment, and stress
reduction techniques (Linehan 1993). The patient can
also be encouraged to use self-imposed “time-out”
when jealousy and anger escalate, so that she can
remove herself temporarily from interactions with the
partner until she has used her emotion regulation skills.
The patient and therapist clarified the aim of the
treatment as involving the cultivation of an ability to
notice, tolerate, and regulate the jealousy response
rather than as an attempt to avoid any feelings of
jealousy and apprehension altogether. Rather than
pursuing a goal of “not being jealous,” the patient
was taught to distinguish between “productive” and “non-
productive” jealousy based predictions, and the founda-
tion for a flexible response strategy was put in place.
7. Build Relationship Enhancement Skills: Since many
relationships can focus on jealousy to the exclusion of
productive behavior, the therapist can assist the patient
in decreasing destructive behavior (withholding, con-
tempt, stone-walling, criticizing, labeling, and mind-
reading) and increasing positive behavior (positive
tracking, reward, active listening skills, developing
shared activities, and validating the partner that one’s
jealousy has been damaging)
Many young people are not yet developed enough to
think in complex ways about a range of issues. Immature
cognition often leads to simple solutions to problems, and a
lack of ability to see things from other people’s perspec-
tives. They are usually extreme at understanding things and
situations. This type of thought is present-focused and tied
to extremes.
Mature adult thinking includes the ability to think in the
abstract and to consider a number of solutions to a problem.
Attainment of such thinking is not universal, even in
adulthood. Many young people have difficulty with
advanced thinking skills. Children who have been
neglected or abused, for example, may have had less
exposure to experiences that foster mature thinking. “Black
and white thinking” is a common manifestation of
immature thought; thinking that is rigid, stubborn and often
extreme, with few ‘grey areas’.
Black and white thinking creates dialectical dilemmas
associated with interpersonal situations. This dilemma can
be resolved by balancing or synthesizing the polarized
opinions and finding a middle path through acceptance and
change.
Black and white thinking reflects the construct of
“splitting” in psychological terms. Clients include dichot-
omous, rigid thinking and behavioral and emotional
extremes, dialectical philosophy and strategies offer a
means of reconciling differences so that conflicts in therapy
are met with movement rather than with impasse. The black
and white thinking is a kind of ‘all or nothing’ thinking
where one is either right or wrong—either good or bad—
there are no in-betweens, no shades of gray, and no middle
ground. When we judge ourselves or others, or the situation
based on these extremes, without seeing the shades of gray
in-between, it can be very easy to feel negative emotions,
such as disappointment, frustration, anger and anxiety and
jealousy.
A number of strategies are included in DBT that serve
the function of keeping polarized positions from remaining
polarized. The first of these is that core strategies are used
to balance acceptance and change. Encourage the young
person to explore their own thinking and whether it is
serving them well in their relationships with their family
and friends. Accept that some young people are simply not
developmentally ready to think in other ways.
Various strategies have been developed to help the
client–therapist dyad manage the relationships with other
clinicians and family members. DBT is weighted toward a
consultation-to-the-client strategy that emphasizes change.
The DBT therapist will intervene in the environment on the
client’s behalf when the short-term gain is worth the long-
term loss in learning. Other dialectical strategies include use
of metaphor or assuming the position of devil’s advocate in
order to prevent polarization.
The dialectical tension is resolved by finding the
synthesis, by seeking to find what is being left out of the
thesis and antithesis (e.g., validating the need to relieve
distress while helping the client utilize skills that function
to reduce stress and the long-term negative consequences of
repeated self-injury). The middle path approach of dialec-
tics is an inherent feature of Zen, and DBT utilizes these
principles in an effort to help clients behave more
effectively and live more balanced lives.
 Author's personal copy
DBT as Problem Solving
Whenever one of the targeted problem behaviors occurs,
the therapist and the client conduct an in-depth analysis of
events and situational factors before, during, and after that
particular instance (or set of instances) of the targeted
behavior. The goal of this chain analysis is to provide an
accurate and reasonably complete account of the behavioral
and environmental events associated with the problem
behavior. As the therapist and the client discuss a chain of
events, the therapist highlights dysfunctional behavior,
focusing on emotions, and helps the client gain insight by
recognizing the patterns between this and other instances of
problem behavior. Together they identify where an alterna-
tive client response might have produced positive change
and why that more skillful alternative did not happen. This
process of identifying the problem and analyzing the chain
of events moment to moment over time to determine which
variables control/influence the behavior occurs for each
targeted problem behavior as it occurs.
The goal of the treatment approaches can be distilled
down into the following process: the reduction of ineffec-
tive action tendencies linked with dysregulated emotions
(Chapman and Linehan 2006 cf Linehan et al. 2006a, b).
The primary goal of treatment is to help the patient to
engage in functional, life-enhancing behavior, even when
intense emotions are present. DBT is a flexible treatment
that varies in its approach depending on the client’s current
level of disorder.
Conclusion
The client having interpersonal problems can begin to
practice dialectical behavior therapy daily as a “preparato-
ry” exercise for the applied mindfulness and acceptance
techniques involved in coping with negative feelings. These
techniques can be appealing to the patient, as he may
greatly enjoy the “relaxation” and stress reducing effects
found in a yoga class, which is similar in DBT. As the
client had no history of acting out and also had sufficient
insight to see that his anger and jealousy based cognitions
and predictions are baseless and unproductive, this compo-
nent of the intervention can be easily addressed. By
examining the possibility of productive and unproductive
cognitions and emotions, the client may reportedly feel
further validated with regards to the legitimacy of his
emotional response, while not feeling compelled to buy into
his difficult and negative thoughts. Rather than engage in
experiential avoidance or thought suppression through
trying to “not be angry and jealous” the patient may
actively engage with his emotions and cognitions in an
adaptive way. Similarly, immature extreme thinking styles
Psychol Stud
such as black and white thinking can effectively be dealt
with mid-way path of acceptance and change. The
complementary DBT techniques proposed in this article
aim to: 1) provide clients an understanding of problems in
relationships in a clear, nonjudgmental way; 2) give a clear
picture of the clients’ thoughts and feelings that augment
his difficulties in maintaining healthy relationships; 3)
enhance the contributions and capabilities of clients to a
mutually validating environment; and 4) address clients’
emotional and interpersonal skills deficits.
Thus, relationship interventions in DBT may be consid-
ered: 1) as psychoeducation, to augment individual DBT; 2)
as a treatment of the individuals per se, targeting improve-
ment of interpersonal relationships and satisfaction; or 3) as
both. The theoretical relevance of the results for treating
interpersonal issues by dialectical behavior therapy is
indicated, as well as implications of the findings for clinical
practices are elaborated.
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