Dialectics in Behavior Therapy

Dialectics in Balancing Goals

Maintaining a dialectical stance can be hard for therapists because the pull is to become locked into a concept at either end of the pole rather than directly experience how two truths stand side by side as part of a larger synthesis. This can be particularly difficult for two of DBT's main goals enhancing client emotion regulations and decreasing priority targets such as self-injury. For this reason, DBT therapists view both these goals in dialectical terms.

Dialectics of Emotion Regulation

DBT (Dialectical Behavior Therapy) proposes a dialectical goal regarding emotion regulation. Clients learn skills to change emotion and to accept emotion as it is. In the abstract, these positions seem contradictory, a mixed message about how to respond to private experience. Yet we examine our actual experience, the paradox resolves. The most difficult moments of our lives often require both downregulating (changing and mindfully experiencing (accepting) our emotional responses..

Consider a clinical example. A client, in bitter divorce proceedings, lost primary custody of her 2-year-old daughter. The husband's lawyer built a humiliating account of her repeated psychiatric hospitalizations and suicide attempts, successfully negating her more recent treatment progress. Anyone would feel anguished at losing custody, especially when one's own transgressions contributed to the decision. However, for this client, her emotions were at an unrelenting, all-consuming intensity. She was crazed with pain. Contact with her ex-husband, both in real life and imagination, was like a match to gasoline. Her pain would ignite into rage and revenge fantasies. She loathed herself, certain that his claim she was a terrible mother was true and her daughter would be better off without her. She sobbed, grief-stricken each time she imagined a future without living day to day with her daughter. She had urges to capitulate and give up visitation rather than endure the pain. She sat in shock, detached and numb for hours.

She had little time, however, to sort out these feelings to inform her next set of actions because the court required that she begin mediation to determine visitation privileges. To establish credibility and best negotiate terms for visitation the client needed to demonstrate her competence. In these emotionally challenging interactions with the court or her ex-husband, her mind was in an uproar. Yet if she displayed even a whiff of emotion dysregulation, her husband would use it against her. Her goals in the situation demanded exquisite emotion regulation.

Dialectics in our beliefs. Photo by Elena.

Based on the chain analysis, the therapist and client identified shame as the primary emotion that led to the most escaping into problematic responding. This was especially the case when the client heard or thought she was a “bad mother.” In one extended session, the client and therapist looked in an unflinching way at how this criticism was true; that is, the client listed all the ways she had failed her daughter and failed to meet her own standards. The therapist used validation to hold the client in informal exposure episodes so that she could experience shame without escaping into problematic secondary responses.

Validation also cued adaptive emotion: the reason for her hurt and shame was how desperately she loved and wanted the best for her daughter, how terribly she longed to be a good mother. The client and therapist practiced the Dialectical Behavior Therapy skill of radical acceptance, looking at the causal web that created all the conditions that led to the failings as a mother, without sugarcoating the harm the client had done. Both spontaneously and with the therapist's help, the client experienced how shame transformed into deep regret and the healthy action urge to make amends and repair the damage. She found a kernel of pride at how fiercely she was using this therapy to change to do better by her daughter.

The client also struggled with rage at her husband, Here the therapist helped the client actively downregulate anger and avoid anger cues in order to avoid physically or verbally attacking her husband or his property (which she had done many times in the past). For example, the client's friends loyally sided with her, and fueled her anger by doing things like using the husband's picture as a dartboard, plotting to ruin his reputation at work, and talking endlessly about how unfair he had been. In the lead up to the mediation meeting, the client recruited her friends to change tactics with her: they either talked about the circumstances in a completely low-key nonjudgmental manner (e.g., “divorces are really hard”, “there are things about this situation I don't like”) or they avoided the topic and focused on areas where the client was building a new life.

Balancing therapy and life. Photo by Elena.

Further, the client and therapist identified the two most anger-provoking things the husband did and practiced drills where the therapist presented the cues and the client deliberately altered her breathing to calm herself. She inhaled for a count of 3, held her breath for a count of 2, then exhaled for 5, slowly and fully, pausing for 2 counts at the end of the exhalation. In this practice, she actively imagined picking up each thought or emotion about her situation and putting it in a box, gently saying “later”. She practiced this exercise and radical acceptance of shame on her own while gazing at a picture of her husband holding their daughter. She repeatedly put the picture into an envelope and then brought it out again to gaze at the picture and practice. The client learned how to control her attention in order to make fuller contact with emotion cues. She also learned to distract from emotion cues in order to down-regulate emotion. From a dialectical perspective, both approaches are valid and the focus was to help the client discriminate when either strategy did or did not fit her goals in the moment.

Dialectically Balancing Strategies

Using strategies dialectically keeps the therapy moving through impasse.  Validation strategies are dialectically balanced with behavioral strategies such as orienting, commitment, chain analysis, and problem solving. Three other important strategy sets are used dialectically to prevent rigid polarization: stylistic strategies, case management strategies, and specific dialectical strategies. Stylistic strategies  offer a practical dialectic in how the therapist communicates, balancing being warmly reciprocal and irreverently confrontive. Case management strategies concern how the therapist helps the client to navigate his or her social environment, balancing consulting to the client with direct intervention on the client's behalf in some limited cases. Specifically, dialectical strategies directly target polarization. In each case, the aim is to create the appropriate mix of acceptance of the client's vulnerability and change that recognizes the client's strengths.

Doing Dialectical Behavior Therapy (A Practical Guide by Kelly Koerner).

The last leaves. Photo by Elena.