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Mental Disorders

Cognitive-Behavioral Theory Expanded: The Dialectical Behavioral Approach

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.

When first introduced, the basic cognitive-behavioral therapeutic approach proved to be quite successful for treating depressed and anxious clients. However, it was less successful when applied to the treatment of personality disorders. This difficulty was particularly pronounced with regard to the treatment of clients with Borderline Personality Disorder.  This observation prompted psychologist Marsha Linehan, Ph.D. to expand and enhance the basic cognitive-behavioral model.  Her modifications were specifically designed to address the special difficulties of emotional dysregulation and self-destructive behaviors.  These are problems that are commonly associated with the Borderline Personality Disorder.

man feeling shameLinehan noted that people with Borderline Personality Disorder are exceptionally sensitive. They tend to react very strongly and intensely to situations in which they feel invalidated. Their childhood histories often reflected a poor match between these highly sensitive children, and their caregivers. This mismatch resulted in a negative emotional climate where the child's intense emotional expressions were often minimized, denied, or otherwise invalidated. Invalidation occurs whenever caregivers shame, punish, negate, criticize, reject, or deny the validity of the child's emotional experiences. For instance, suppose a young boy is crying but instead of being comforted he is angrily told, "Big boys don't cry." This critical comment shames him for crying and negates the validity of his distress because in fact, he is crying. In addition to an exceptional sensitivity, people with Borderline Personality Disorder take a comparatively long time to calm down and recover from their strong reactions.

These observations led Linehan to conclude that conventional cognitive-behavioral therapy's constant emphasis on challenging beliefs and altering behavior, felt profoundly invalidating to her clients.  As a result, these clients could not engage in, nor benefit from this therapy because of the way the therapy itself was experienced as painfully invalidating.  In response to this insight, Linehan introduced several innovations to her therapeutic approach. The most significant change was a new emphasis on the acceptance and validation of her client's emotional and behavioral states. This important change was intended to counter-balance the traditional cognitive-behavioral emphasis on changing those states.

Naturally, acceptance and change are somewhat incompatible agendas. It is difficult or impossible to promote both simultaneously.  If you are working to accept someone's response to a personal crisis, it is contradictory to simultaneously suggest better ways they might have handled it. By doing so, you have implicitly invalidated how that person did handle it.  Linehan's solution to the problem of integrating these incompatible agendas of change and acceptance was to move back and forth between them during therapy, in a "dialectical" manner. The term dialectic refers to a philosophical mode of argument.

Therapy based on Linehan's approach is called Dialectical Behavioral Therapy (DBT). Some of the time, the therapist accepts and validates the client's experience and response.  At other times, the therapist challenges the client to consider other alternatives.  The therapist moves between these two modes as required by the client's ability to tolerate the emotions surrounding requests for change.  Thus was born Linehan's Dialectical Behavioral Therapy. It is described in detail in the treatment section.