Dialectical Behavior Therapy

Dr. David L. Kupfer, Ph.D.


Dialectical Behavior Therapy (DBT), based on the work of Marsha Linehan, is a marriage of cognitive-behavior therapy and Buddhist mindfulness that has proved quite helpful to clients experiencing borderline personality disorder, bipolar disorder, and other problems with anxiety and mood. The term “dialectical” is used to describe this therapy program’s ability to help people re-examine the apparent “either-or” contradictions that have confused them, and find a higher truth in saying yes to both ends of a continuum. A dialectical approach accepts both sides of a debate as potentially true and useful. Typical dialectics that bother psychotherapy clients include acceptance/change, assertiveness/submission, rational/emotional, and pleasing self/pleasing others. < Linehan believes clients develop rigid styles of dealing with stress when they have not been acknowledged or validated in a responsive manner during childhood. DBT emphasizes the wisdom of learning a variety of emotional and interpersonal skills, and being flexible enough to use whichever skills are most effective in a specific situation.

In DBT, clients are often seen both in individual psychotherapy and in groups that focus on learning four types of life skills. These four skill modules are Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation

In mindfulness, group members learn to shift from judging themselves “I’m too anxious to go out” to observing their own experiences with acceptance “I am anxious, my heart is beating rapidly, I am worrying, and it is OK.” They learn to participate fully in each moment of their lives by losing themselves in their present experiences.

Interpersonal effectiveness skills taught in DBT go beyond the assertiveness skills that are the focus of behavior therapy. In addition to learning how to ask for what they want and to say no calmly, clients learn to value the relationships they have. They learn when it is wise not to be assertive in ways that could damage a valuable relationship.

Distress Tolerance skills are similar to those learned in many spiritual teachings. Clients learn to accept what they cannot change. They move from “I can’t stand it” to “I can stand it” when facing discomfort. Participants learn to soothe themselves and live with situations that they don’t necessarily like, often by finding a higher level of meaning in their sometimes-unpleasant lives.

Emotion Regulation classes teach feelings can’t always be changed and that they don’t have to be controlled. Clients learn to deal with unwanted emotions through the principles of Opposite Action: For example, when afraid, approach; when angry, be kind.