An Illustration of Dialectical

Behavior Therapy

MARSHA M. LINEHAN
University of Washington

This article describes a form of behavior primarily from rational-emotive therapy),

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
communication strategies (irreverent and
reciprocal communication), and case-
management 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). Border-
line 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
22 • 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-of-
control 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 self-
monitor 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 behav-
ior 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 re-
sponses. The treatment draws from models of borderline behavior patterns that the-
orizes (1) BPD individuals lack important interpersonal, self-regulation (including
emotional regulation), and distress-tolerance skills and capabilities; and (2) charac-
teristics of the person and of the environment inhibit and/or block the use of capa-
bilities the individual does have, interfere with the development of new skills and
capacities, and often reinforce inappropriate and ineffective behaviors. DBT as-
sumes 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 ca-
pabilities 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-
 Illustrations of DBT • 23

proving motivation or by enhancing skills, is often experienced as self invalidat-

ing by individuals meeting criteria for BPD and often precipitates either with-
drawal from the therapist and therapy, including, at times, early drop-out from
treatment; a hostile attack on the therapist; or vacillation between the two modes
of responding; (2) teaching and strengthening new skills (e.g., for regulating emo-
tions, interacting with other people, tolerating distress, and experiencing rather
than avoiding the moment) to the extent believed necessary is extraordinarily dif-
ficult if not impossible within the context of a therapy oriented to reducing the
motivation to die, quit trying, and/or act in an out-of-control fashion; (3) suffi-
cient attention to motivational issues cannot be given in a treatment with the rig-
orous control of therapy agenda needed for skills training; (4) new behavioral
coping skills, such as mindfulness to the moment, are extraordinarily difficult to
remember and apply when one is in a state of crisis, making actual application of
these skills to situations associated with high stress and negative emotions extra-
ordinarily difficult without additional help; and (5) borderline individuals’ be-
haviors often unwittingly reinforce therapists for iatrogenic treatment (for in-
stance, 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 un-
reasonable or demanding request) and punish them for effective treatment strate-
gies (for example, a client may be silent in sessions if the therapist confronts their
ineffective behavior or may respond with a drug overdose when the therapist re-
fuses to recommend hospitalization stays that have been determined to be rein-
forcing suicide threats)—a state of affairs that can reduce the competency of an
otherwise competent therapist.
Three modifications in standard behavior therapy are useful to take these factors
into account. First, strategies that more clearly reflect radical acceptance and vali-
dation of clients’ current capacities and behavioral functioning must be added to the
treatment. The dialectical emphasis in DBT ensures the balance of acceptance and
change within the treatment as a whole and within each treatment interaction. This
dialectical emphasis brings together in DBT the “technologies of change” based
both on principles of learning and crises theory and the “technologies of accep-
tance” (so to speak) drawn from principles of eastern Zen and western contempla-
tive practices. Second, it can be extremely useful to split therapy into several dif-
ferent components including ones that focus primarily on learning new skills (for
example group or individual structured skills training), on motivational issues and
coaching and reinforcing new skills (individual psychotherapy), and on application
of skills to everyday life outside the treatment context (via phone and in vivo con-
sultations). Third, a consultation/team meeting focused specifically on keeping
therapist motivated and within an effective treatment frame is important. The four
modes in standard outpatient DBT are highly structured individual or group ther-
apy (for skills training), individual psychotherapy (addressing motivational and
skills strengthening), telephone contact with the individual therapist (addressing
application of coping skills), and peer consultation/supervision meetings (to treat
the therapist). On a psychiatric inpatient or day treatment unit, the coaching might
be done by the milieu; in community mental health settings it might be done by af-
terhours teams or crisis phone workers. In DBT for substance abusers (and with
other populations with a high incidence of social phobia and/or treatment avoid-
ance), brief, individual skills coaching session (in person or by phone) with one of
the skills trainers may be added.
24 • LINEHAN

TREATMENT STAGES AND TARGETS

Treatment in DBT is conceptualized as occurring in stages, with each stage having its
own outcome goals (Linehan, 1997). In Stage I, the tasks of treatment are to achieve
reasonable self-control, including a reasonable immediate life expectancy (for exam-
ple, blocking suicide), connection to helping individuals, stability and control of ac-
tion, and basic capabilities needed to achieve these tasks. Individuals in Stage I have
multiple problems, are comorbid for many disorders and the major goal is to simply
get them in control of themselves and their lives. If you can’t keep the client alive, it
doesn’t make much difference how potentially effective the treatment is. In Stage II,
the clients have action under reasonable control, are connected to treatment and are
focusing on their ability to experience emotions without trauma and to form and
maintain connections to people, places, and activities (such as work). An important
focus of treatment in this stage is to understand and reduce the sequelae of early trau-
ma, especially neglect and physical and sexual assaults. Treatment needs and capabil-
ities here are different than in Stage I. With behavior under control, the therapist can
move to focused exposure (via recall, imagery, discussion topics, role plays, or in vivo
activities) to events, places, persons, or activities associated with childhood traumat-
ic events. In Stage III, 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. Although self-respect and self-trust are im-
portant throughout treatment, they become central at this point. Many individuals
are content with Stage III functioning. Most, however, have a residual sense of in-
completeness; its resolution and achievement of a capacity for sustained joy are the
goals of Stage IV. Here the tasks are expanded awareness, spiritual fulfillment, and the
movement into flow or peak experiencing (cf. Maslow, 1970).
Treatment goals and session agenda in DBT depend on stage of treatment and,
within stage, are hierarchically arranged in order of importance. All of the research
to date has been on Stage I and the case illustration described below is also Stage I.
In Stage I the hierarchy is as follows:

1. Reducing high-risk suicidal behaviors (parasuicide acts, including suicide at-

tempt, high-risk suicidal ideation, plans and threats).
2. Reducing both client and therapist behaviors that interfere with the therapy
(for instance, missing or coming late to sessions, or avoiding topics during
sessions, noncompliance, invalidating the other, phoning at unreasonable
hours or otherwise pushing a therapist’s limits, not returning phone calls or
otherwise pushing a client’s limits).
3. Reducing behavioral patterns serious enough to substantially interfere with
any chance of a reasonable quality of life, including patterns that put clients
in a high-risk group for suicidal behaviors (severe depression and other Axis
I disorders would qualify here, also homelessness, chronically losing rela-
tionships or jobs).
4. Learning sufficient life skills to meet client goals (skills in emotion regulation,
interpersonal effectiveness, distress tolerance, self-management, as well as
mindfulness, (that is, the ability to observe, describe, and participate in a man-
ner that is nonjudgmental, effective, and experiential of the present moment).

With respect to each goal, the task of the therapist is first—and many times there-
after—to elicit the client’s collaboration in working on the relevant behavior, then
 Illustrations of DBT • 25

to apply the appropriate treatment strategies described below. Attention to each

goal within individual therapy, ordinarily involving direct and focused work on the
behaviors relevant to the goals, 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. Thus, treatment is oriented to current behaviors, with
parasuicidal acts and life-threatening suicidal ideation, planning, and urges taking
precedence over all other topics. Because therapeutic change is usually not linear,
progress through the hierarchy of goals is an iterative process over time.

TREATMENT STRATEGIES

DBT addresses all problematic client behaviors and therapy situations in a system-
atic, problem-solving manner that interweaves conducting a collaborative behav-
ioral analysis, formulating hypotheses about possible factors influencing the
problem, generating possible changes (behavioral solutions), and trying out and
evaluating the solutions. The context for these analyses and this solution-oriented
approach is that of validation of each client’s experiences, especially as they relate
to the individual’s vulnerabilities and sense of desperation. In contrast to many be-
havioral approaches, at least as described in print, DBT places great emphasis on
the therapeutic relationship. In times of crisis, when all else fails, it is the relation-
ship itself that may hold the client in this life.
The treatment itself integrates cognitive-behavioral interventions with eastern
Zen and western contemplative practices and teaching techniques. It also shares el-
ements in common with psychodynamic, client-centered, gestalt, paradoxical and
strategic approaches (cf. Soloff et al., 1987). Treatment strategies are divided into
those most related to acceptance and those most related to change. DBT requires
that the therapist balance use of these two types of strategies within each treatment
interaction, from the rapid juxtaposition of change and acceptance techniques to the
therapist’s use of both irreverent and warmly responsive communication styles.
Treatment strategies are divided into five sets:
1. dialectical strategies.
2. core strategies (validation and problem solving).
3. change procedures (use of operant learning principles, skills training, and ex-
posure/response prevention techniques from behavior therapy and cognitive
modification techniques taken primarily from rational-emotive therapy).
4. communication strategies (irreverent and reciprocal communication).
5. case management strategies (consultation to the patient, environmental in-
tervention, supervision/consultation with therapists).
There are, as well, a number of specific behavioral treatment protocols covering sui-
cidal behavior, crisis management, therapy-interfering behavior and compliance is-
sues, relationship problem solving, and ancillary treatment issues, including psy-
chotropic medication management. These are more fully described in the treatment
manuals (Linehan, 1993a; Linehan, 1993b).

Dialectical Strategies
Dialectical strategies are woven throughout all treatment interactions. The prima-
ry dialectical strategy is the balanced therapeutic stance described above. Thus, the
26 • LINEHAN

constant attention to combining acceptance with change is the very essence of the
dialectical strategy. The goal is to bring out the opposites, both in therapy and
the client’s life, and to provide conditions for syntheses. The key idea guiding the
therapist’s behavior is that for any point, an opposite position can be held. Thus,
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, and then assisting the client
to create new orderings that embrace and include what was previously excluded.
The therapist helps the client move from “either-or” to “both-and.” Strategies in-
clude extensive use of stories, metaphor, myth, and paradox; the therapeutic use of
ambiguity; 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; cognitive chal-
lenging and restructuring techniques; and reinforcement for use of intuitive, expe-
riential knowledge bases.

Core Strategies

Core strategies consist of the balanced application of validation and problem-solv-

ing strategies. Validation requires the therapist to search for, recognize, and reflect
the current validity, or sensibility, of the individual’s response. Validation is re-
quired in every interaction and is used at any one of six levels:
Level 1. Listening to the client with interest.
Level 2. Reflection, paraphrasing, summarizing.
Level 3. Articulating or “mind-reading” that which is unstated, such as fears
of admitting emotions or thoughts, but without pushing the interpre-
tation on the client.
Level 4. Validating the client’s experience in terms of past experiences (for ex-
ample, invalidating families, maladaptive modeling, sexual abuse, and
so forth) or in terms of a disease or brain-disorder model.
Level 5. Validating the client in terms of present and normal functioning (for
instance, high emotional arousal disorganizes cognitive functioning in
all people, it is reasonable to not completely trust someone you have
just met, and so on).
Level 6. Radical genuineness with clients, i.e., being one’s genuine self within
the therapeutic relationship, meeting the client on a person-to-person
basis, and seeing the person as an equal individual rather than through
the guise of “client.” This aspect of validation is best described by
Rogers in his discussion of genuineness in the therapeutic relationship
(see Rogers & Truax, 1967, p. 101).
In line with this latter prescription of the treatment, the therapist does not treat
clients as fragile or unable to solve problems. As can be seen, validating is not sim-
ply building up self-esteem—although cheerleading, focusing on the strengths of
the individual, and believing in the individual no matter what, are important parts
of validation.
Problem-solving is a two-stage process involving, first, an analysis and accep-
tance of the problem at hand and, second, an attempt to generate, evaluate, and im-
plement alternative solutions that might have been made or could be made in the
future in similar problematic situations. Analyses of the client’s problem behaviors,
including dysfunctional actions, emotions, physiological responses, thoughts and
 Illustrations of DBT • 27

ways of processing information requires a very detailed chain analysis of the spe-
cific environmental events, thoughts, interpretation and implicit assumptions, sen-
sations, emotions, and feelings, actions and action urges that follow each other link-
by-link leading up to and following the particular problematic response at hand.
Over time, 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 trans-
actions with the environment over time is repeated for every instance of targeted
problem behaviors (for example, parasuicide, serious suicide threats, increase in sui-
cidal ideation) until both therapist and client achieves an understanding of the re-
sponse patterns involved. The second stage, which is actually interwoven with the
first, requires the generation of alternate responses (that is, adaptive solutions to the
problem), as well as an analysis of the individual’s response capabilities. At each link
in the chain of events leading from a precipitating situation to a suicidal response,
the therapist engages the client in looking for an alternate, more adaptive response
that might have been made. This process often leads into brief teaching of new cop-
ing skills (for example, modeling, suggesting, or advising) and/or work on motiva-
tion and strengthening of skills the individual already has via both reinforcing more
adaptive functioning (and extinguishing or responding aversively to dysfunctional
responses). Also involved is the highlighting of consequences in the natural envi-
ronment for both effective and ineffective behaviors, therapeutic exposure to re-
duce emotions inhibiting more adaptive behavior, and changing thoughts and im-
plicit assumptions and beliefs that lead to dysfunctional behaviors.

Communication Strategies

In DBT, the therapist balances two communication strategies that represent rather
different interpersonal styles. The modal style is the reciprocal strategy, which in-
cludes responsiveness to the client’s agenda and wishes, warmth, and self-disclosure
of both personal information that might be useful to the client as well as immedi-
ate reactions to the client’s behavior. Reciprocity is balanced by an irreverent com-
munication style, which is characterized by a matter-of-fact attitude, where the
therapist takes the client’s underlying assumptions or unnoticed implications of the
client’s behavior and maximizes or minimizes them, in either an unemotional or
overemotional manner to make a point the client might not have considered before.
The essence of the strategy is that it “jumps track,” so to speak, from the client’s
current pattern of response, thought, or emotion.

Case Management Strategies

There are three Case Management Strategies designed to guide each therapist dur-
ing interactions with individuals outside the therapy dyad. The consultation/su-
pervision strategy requires that each DBT therapist meet regularly with a supervi-
sor or consultation team. The idea here is that severely suicidal individuals should
not be treated alone. The consultant-to-the-client strategy is a simple concept but
very hard to carry out. The strategy is the application of the principle that the DBT
therapist teaches the client how to interact effectively with the client’s environment,
rather than teaching the environment how to interact with the client. This strategy
represents a point of view that looks at adversity and “bad” treatment of the client
28 • LINEHAN

by the environment (including other professional helpers) as an opportunity for

practice and learning. From another perspective, it views the role of the therapist as
teaching the client to live in the world as it is, with all its problems and inequities.
When absolutely necessary, however, the therapist actively intervenes in the envi-
ronment to protect the client or to modify situations that the client does not have
the power to influence.

ILLUSTRATIVE TRANSCRIPTS

The following three (composite) transcripts represent actual examples of the

process of therapy that transpired over several sessions with different clients. These
particular dialogues are chosen to provide the reader with examples of the applica-
tion of a range of DBT treatment strategies for dealing with such issues as orient-
ing clients to the therapy and getting their commitment, dealing with suicidal be-
havior, and helping clients regulate their emotions and improve their interpersonal
effectiveness. 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.

Session goal: Orienting and commitment

Strategies: Validation, problem solving (insight, orienting and commitment), di-
alectical (devil’s advocate), integrated (relationship enhancement).

The following is a first session with a client following a referral from her pharma-
cotherapist and an initial meeting with the client and her family following her dis-
charge from an inpatient psychiatric unit. In the first therapy session with a suici-
dal client, the most important therapy focus is to keep the client alive until the next
session and to stop intentional self-injury and suicide attempts. Obtaining the
client’s commitment is a crucial first step in this endeavor. As illustrated in the fol-
lowing transcript, the dialectical technique of devil’s advocate can be effective when
used as a commitment strategy. I begin by orienting the client to the purpose of this
initial session.

THERAPIST : So, are you a little nervous about me?

CLIENT : Yeah, I guess I am.

THERAPIST : Well, that’s understandable. For the next fifty minutes or so we have
this opportunity to get to know each other and see if we want to work togeth-
er. So what I’d like to do is talk a little bit about the program and how you got
here. (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.

THERAPIST : Well, what’s wrong with you?

CLIENT : I’m a mess (laughs).

THERAPIST : How so?

CLIENT : Um. I don’t know. I just can’t even cope with everyday life right now. And
I can’t even . . . I’m just a mess. I don’t know how to deal with anything.
 Illustrations of DBT • 29

THERAPIST : So, what does that mean exactly?

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

THERAPIST :Does it seem like maybe your emotions are in control, that you are a
person who does things when you’re in the mood?
CLIENT : Yes. Everything’s done by the mood.
THERAPIST : So you’re a moody person.
CLIENT : Yes. 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,
I mean just immaculate, and then when I’m in the mood I go back to being a
mess again.
THERAPIST :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.
CLIENT : Right.
In the above dialogue, I use insight to highlight observed interrelationship between
the client’s emotions and her behavior. I then in the next section begin to shape a
commitment using the dialectical strategy of devil’s advocate. The use of devil’s ad-
vocate in this case is to get the client to construct arguments against her own dys-
functional urges and behavior. The approach is based on the effectiveness of coun-
terattitudinal writing and speaking as a method of attitude change.

THERAPIST :
That of course is going to be hell to do, don’t you think? Why would
you want to do that? It sounds so painful.
CLIENT : Well, I want to do it because it’s so inconsistent. It’s worse, you know, be-
cause when I’m, I know that, like with budgeting money, or whatever, I know
I need to do it and then when I don’t do it makes me even more upset.
THERAPIST : Why would you ever want to do something you’re not in the mood for?
CLIENT : Because I’ve got to. Because I can’t survive that way if I don’t.
THERAPIST : Sounds like a pretty easy life to me.
CLIENT :Yeah, but I can’t afford to live if I just spend money on fun and stupid friv-
olous things that I . . .
THERAPIST : Well, I guess maybe you should have some limits and not be too off the
wall, but in general, I mean, why clean the house if you’re not in the mood?
CLIENT : Because it pisses me off when it’s a mess. And I can’t find things, like I’ve
lost bills before and then I end up not paying them. And now I’ve got collec-
tion agencies on my back. I can’t deal with all this, and I end up self-harming
and going into the hospital. And then I just want to end it all. But it still does-
n’t seem to matter because if I’m not in the mood to clean it, I won’t.
THERAPIST : So, the fact that it makes horrible things happen in your life so far has-
n’t been enough of a motivation to get you to do things against your mood,
right?
CLIENT : Well, obviously not (laughs), because it’s not happening.
THERAPIST :Doesn’t that tell you though, this is going to be a big problem, don’t
you think? This isn’t going to be something simple. It’s not like you’re going
to walk in here and I’m going to say, “OK, magic wand,” and then all of a sud-
den you’re going to want to do things that you’re not in the mood for.
CLIENT : Yeah.
 Illustrations of DBT • 31

THERAPIST : Yeah, so it seems to me that if you’re not in the mood for things, if
you’re kind of mood dependent, that’s a very tough thing to crack. As a mat-
ter of fact, I think it’s one of the hardest problems there is to deal with.
CLIENT : Yeah, great. (Looks down and slumps.)

THERAPIST : I think we could deal with it but I think it’s going to be hell. The real
question is whether you’re willing to go through hell to get where you want to
get or not. Now I figure that’s the question.
CLIENT : Well, if it’s going to make me happier, yeah.

THERAPIST : Are you sure?

CLIENT : Yeah, I’ve been going through this since I was eleven years old. I’m sick of
this shit. I mean, excuse my language, but I really am, and I’m backed up against
the wall. Either I need to do this or I need to die. Those are my two choices.
THERAPIST : Well, why not die?

CLIENT : Well, if it comes down to it I will.

THERAPIST : Uh huh, but why not now?

CLIENT : Because, this is my last hope. Because if I’ve got one last hope left, why not
take it?
THERAPIST : So, in other words, all things being equal, you’d rather live than die, if
you can pull this off.
CLIENT : If I can pull it off, yeah.

THERAPIST : OK, that’s good, that’s going to be your strength. We’re going to play
to that. You’re going to have to remember that when it gets tough. But now I
want to tell you about this program and how I feel about you harming your-
self and then we’ll see if you still want to do this.
As illustrated by the foregoing segment, use of devil’s advocate has achieved “the
foot in the door” and an initial client commitment. I then “up the ante” with a brief
explanation of the program and its goals.

THERAPIST : Now, the most important thing to understand is that we are not a sui-
cide-prevention program, that’s not our job. But we are a life-enhancement
program. The way we look at it, living a miserable life is no achievement. 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. You should also know
that I look at suicidal behavior, including drinking Clorox, as problem-solving
behavior. I think of alcoholism the same way. The only difference is that cut-
ting, burning, unfortunately, it works. If it didn’t work, nobody would do it
more than once. But it only works in the short term, not the long term. So quit-
ting cutting, trying to hurt yourself, is going to be exactly like quitting alcohol.
Do you think this is going to be hard?
CLIENT : Stopping drinking wasn’t all that hard.

THERAPIST : Well, in my experience, giving up self-harm behavior is usually very

hard. It will require both of us working, but you will have to work harder. And
like I told you when we talked last week, if you commit to this it’s for one year.
Individual therapy with me once a week, and group-skills training once a week.
So, the question is, are you willing to commit for one year?
CLIENT : I said I’m sick of this stuff. That’s why I’m here.

THERAPIST : So you’ve agreed to not drop out of therapy for a year, right?
32 • LINEHAN

CLIENT : Right.
THERAPIST : And you do realize that if you don’t drop out for a year, that really does,
if you think about it, rule out suicide for a year?
CLIENT : Logically, yeah.

THERAPIST : So, we need to be absolutely clear about this, because this therapy won’t
work if you knock yourself off. The most fundamental mood related goal we
have to work on is that, no matter what your mood is, you won’t kill yourself,
or try to.
CLIENT : All right.

THERAPIST : So that’s what I see as our number-one priority, not our only one but
our number one, that we will work on that. And getting you to agree, mean-
ingfully of course, and actually following through on staying alive and not
harming yourself and not attempting suicide no matter what your mood is.
Now the question is, whether you agree to that.
CLIENT : Yes, I agree to that.

At this point, I have obtained the client’s commitment to work on suicidal behav-
ior. To have her enhance the strength of the commitment, I again employ the strat-
egy of devil’s advocate.
THERAPIST : Why would you agree to that?

CLIENT : I don’t know (laughs).

THERAPIST : I mean, wouldn’t you rather be in a therapy where if you wanted to kill
yourself, you could?
CLIENT : I don’t know. I mean, I never really thought about it that way.

THERAPIST : Hmmm.

CLIENT : I don’t want to . . . I want to be able to get to the point where I could feel
like I’m not being forced into living.
THERAPIST : So . . . are you agreeing with me because you’re feeling forced into
agreeing?
CLIENT : You keep asking me all these questions.

THERAPIST : What do you think?

CLIENT : I don’t know what I think right now, honestly.

Sensing when the client has been pushed to her limits is an important validation
strategy. Stepping back and at least temporarily refraining from further pressuring
is an example of a response that, although it may not verbally validate, functions to
communicate that the client’s response or communication is valid. In instances such
as this, continued pressure is likely to boomerang and have the opposite effect of
what I intend. Here I notice the client’s confusion. Consequently I step back and
move in with validation.

THERAPIST : So you’re feeling pushed up against the wall a little bit, by me?
CLIENT : No, not really. (Client starts to cry)

THERAPIST : What just happened . . . just now?

CLIENT : (Pause) - I don’t know. I mean, I don’t think I really want to kill myself. I
think I just feel like I have to. I don’t think it’s really even a mood thing. I just
 Illustrations of DBT • 33

think it’s when I feel like there’s no other choice. I just say, “Well, you know
there’s no other choice, so do it.” You know. And so, right now I don’t see any
ray of hope. I’m going to therapy, which I guess is good. I mean I know it’s
good, but I don’t see anything any better than it was the day I tried to kill my-
self.
THERAPIST : Well, that’s probably true. Maybe it isn’t any better. I mean, trying to
kill yourself doesn’t usually solve problems. Although, it actually did do one
thing for you.
CLIENT : It got me in therapy.

THERAPIST : Yeah. So my asking you all these questions makes you start to cry. You
look like you must be feeling pretty bad.
CLIENT : Just overwhelmed, I guess the word is.

THERAPIST : That’s part of the reason we’re having this conversation, to try to struc-
ture our relationship so that it’s very clear for both of us. And that way, at least,
we’ll try to cut down on how much you get overwhelmed by not knowing
what’s going on with me. OK?
CLIENT : Uh huh.

THERAPIST : And so, I just want to be clear on what our number one goal is, and how
hard this is because if you want to back out, now’s the time. Because I’m going
to take you seriously if you say, “Yes, I want to do it.”
CLIENT : I don’t want to back out.

THERAPIST : OK. Good. Now, I just want to say that this seems like a good idea right
now. You’re in kind of an energized mood today, getting started, a new pro-
gram. But in five hours it might not seem like such a good idea. It’s kind of like
it’s easy to commit to a diet after a big meal, but much harder when you’re hun-
gry. But we’re going to work on how to make it keep sounding like a good idea.
It’ll be hell, but I have confidence, I think we can be successful working to-
gether.

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. Cheerleading, a
validation strategy, and relationship enhancement lay the foundation for a strong
therapeutic alliance. A standard assessment of imminent suicide risk is done before
ending the session.

session goal: Reduce suicidal behavior

strategies: Validation, problem solving (clarifying consequences of behavior, didac-
tic, behavioral and solution analysis), stylistic (irreverent communication), di-
alectical (metaphor, making lemonade out of lemons), skills training (distress
tolerance).

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. I have reviewed the
client’s diary card and note a recent parasuicide in which the client opened up a pre-
viously self-inflicted tendon tear following her physician’s refusal to provide pain
medication. Following getting a description of exactly what further harm the client
34 • LINEHAN

had done to her leg, I begin with a detailed analysis of the factors influencing the
client’s self-harm.

THERAPIST : OK. Now. You were in here last week telling me you were never going
to hurt yourself again because this was so ridiculous, you couldn’t stand it, you
couldn’t hurt yourself any more. So let’s figure out how that broke down on
Sunday so we can learn something from it. OK. So when did you start having
urges to hurt yourself?
CLIENT : My foot began to hurt on Wednesday. I started to have a lot of pain

THERAPIST : It hadn’t hurt before that?

CLIENT : No.

THERAPIST : So the nerves were dead before that or something, huh? So you started
having a lot of pain. Now, when did you start having the pain and when did the
urge to harm yourself come?
CLIENT : At the same time.

THERAPIST : They just come at the identical moment?

CLIENT : Just about.

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 behav-
ior. Here I begin by directly inquiring when the urges to parasuicide began.

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, maybe it wasn’t till Thursday, but I asked my nurse. I go,
look, I’m in a lot of pain you know. I’m throwing up my food because the pain
is so bad. And the nurse tried. She called the doctor and told him I was in a lot
of pain, and asked if he’d give me some painkillers. But no! So I kept asking,
and the answer kept being no, and I got madder and madder and madder. So I
felt like I had to show somebody that it hurts because they didn’t believe me.
THERAPIST : So let’s figure this out. So is it that you’re assuming that if someone be-
lieved it hurt as bad as you said it does, they would actually give you the pain
killers?
CLIENT : Yes.

THERAPIST : OK. That’s where the faulty thinking is. That’s the problem. You see,
it’s entirely possible that people know how bad the pain is, but still aren’t giv-
ing you medication.
CLIENT : I believe firmly, and I even wrote it in my journal, that if I’d gotten pain
medication when I really needed it I wouldn’t have even thought of self-harm-
ing.

I have proceeded by beginning to obtain a description of the events concurrent with

the onset of the problem. Here it has become apparent that maladaptive thinking
has been instrumental in the client’s decision to self-harm. In the following segment
I use the dialectical strategy of metaphor to highlight for the client her faculty think-
ing.
 Illustrations of DBT • 35

THERAPIST : Now. Let me ask you something. You’ve got to imagine this, OK? Let’s
imagine that you and I are on a raft together out in the middle of the ocean. Our
boat has sunk and we’re on the raft. And when the boat sunk your leg got cut
really badly. And together we’ve wrapped it up as well as we can. But we don’t
have any pain medicine. And we’re on this raft together and your leg really
hurts and you ask me for pain medicine and I say no. Do you think you would
then have an urge to hurt yourself and make it worse?
CLIENT : No, it would be a different situation.

THERAPIST : OK, but if I did have the pain medication and I said no because we have
to save it, what do you think?
CLIENT : If that were logical to me I’d go along with it and wouldn’t want to hurt
myself.
THERAPIST : What if I said no because I didn’t want you to be a drug addict?

CLIENT : I’d want to hurt myself.

THERAPIST : OK. So we’ve got this clear. The pain is not what’s setting off the desire
to self-harm. It’s someone not giving you something to help, when you feel they
could if they wanted to.
CLIENT : Yes.

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. In the following segment,
I continue to highlight the communication function of parasuicide, becoming also
slightly irreverent.

THERAPIST : OK, so in other words, hurting yourself is communication behavior,

OK? So what we have to do is figure out a way for the communication behav-
ior to quit working.
CLIENT : Why?

THERAPIST: Because you’re not going to stop doing it until it quits working. It’s
like trying to talk to someone; if there’s no one in the room you eventually
quit trying to talk to them. It’s like when a phone goes dead, you quit
talking.
CLIENT : I tried three nights in a row in a perfectly assertive way and just clearly stat-
ed I was in a lot of pain.
THERAPIST : You know, I think I’ll switch chairs with you. You’re not hearing what
I’m saying.
CLIENT : And they kept saying, “No,” and then some little light came on in my head.

THERAPIST : I’m considering switching chairs with you.

CLIENT : And it was like, “Here, now can you tell that it hurts a lot?”

THERAPIST : I’m thinking of switching chairs with you.

CLIENT : Why?

THERAPIST : Because if you were sitting over here I think you would see that, no
matter how bad the pain is, hurting yourself to get pain medication is not a rea-
sonable response. The hospital staff may not have been reasonable either. It may
be that they should have given you pain medicine. But we don’t have to say
36 • LINEHAN

they were wrong in order to say that hurting yourself was not the appropriate
response.
CLIENT : No, I don’t think it was the appropriate response.

THERAPIST : Good. So what we’ve got to do is figure out a way to get it so that the
response doesn’t come in, even if you don’t get pain medicine. So far it has
worked very effectively as communication. And the only way to stop it is to
get it to not work anymore. And of course it would be good to get other things
to work. What you’re arguing is “Well, OK, if I’m not going to get it this way
then I should be able to get it another way.”
CLIENT : I tried this time!

THERAPIST : Yes, I know you did, I know you did.

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.
THERAPIST : Now, we’re not on the same wavelength in this conversation.

CLIENT : Yes we are. What wavelength are you on?

THERAPIST : I’m on the wavelength that it may have been reasonable for you to get
pain medicine, and I certainly understand your wanting it. But I’m also saying
that, no matter what’s going on, hurting yourself is something we don’t want
to happen. You’re functioning like if I agreed with you that you should get pain
medication I would think this was OK.
CLIENT : Hmmm?

THERAPIST : You’re talking about whether they should have given you pain med-
ication or not. I’m not talking about that. Even if they should have, we’ve got
to figure out how you could have gotten through without hurting yourself.

As illustrated by the foregoing exchange, borderline clients often want to remain

focused on the crisis at hand. This poses a formidable challenge for the therapist,
who must necessarily engage in a back-and-forth dance between validating the
client’s pain and pushing for behavioral change. This segment also illustrates how
validation does not necessarily imply agreement. Although the therapist validates
the client’s perception that the refusal to provide pain medication may have been
unreasonable, she remains steadfast in maintaining the inappropriateness of the
client’s response.

CLIENT : I tried some of those distress-tolerance things and they didn’t work.
THERAPIST : OK. Don’t worry, we’ll figure out a way. I want to know everything
you tried. But first I want to be sure I have the picture clear. Did the urges start
building after Wednesday and get worse over time?
CLIENT : Yeah. They started growing with the pain.

THERAPIST : With the pain. OK. But also they started growing with their continued
refusal to give you pain medicine. So you were thinking that if you hurt your-
self they would somehow give you pain medicine?
CLIENT : Yeah. Cause if they wouldn’t listen to me then I could show them.

THERAPIST : OK, so you were thinking, “If they won’t listen to me I’ll show them.”
And when did that idea first hit? Was that on Wednesday?
CLIENT : Yeah.
 Illustrations of DBT • 37

THERAPIST : OK. Well, we’ve got to figure out a way to tolerate bad things without
harming yourself. So let’s figure out all the things you tried, and then we have
to figure out some other things because those didn’t work. 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, and it would normally be premature to
move to the stage of solution analysis. However, 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, in fact, attempted to use some coping skills.

CLIENT : I thought that if I just continued to be assertive about it that the appropri-
ate measures would be taken.
THERAPIST : OK, but that didn’t work. So why didn’t you harm yourself right then?

CLIENT : I didn’t want to.

THERAPIST : Why didn’t you want to?

CLIENT : I didn’t want to make it worse.

THERAPIST : So you were thinking about pros and cons, 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. Here I use the dialectical strat-
egy of turning lemons into lemonade by highlighting for the client how she did, in
fact, use coping skills. Note in the following response how I immediately reinforce
the client’s efforts with praise.

THERAPIST : That’s good thinking. That’s when you’re thinking about the advan-
tages and disadvantages of doing it. OK, so at that point the advantages of mak-
ing it worse were outweighed by the disadvantages. OK. So you keep up the
good fight here. Now what else did you try?
CLIENT : I tried talking about it with other patients.

THERAPIST : And what did they have to say?

CLIENT : They said I should get pain medication.

THERAPIST : Right. But did they say you should cut yourself or hurt yourself if you
didn’t get it?
CLIENT : No. And I tried to get my mind off my pain by playing music and using
mindfulness. I tried to read and do crossword puzzles.
THERAPIST : Um hmmm. 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. And you just give yourself up to that situation. You
just accept that it ain’t going to happen, that you’re going to have to cope in
some other way.
CLIENT : Which I did yesterday. I needed a little Ativan to get me there but I got
there.
38 • LINEHAN

THERAPIST : Yesterday?
CLIENT : Yeah. I took a nap. When I woke up I basically said, “Hey, they’re not go-
ing to change, 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 border-
line personalities. I’m still very angry about that.
THERAPIST : OK. That’s fine. Did it help though, to accept.

CLIENT : Um hmmm.

THERAPIST : That’s good. That’s great. That’s a great skill, a great thing to practice.
When push comes to shove, when you’re really at the limit, when it’s the worst
it can be, radical acceptance is the skill to practice.
CLIENT : That’s AA [Alcoholics Anonymous].

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.
Here I suggest a solution that is also taught in the DBT skills-training module on
distress tolerance. The notion of radical acceptance stresses the idea that acceptance
of one’s pain is a necessary prerequisite for ending emotional suffering.

THERAPIST : OK. Now let’s go back to how did you give in to the urge. Because you
really managed to battle all the way till then, right? OK. Usually with you we
can assume that something else happened. So let’s figure out Sunday and see if
there wasn’t an interpersonal situation on that day that made you feel criticized,
unloved, or unacceptable.
CLIENT : Well, on Saturday I was so pissed off and I went to an AA meeting. And it
got on my brain how alcohol would steal away my pain. I went looking all
around the neighborhood for an open store. I was going to go get drunk. That’s
how much my pain was influencing me. But I couldn’t find a store that was
open so I went back to the hospital.
THERAPIST : So you got the idea of getting alcohol to cure it, and you couldn’t find
any so you went back to the hospital, you were in a lot of pain, 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, that’s how bad my pain is. And that wasn’t listened to.
THERAPIST : So you figured that should have done it?

CLIENT : Yeah.

THERAPIST : Yeah. Cause that’s a high level communication, that’s like a suicide
threat. Very good though. I want you to know, that’s better than a suicide threat
because that means you had moved your threats down.

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. The therapeutic
utility of irreverence is often in its shock value, which may temporarily loosen a
client’s maladaptive beliefs and assumptions and open up the client to the possibil-
ity of other response solutions.

CLIENT : And I just told her how I was feeling about it, and I thought that would do
it. And the doctor still wouldn’t budge.
 Illustrations of DBT • 39

THERAPIST : So what did she do? Did she say she would call?
CLIENT : She called.

THERAPIST : OK. And then what happened?

CLIENT : She came back, she was really sweet and she just said, “I’m really sorry, but
the doctor said no.”
THERAPIST : Then did you feel anger?

CLIENT : I don’t know if I was really angry, but I was hurt.

THERAPIST : Oh really? Oh, that’s pretty interesting. OK. So you were hurt . . .

CLIENT : Because I ended up hugging my teddy bear and just crying for a while.

THERAPIST : Before or after you decided to hurt yourself?

CLIENT : Before.

THERAPIST : OK. So you didn’t decide right away to hurt yourself. You were think-
ing about it. But when did you decide to do it?
CLIENT : Later on Saturday.

THERAPIST : When?

CLIENT : After I got sick of crying.

THERAPIST : So you lay in bed and cried, feeling uncared about and hurt, abandoned
probably, and unlovable, like you weren’t worth helping?
CLIENT : Yes.

THERAPIST : That’s a really adaptive response. That’s what I’m going to try to teach
you. Except that you’ve already done it without my teaching it to you. So how
did you get from crying, feeling unloved and not cared about and you cry and
sob? How did you get from there to deciding to hurt yourself, instead of like
going to sleep? . . .
CLIENT : Because then I got angry. And I said, “Fuck this shit, I’ll show him.”

THERAPIST : Now did you quit crying before you got angry, or did getting angry
make you stop crying?
CLIENT : I think getting angry made me stop crying.

THERAPIST : So you kind of got more energized. So you must have been ruminating
while you were lying there, thinking. What were you thinking about?
CLIENT : For a long time I was just wanting somebody to come care about me.

THERAPIST : Uh huh. Perfectly reasonable feelings. Makes complete sense. Now

maybe there you could have done something different. What would have hap-
pened if you had asked the nurse to come in and talk to you, 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, notated with possi-
ble alternative pathways. Here I am searching for junctures in the map where pos-
sible alternative responses are available to the client.

CLIENT : They don’t have time to do that.

THERAPIST : They don’t? Do you think that would have helped?

CLIENT : I don’t know. She couldn’t help me.

THERAPIST : She could have made you feel cared about. That would have been a car-
ing thing to do.
40 • LINEHAN

CLIENT : Yeah, but I don’t think it would have helped.

THERAPIST : What would have helped?

CLIENT : Getting pain medication.

THERAPIST : I thought you’d say that. You have a one-track mind. Now listen, we’ve
got to figure out something else to help you, because it can’t be that nothing
else can help. That can’t be the way the world works for you. There’s got to be
more than one way to get everywhere, because we all run into boulders on the
path. Life is like walking on a path, you know, and we all run into boulders. It’s
got to be that there are other paths to places. And for you, it really isn’t the pain
in your ankle that’s the problem, it’s the feeling of not being cared about. And,
probably, a feeling that has something to do with anger, or a feeling that other
people don’t respect you, a feeling of being invalidated.
CLIENT : Yes.

THERAPIST : So I think it’s not actually the pain in your ankle that’s the problem. Be-
cause 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, right? So it’s really not the pain, it’s the
sense of being invalidated and the sense of not being cared about. That’s my
guess. Do you think that’s correct?
CLIENT : Yes.

THERAPIST : See, the question is, is there any other way for you to feel validated and
cared about other than them giving it to you?
CLIENT : No.

THERAPIST : Now is this a definite, like, “I’m not going to let there be any other
way,” or is it more open, like, “I can’t think of another way but I’m open to the
possibility?”
CLIENT : I don’t think there’s another way.

THERAPIST : Does that mean you’re not even open to learning another way?

CLIENT : Like what?

THERAPIST : I don’t know. We have to figure it out. 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 tak-
en seriously, invalidated. That’s what sets you up to hurt yourself, and also want
to die. 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. Are you open to that?
CLIENT : Yeah.

As illustrated above, this fine-grained analysis is often an excruciating and labo-

rious process for client and therapist alike. Therapists often feel demoralized and
tempted to abandon the effort, which may be likened to trying to find a pair of foot-
prints hidden beneath layers of fallen leaves; the footprints are there, but it may take
much raking and gathering of leaves before they are uncovered. With repeated
analyses, however, clients learn that their therapist will not back down. Such per-
sistence will eventually undermine a client’s refusal to attempt new and adaptive
problem-solving behaviors. As clients increasingly acquire new coping skills, more
adaptive attempts at problem resolution will eventually become discernible.

Session goal: Emotion regulation, interpersonal effectiveness

 Illustrations of DBT • 41

Strategies: Dialectical (metaphor), validation (cheerleading), problem solving (clar-

ification of consequences of behavior, use of reinforcement procedures), sty-
listic (reciprocal communication, irreverent communication), integrated (rela-
tionship enhancement).

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 sun-
glasses (again) and is angry because collection agencies have been persistent in pres-
suring her for payment on delinquent accounts. This first segment follows a long,
guarded, and somewhat tortured telling me of her week’s problems. I use cheerlead-
ing, clarifying the contingent consequences of her behavior, and then try to shape
her behavior so that she removes her sunglasses and works on expressing her anger.

THERAPIST : It’s not a catastrophe that the collector did this to you, and it’s not a ca-
tastrophe to be mad at the collector. It’s made your life a lot harder, but you can
handle this, you can cope with this, this is not more than you can cope with.
You’re a really strong woman, you’ve got it inside you. But you’ve got to do
it, you’ve got to use it. I’m willing to help you but I can’t do it alone, you have
to work with me.
CLIENT : How?
THERAPIST : Well, by taking off your sunglasses, for starters.

I have begun the exchange by attempting to normalize the issue (“It’s not a cat-
astrophe . . .”), validating the client (“It’s made your life a lot harder . . .”), and
cheerleading (“ . . . you can handle this, you can cope . . . you’re a really strong
woman . . .”). I then move to clarify the contingent consequences of the client’s be-
havior by pointing out that provision of my assistance is contingent on her will-
ingness to work. I immediately follow this by requesting a response the client is ca-
pable of making.

CLIENT : I knew you’d say that.

THERAPIST : And I knew you knew I’d say that.

CLIENT : Sunglasses are your biggest bitch, I think.

THERAPIST : Well, how would you like to look at yourself talking to someone else?
(long pause) They make it difficult for me. And I figure they make it harder for
you; I think you do better when you’re not wearing those sunglasses. It’s like
a step, you always do better when you go forward. And when you do, you feel
better. I’ve noticed that. (long pause) So that’s what you should do, you should
take off your sunglasses and then we should problem solve on how to cope
when you can’t get angry. 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 we
just have to deal with that, you and me. It’s just a problem to be solved, it’s not
a catastrophe, it’s not the worst thing any one ever did. It’s just a problem that
you have, and that’s what you and I do, we solve problems, we’re a problem-
solving team. (pause)
CLIENT : (Removes sunglasses) All right.

THERAPIST : Thank you. That’s a big step, I know, for you.

42 • LINEHAN

My use of reciprocal communication informs the client of her feelings regarding the
sunglasses. Note my matter-of-fact attitude and my continued attempt to normal-
ize the issue (that is, “There’s nothing freakish about that . . . It’s not the worst thing
any one ever did.”). Also note the framing of the issue as a problem to be solved, as
well as my use of the relationship strategy to enhance the therapeutic alliance. I also
make a point of validating the client by letting her know that I realize this was dif-
ficult for her. Somewhat later in the session I move to elicit new behavior.

THERAPIST : Now c’mon, I want you to find it inside yourself, I know you’ve got it,
I know you can do it. You can’t give up, you can’t let your feet slip. Keep go-
ing, just express directly to me how you feel. That you’re angry at yourself, that
you’re angry at the collection agency and that you’re damn angry with me.
(Long pause)
CLIENT : (Barely audible) I’m angry at you, at myself, and the collection agency.

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.

THERAPIST : Good, that kill you? (Long pause) That’s great. Is that hard? (Long
pause) It was, wasn’t it? Now say it with a little vigor. Can’t you say it with a
little energy?
CLIENT : (Shakes her head no)
THERAPIST : Yes you can. I know you’ve got it in you. I have a good feel for what
your strengths are. I don’t know how I’ve got this good feel, but I do. And I
know you can do it and you need to do it, and you need to say it with some en-
ergy. Express how angry you are, you don’t have to yell and scream or throw
things. Just say it aloud - “I’m angry!” (long pause) You can scream of course
if you want, you can say, “I’m Angry! . . .”
CLIENT : That’s it. That’s all I can do.

THERAPIST : Listen, you have to take the risk. You’re not going to get past this or
through this. You have to take the risk. You are like a person mountain climb-
ing and we’ve come to this crevasse and it’s very deep, but we can’t go back be-
cause there’s an avalanche and the only way to go forward is for you to jump
over this crevasse. You’ve got to do it. Tell me how mad you are, in a way that
I can understand how you really feel.
CLIENT : (long pause) I can’t do any of it.

THERAPIST : That is bullshit.

CLIENT : You want me to get angry at you, don’t you?

THERAPIST: I don’t care who you get angry at. I think you already are angry. I just want
you to express it. I’m not going to ask you to do anything more today, by the way.
I figure the only thing today you have to do is say, “I’m angry,” in a voice that
sounds angry, and I figure you’re capable of that. And I might be angry if you
don’t do it. I don’t think I will be, but I might. That’s okay, I can be angry, you
can be angry, we can be angry sometimes and it isn’t going to kill either one of us.

Cheerleading and metaphor have been unsuccessful in moving the client to ex-
press her anger more forcefully. Consequently I switch to irreverent communica-
 Illustrations of DBT • 43

tion in an attempt to get the client to jump track. Also note how I have communi-
cated to the client the potential negative consequences of her continued refusal to
express her anger (that is, “. . . I might be angry . . .”). In this manner, I am both us-
ing the relationship as a contingency and am also modeling comfort with anger.

THERAPIST : OK, so how angry are you? On a scale of one to a hundred, how angry
would you say you are?
CLIENT : (Barely audible) Maybe one hundred.

THERAPIST : Really?

CLIENT : They know my situation.

THERAPIST : Um hum.

CLIENT : They’re persistent.

THERAPIST : Um hum. (pause) Who’s the safest to be angry at? Yourself, me, or the
collection agency?
CLIENT : Collection agency.

THERAPIST : OK, then, tell me how angry you are. You don’t have to make it sound
like a hundred; try to make it sound like a fifty.
CLIENT : They really pissed me off! (Said in a loud, angry voice)

THERAPIST: Well, damn right. Piss me off too!

CLINICAL ISSUES AND SUMMARY

As illustrated by the foregoing exchanges, a primary difficulty in working with bor-

derline clients is their not-uncommon tendency to refuse to engage in tasks recom-
mended by the therapist. 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” state-
ments. In situations like these, the use of irreverent communication and dialectical
strategies such as story telling and metaphor often succeed in producing a break-
through and gaining the client’s working alliance. The role of validation is central
to this alliance. The therapist validates the importance of the client’s problem, pain,
and difficulty, the client’s sense of place, the sense of being out-of-control and the
fact of dysregulation in order to balance the behavior-change strategies and dialec-
tical strategies that move both therapist and client away from verbal constructs to-
ward experiencing the moment. This process is indispensable to maintain thera-
peutic movement and flow.
A colleague, Bruce Rounsaville, has described DBT as the process of playing
jazz. The therapist must have a firm grounding in both theory and technique, be
able to play with flexibility and spontaneity, and play within and in response to a
relationship with others playing in the moment. In DBT, the therapist has to have
expertise in a wide range of behavioral, acceptance, and dialectical procedures and
have an overall “frame” of dialectics and of radical genuineness. The therapist must
also be able to put them together flexibly and spontaneously to address the prob-
lems presented in the moment with the client, moving then to the next moment and
the next problem without losing rhythm or relationship to the client.
The procedures that make up DBT have to be overlearned, to keep the focus on
the client rather than on the procedure or on the therapist. The therapist must be
44 • LINEHAN

able to quickly hear the problem being presented in the moment, select and imple-
ment the procedure most likely to be effective for the problem presented—and then
move to the next problem being presented in the moment, select and implement the
next procedure, and so on. It is the flexibility and spontaneity in applying princi-
ples 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. DBT requires a very focused attention, an abili-
ty to be in one’s own shoes while simultaneously being in the client’s shoes, modi-
fying a sentence before it is even finished in response to how it sounds to the client’s
ear.

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