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East Meets West in Dialectical Behavior Therapy

DBT engages and motivates patients for treatment with a non-judgmental attitude of acceptance and dignity, recognizing that each person has inherent worth and the capability to learn skills for effective living.

Dialectical Behavior Therapy (DBT) is a behavior therapy approach that was originally developed to treat patients with borderline personality disorder. It is considered an empirically validated treatment, meaning scientific studies have shown that the treatment works. The core features of borderline personality disorder are unstable mood, unstable relationships, all-or-nothing thinking, trouble managing emotions, and self-injurious behaviors. These symptoms are not limited to borderline personality disorder. People with eating disorders, trauma disorders, substance abuse disorders, bipolar disorder, depression and anxiety often have difficulty regulating their emotions. The treatment is also effective in treating symptoms related to suicidal thoughts or thoughts/behaviors related to self-harm, like cutting oneself. Marsha Linehan, the originator of DBT (1993a), found that patients being treated with DBT dropped out of treatment less, stayed out of the hospital more, and overall had a better treatment outcome. Even though DBT has been scientifically studied primarily for borderline personality disorder, the dialectical perspective and the skill sets can be very useful for almost anyone (with or without a mental health disorder).

Are our problems or symptoms related to nature or nurture? In most cases, the answer is both. Biologically (nature), we all come with the nervous system we inherited. Some people come with very sensitive nervous systems while others tend to have a nervous system that does not react very much. We grew up with the parents and environments into which we were born (nurture). The goal of DBT is to develop dialectical thinking and practice skills to effectively manage emotions, suffering, and relationships. DBT is predicated on a biopsychosocial viewpoint of emotional dysregulation, a dialectical worldview, and the integration of cognitive-behavioral therapy (CBT) and Eastern approaches (such as mindfulness) with the ultimate goal of gaining a life worth living.

DBT begins with a dialectical worldview. Dialectical is defined as the art of arriving at the truth by the exchange of logical arguments. A worldview is the prism through which we look at ourselves, our world, and our future. Our worldview significantly influences how we think which, in turn, affects how we feel. A dialectical worldview embraces the inherent tensions in life and offers a way of thinking that helps to synthesize tensions by recognizing that two seemingly opposing thoughts or feelings can both be true at the same time. For example, one might be both sad and hopeful or one may be both anxious and excited about an upcoming trip. In relationships, both people’s needs or wants are legitimate, even if they appear to conflict with one another. A dialectical worldview suggests that we balance acceptance and change resulting in a synthesis of the two while avoiding all-or-nothing approaches.

Often we can be so focused on changing our minds, our feelings, our symptoms, or ourselves, that we neglect to notice that perhaps by accepting ourselves, we can decrease our emotional suffering. Acceptance does not mean resignation and does not mean that there are not habits, thoughts, feelings or behaviors that we would like to change. As Linehan has stated “to accept something is not the same as judging it good.” Oftentimes, it is easier to change once we have accepted ourselves. DBT supports that one’s needs and feelings are valid. Pain does, indeed, exist. DBT strives to decrease needless suffering, like feeling depressed about feeling depressed. Linehan has been quoted as saying “pain creates suffering only when you refuse to accept the pain.” DBT would assert that we may not have caused all of our problems, but they are ours to solve. Jon Kabat-Zinn, founding director of the Center for Mindfulness in Medicine, Health, and Society, has been quoted as saying “you cannot stop the waves, but you can learn to surf.”

DBT begins with identifying and prioritizing the behavioral targets needing skill development. DBT helps us to learn more skillful ways of having our needs met that decrease suffering, interpersonal conflict, and behavioral consequences. DBT skills training involves learning core mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills (Linehan, 1993b). Mindfulness is an acceptance skill and the core DBT skill. Mindfulness is about staying in the present moment, because that is the only real moment that exists. Depression occurs when our attention gets dragged to the past, whereas anxiety occurs when our attention gets dragged into the future. Mindfulness practice cultivates “attention control muscles” so that the person is better able to direct and keep their attention in the present moment, which reduces suffering. Mindfulness is needed in order to be aware of one’s thoughts and feelings and provides the opportunity to practice the other skill sets.

Distress tolerance is an acceptance skill that helps the person get through a difficult moment. Some strategies may include distraction, self-soothing, and strategies to improve the moment. Emotion regulation is a change skill where the person tries to change their emotional experience. Some strategies are aimed at reducing vulnerability to negative emotions, such as getting enough sleep, eating well, exercising, and avoiding the use of mind altering substances, like alcohol. Other strategies involve “acting opposite” to the emotion (for example, watching a comedy movie when you are feeling down), “checking the facts” to determine whether or not the emotional reaction is effective for the current situation, or cultivating more positive life experiences. Interpersonal effectiveness is also a change skill. The major goals of becoming more skillful in interpersonal interactions are to achieve objectives and to preserve relationships and one’s self-respect. These skill sets help to balance acceptance (of self and situation) and change.

DBT is a very structured treatment approach that may be different from other types of therapy many people have experienced and may take some adjustment. DBT is focused on learning new behaviors. It provides hope and a path toward peace. Regardless of what nervous system you were born with, what parents you had, or what environment you grew up in, you can learn to think differently about yourself, your world, and your future while learning concrete skills to help you stay in the moment and manage your emotions and your relationships supporting quality of life. It is not a moral judgment if you do not have particular skills necessary for effectiveness, it just means that there is an opportunity for you to learn while balancing acceptance and change and recognizing that both approaches are needed for recovery, well being, and peace.

Maria Mouratidis, Psy.D.

Psychologist, The Retreat at Sheppard Pratt



Linehan, M. (1993a). Cognitive-Behavioral Treatment of Borderline Personality Disorder. The Guilford Press

Linehan, M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. The Guilford Press



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Last modified: Saturday, April 19, 2014

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