Cognitive-Behavioral Theory Expanded: The Dialectical Behavioral Approach

The basic cognitive-behavioral therapeutic approach proved to be quite successful for treating depressed and anxious clients, but 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, prompting psychologist Marsha Linehan, Ph.D. to expand and enhance the basic cognitive-behavioral model to better account for the special difficulties of emotional dysregulation and self-destructive behaviors that are commonly associated with the Borderline Personality Disorder.

Linehan noted that people with Borderline Personality Disorder are exceptionally sensitive, and 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 important of which was a new emphasis on the acceptance and validation of her client's emotional and behavioral states, to counter-balance the traditional cognitive-behavioral emphasis on changing those states.

Acceptance and change agendas are incompatible, and difficult or impossible to promote 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 because by doing so you have 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 being borrowed from the philosophical mode of argument). Some of the time she would be accepting while at other times she would be challenging, moving between these two modes as required by her client's ability to tolerate the emotions surrounding requests for change. Thus was born Linehan's Dialectical Behavioral Therapy, described in detail in the treatment section.