Psychol Stud (January–March 2012) 57(1):46–54 DOI 10.1007/s12646-011-0132-8

REVIEW ARTICLE

Dialectical Behavior Therapy for Managing Interpersonal Relationships Shalini Choudhary & Komilla Thapa

Received: 14 July 2011 / Accepted: 24 October 2011 / Published online: 20 December 2011 # National Academy of Psychology (NAOP) India 2011

Abstract Dialectical Behavior Therapy (DBT) is a treatment designed for individuals having borderline personality disorder (BPD), patients having binge eating disorder, comorbid substance dependence and BPD, and depressed older adults. This paper aims to explore the use of DBT and to ascertain the status of DBT education in treating difficulties in handling interpersonal relationships among clients seeking counseling and psychotherapy. The skills training mode can be employed for teaching skills to solve relationship problems. Validation and acceptance strategies can lessen rejection sensitivity and negative feelings that make interpersonal situations chaotic. Black and white thinking can be resolved by finding a middle path through acceptance and change. This paper suggests the possible utility of DBT for enhancing psychological well-being in clients. Keywords Dialectical behavior therapy . Interpersonal relationships . Managing relationship problems

Healthy relationships are a crucial part of human development and individual growth. Through close relationships (e.g. friendships), people are able to empathize with others, experience both feelings of independence and dependence within a relationship, trust others, and communicate more easily in times of conflict. Jourard and Landsman (1980) said that a healthy relationship has (1) open, honest communication, (2) reasonable expectations or demands S. Choudhary (*) : K. Thapa Centre for Advance Studies in Psychology, Department of Psychology, University of Allahabad, Allahabad 211002, India e-mail: [email protected]

of each other, (3) concern about the other’s well being and (4) freedom for both to be themselves. Individuals generally have needs, feelings and boundaries, but many people become confused when they come in contact with others or form close relationships and these relationships have needs and paths that are in competition with individual needs and goals. Relationship researchers have identified a variety of needs and goals that are often unique to the type of relationship addressed (Berscheid 1994). Hamachek (1982) says about things that interfere with healthy relationships (1) we underestimate the changes we need to make but push too hard for other people to change, (2) not liking ourselves is usually associated with not liking other people, (3) shyness inhibits closeness and intimacy with others and (4) playing deceptive, self-serving “games” and being jealous will drive others away. Brown (1995 cf, Jourard and Landsman 1980) describes the decline of true intimacy in American culture and tries to explain why Americans are becoming more and more unable to sustain meaningful relationships. Most people also accept that individuals change in various ways over time, but are not able to accept that relationships change, grow and decline in their own ways as well. Somehow, relationship or group needs must be considered and balanced with individual needs. Unfortunately, many people do not see the forces and elements involved to be able to create this balance. This leads to common interpersonal difficulties or problems raised by persons seeking counseling. Interpersonal problems are recurrent difficulties in relating to others, in clinical as well as nonclinical sample (Reeves et al. 2010) and are a common reason why people seek psychotherapy (Horowitz et al. 1993). People having Borderline Personality Disorder (BPD) usually have disturbed relationships as a core characteristic. The relational style of borderline personality disorder

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patient is characterized as intense and unstable relationships, marked further by abandonment fears and by vacillating between idealization and devaluation (Gunderson 2007). Many interventions and therapeutic strategies are available for dealing with such interpersonal problems. Dialectical Behavior Therapy (DBT) is a treatment designed specifically for individuals who meet criteria for BPD and a host of co-occurring problems (e.g., depression, anxiety, substance abuse & eating disorders). DBT (Linehan 1993) was initially developed to treat the problems of emotion dysregulation and interpersonal deficits in BPD patients; thus, modifying DBT to treat people having chaotic relationships is a logical step and can be suggested to a nonclinical group. There are several levels of adapting DBT that are possible. First, one could simply apply DBT essentially intact to new populations (for example, to battering men; Fruzzetti et al. 1998 cf; Fruzzetti 2006). Or, one could use the existing treatment to augment outcomes with borderline clients (like teaching the original DBT skills to family members or partners of borderline clients; Fruzzetti 2006). Finally, one could also develop new interventions (skill modules and/or treatment strategies), consistent with the transactional model, to intervene specifically at the level of the environment (a family; Fruzzetti 2006). Thus effectiveness and success of DBT techniques can also be tried on other populations seeking therapy. Many clients seeking counseling and psychotherapy report interpersonal problems or difficulties in relating to others. Over the last few decades, research has shown that satisfying close relationships and active social support networks have important implications for health outcomes and behaviors (Berkman et al. 2000; Uchino et al. 1996 cf, Uchino 2004). DBT balances acceptance and change, with the overall goal of helping patients not only to survive, but also to build a life worth living. The “personality-event congruence hypothesis,” which posits that people who have an insecure relational phenotype experience stressful interpersonal events more drastically, has been confirmed that interpersonally preoccupied or needy people are more disposed to respond to interpersonal stressors by becoming stressed (Little and Garber 2005). The interpersonal situation becomes a kind of stressor to them thereby leading them to seek counseling. The nonclinical sample can also be treated through psychotherapeutic methods such as DBT. Dialectical Behavior Therapy is a branch or modification of cognitive-behavioral therapy (CBT) that includes an eclectic mix of methods common to several other approaches and biosocial theory. It uses standard CBT interventions (e.g., self-monitoring, behavioral analysis and solution analysis, didactic and orienting strategies, contingency management, cognitive restructuring, skills training, and exposure procedures).

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Although the intervention resembles cognitive behavior therapy there are several important distinctions. First, it is an intervention designed for non clinical sample. Second, it augments and reinforces the client’s individual treatment since it teaches many of the same skills (in addition to others) taught in the cognitive therapy. DBT for relationship management is viewed as an “additional” treatment to the individual. Third, it teaches emotion regulation techniques for specific negative emotions experienced in interpersonal situations. Fourth, the “Consultation Hour” (where clients bring up relationship issues like rejection sensitivity and interpersonal conflicts for consultation, with the goals of skill application/generalization and problem solving) is introduced. Finally, the program can be adapted for synthesizing dialectical dilemmas as in black and white thinking. Interpersonal conflict is a situation in which one or both persons in a relationship experience difficulty in working or living with each other. This usually occurs due to different or incompatible needs, goals or styles. The existence of conflict is usually signaled by negative feelings such as anger, jealousy, confusion, hostility, etc. A social cognitive approach to understanding interpersonal problems assumes that people who react differently to social situations think differently about those situations (Andersen and Chen 2002; Baldwin 1992 cf, Anderson and Chen 2002). DBT therapists take every opportunity to strengthen clients’ valid responses, which alone and in combination with CBT interventions facilitate change (Linehan et al. 2002 cf, Linehan et al. 2006a). Comprehensive DBT involves addressing five different functions in treatment: (a) enhancing client skills and capabilities (mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness skills); (b) generalizing those skills to everyday life; (c) increasing client motivation to use these skillful alternatives to reduce previous problematic behaviors and distress; (d) ensuring that the family and social environment do not impede treatment (and, ideally, facilitate it); and (e) enhancing therapist skills and motivation to provide treatment effectively (Linehan 1993).

The Dialectical Approach & & &

Dialectics stresses the basic interconnectedness of reality: to fully understand a person you have to understand his/her context. Reality is composed of opposing forces (thesis and antithesis): there can be no function without dysfunction; distortion without accuracy. The fundamental nature of reality is change. Resolution of the tension between polarities produces a “new”

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reality which, in turn, creates another set of polarities, and so on. DBT explores contradictory emotions, cognitions, and behavior patterns and attempts to find the middle ground. An implication of this premise is that people and their environment are in constant transition and need to adapt to inconsistency and change. Relationships serve as the primary source of affection and support (Levinger and Huston 1990). Difficulties with intimacy are frequently implicated in decisions to seek counseling for interpersonal problems whereas increasing or enhancing intimacy is often one of the goals of using dialectical behavior therapy. The significance of understanding adaptive interpersonal processes, such as intimacy, for well-being and optimal living is becoming increasingly recognized as a necessary area of study (Ryff and Singer 2000). Moreover, a greater understanding of the process that underlies intimacy can assist in identifying what is going awry when people complain of loss of intimate and loving feelings (Huston et al. 2001). With its increase in popularity there have emerged not only different methods of interpersonal interventions (e.g., interpersonal psychotherapy) but also DBT treatments are distinctly targeted for particular populations. Despite the considerable amount of data supporting the effectiveness of DBT for a variety of problems related to emotion regulation (e.g., Chapman 2006 cf, Lynch et al. 2006), DBT has not been evaluated as a treatment for people (nonclinical sample) having interpersonal problems. Considering the above mentioned viewpoint the purpose of this theoretical paper is to explore the use of dialectical behavior therapy (DBT) techniques in treating relationship problems or difficulties in handling relationships among clients seeking counseling and guidance. Another aim is to justify a more rigorous examination of the feasibility, efficacy and effectiveness of DBT as a treatment adapted for relationship conflicts. The DBT method used by the psychotherapists can be modified according to the needs of general population seeking counseling for difficulties in managing relationships or having unstable or chaotic relationships. The challenge in adapting and extending DBT to treat non clinical sample lies in its theoretical foundations.

Principle of Dialectics in Relationships The need to establish and maintain close relationships and connections with others has been identified as a central and fundamental human motivation (Baumeister and Leary 1995). Relationship issues can be understood in terms of Interpersonal Systems Theory (Connors 2007). Relation-

ship systems of Interpersonal Systems Theory constantly interact and change both within and between themselves and cope with a stormy sea of changes inside and outside these systems. The systems concepts of growth cycles and life cycles helps to understand the pain, chaos, awkwardness and risk that are inevitable and necessary for relationship health and productivity over time. Interpersonal Systems Theory reveals the commonalities and connections between relationships with all life forms. This theory strives to understand the complicated world of relationships through systems thinking. Systems Theory sees the universe as composed completely of living systems which connect, work together and evolve over time. The properties of Interpersonal Systems Theory like systems are holistic and that systems constantly involve in change cycles and are changed by the life-cycles, can be understood by a dialectical worldview. A dialectical worldview permeates DBT. A dialectical perspective holds that one can’t make sense of the parts without considering the whole that the nature of reality is holistic even if it appears that one can talk meaningfully about an element or part independently. Interpersonal systems self regulate for balance in order to stay healthy. Applying a dialectical perspective implies that it is natural and to be expected for these differing and partial perspectives to be radically in opposition. The existence of “yes” gives rise to “no,” “all” to “nothing.” From this point of view, polarized divergent opinions should be expected when a client has complex problems that generate strong emotional reactions in his/her helpers. Dialectical means that 2 ideas can both be true at the same time. & & & &

&

There is always more than one TRUE way to see a situation and more than one TRUE option, thought, or dream. Two things that seem like (or are) opposites can both be true. All people have something unique, different, and worthy to teach us. A life worth living has both comfortable and uncomfortable aspects (happiness AND sadness; anger AND peace; hope AND discouragement; fear AND ease, etc.). All points of view have both TRUE and FALSE within them.

Unlike prior approaches that stressed “personal insecurity” or “distorted thinking,” the current approach incorporates meta-cognitive, meta-emotional, and acceptance, change and mindfulness techniques. These techniques allow the client to accept discomfort, emotion, and uncertainty which may be an inevitable part of any relationship.

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The concept of the “invalidating environment,” central to DBT, maintains that invalidation occurs when valid (true, effective, and real) individual behaviors (esp. private behaviors such as thoughts, self-concept, emotional and sensory experiences) are delegitimized, punished, criticized, or pathologized. A validating environment (or validation), on the other hand, confirms what another is thinking, feeling, or experiencing. Validation is not necessarily positive (it may involve acknowledging anger or jealousy), does not necessarily involve agreement with another, and is possible at multiple levels (Linehan 1997 cf, Koerner and Dimeff 2007). Therapist uses dialectics in two ways: 1) Attempts to maintain a collaborative therapeutic relationship by balancing: – – –

Change & acceptance Flexibility & stability Challenging & nurturing

2) Teaches and models dialectical thinking and behavior by: – – – –

Highlighting contradictions in behavior and thinking. By offering opposite or alternative positions. By maintaining that truth is not absolute but is constructed and evolves over time. Attempts to find synthesis of oppositions (Hegel: Thesis, Antithesis, Synthesis)

Dialectical Approach for Relationship Management Exquisite emotional sensitivity, proneness to emotional dysregulation, and a long history of failed attempts to change either this intense emotionality or the problem behaviors associated with it make supportive treatment elements important. The Dialectical approach specifically skills training mode can be employed for teaching mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness skills. Mindfulness primarily has to do with the quality of awareness that an individual brings to the present experience. Mindfulness practice often involves letting go of attachments and becoming one with current experience, without judgment or any effort to change. At the same time, mindfulness involves the use of skillful means and the finding of a middle path between extremes or polarities. Skills to help clients discriminate between black and white thinking and negative feelings (e.g., mindfulness) are necessary in treatment. Skills taught in this module include observing, describing, fully participating, being nonjudg-

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mental, focusing on one thing in the present moment, and being effective over being right. Clients are likely to have difficulty labeling and expressing their emotional experiences accurately (and assertively) as a consequence of invalidation. Therefore, accurate expression is self-validating. Invalidation may be a core component of the many forms of interpersonal conflicts because it communicates non-acceptance (or rejection), criticism, disrespect, contempt, and/or disregard for other’s personal worth and often results in increased emotional arousal and distrust of others and one’s own feelings (Fruzzetti and Iverson 2004 cf, Iverson et al. 2009). Distress-tolerance training attempts to equip clients with a range of specific methods aimed at improving the client’s capacity to tolerate aversive situations, feelings, or thoughts; to survive crises; and to radically accept that which cannot be changed. Emotional regulation difficulties may lead to dysfunctional coping responses, such as problematic interpersonal behaviors, and may negatively affect emotional well-being (Gross et al. 2006). Emotion-regulation training tends to be more change focused and includes specific methods designed to identify what emotion is being experienced, to decide whether the emotion is justified or fits the current circumstances, and then to learn ways to modulate the emotion if the client decides he or she would like to change his or her emotional experience. Emotion intolerance and over-control of emotion can be replaced by self-validation, acceptance, and emotion regulation skills. The multiple emotional problems like anger and jealousy that result for many people in interpersonal situations, emotion regulation may be an important treatment target for this population. In response to intense emotional reactions during therapeutic tasks (e.g., talking about an event from the previous week), the therapist validates the uncontrollable, helpless experience of emotional arousal, and teaches the individual to modulate emotion in session, balancing, moment to moment, the use of supportive acceptance and confrontive change strategies. Finally, interpersonal effectiveness training is designed to help clients interact with others in ways that allow them to improve relationships while simultaneously maintaining their own personal values, self-respect and well being.

Resolving Interpersonal Issues Through DBT DBT validation strategies are meant not only to communicate empathic understanding but also to communicate the validity of the client’s emotions, thoughts, and actions. In addition, validation and acceptance strategies are taught to lessen rejection sensitivity or abandonment fears and negative feelings in interpersonal situations.

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Certain individuals are very sensitive to environmental circumstances. They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g., sudden despair in reaction to a friend’s or partner’s announcing the end of the meeting; distress when there are certain changes in preplanned schedules; panic or fury when someone important to them is just a few minutes late or must cancel an appointment). Rejection sensitivity is a trait closely related to abandonment fears and intolerance of aloneness. They may believe that this “abandonment” implies they are “bad.” These abandonment fears are related to an intolerance of being alone and a need to have other people with them. Brennan et al. (1998 cf DiTommaso 2003) indicated that adult attachments could be described in terms of two orthogonal dimensions: attachment anxiety and attachment avoidance. Adult attachment anxiety is defined as the fear of rejection and abandonment. Adult attachment avoidance is characterized as the fear of intimacy and discomfort with closeness and dependence. This characterizes dependency on others for social, emotional, informational or psychological support. Attachment theory (Bowlby 1988 cf Brennan et al. 1998) represents an important theoretical perspective for understanding an individual’s experience of negative mood and interpersonal problems. The basic premise of attachment theory is that individuals’ emotional experiences with primary caregivers lead to the development of attachment security or insecurity. Attachment security or insecurity is then associated with the individuals’ ability to connect with others and cope with affective or stressful problems (Kobak and Sceery 1988 cf. Brennan et al. 1998). If individuals have caregivers who are consistent in their emotional availability, they are likely to develop attachment security and can effectively cope with negative events that arise in their life (e.g., seek support from a friend). If individuals do not have caregivers who are emotionally available, individuals are likely to develop attachment insecurity and subsequently be less able to cope with stressful events in their lives (e.g., withdraw from others). It has been proposed that rejection leads to self-regulation failure, which in turn can lead individuals to make unhealthy behavior choices. Validation is also used to balance the pathologizing to which both clients and therapists are prone. Clients often have learned to treat their own valid responses as invalid (as “stupid,” “weak,” “defective,” “bad”). Similarly, therapists also have learned to view normal responses as pathological. Validation strategies balance this viewpoint by requiring the therapist to search for the strengths, normality, or effectiveness inherent in the client’s responses whenever possible and by teaching the client to self-

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validate. The same behavior can be both valid and invalid at the same time. From this perspective, all behavior is valid in some way. The DBT therapist strives to identify and communicate what is valid with the client. “Feelings are potentially highly constructive since it is through experiencing and expressing feelings that close friendships are built and maintained” (David Johnson in Reaching Out, p, 87). Quality of life can greatly be improved through the experience and expression of feelings. So a search for quality of life is really a search for a greater range and wider variety of emotions and a desire to build relationships in which emotions are aroused, allowed positive expression and yet controlled, allowing joy for all involved. Negative feelings like anger and jealousy lead to barriers, increased conflicts, and the deterioration of the relationship. People who aren’t aware of feelings, and can’t accept and express them skillfully, have difficulty in interpersonal relationships. These feelings generate certain negative emotions in clients which need to be tolerated and regulated by effective skills training Modules. These negative emotions as a result of negative feelings in relationships can be emptiness, hostility, loneliness, contempt, guilt, etc. Emptiness, an inner experience associated with feeling the lack of the presence of a caring other, arises due to chaotic or deteriorating relationships. The negative feelings, like anger and jealousy, can also be dealt with DBT strategies. Clients seeking therapy raise anger and jealousy as the most common negative feelings that hamper healthy relationships. Intense feelings of frustration and anger weaken an individual’s patience. People need patience to understand and solve complex problems, such as relationship problems. In terms of human relationships and psychotherapy anger is one of the most important emotions. Anger is “a strong feeling of displeasure and antagonism....synonyms are, rage, fury, indignation, wrath, all these mean an intense emotional state induced by displeasure. Anger, the most general term, names the reaction but in itself conveys nothing about the intensity or justification…of the emotional state” (Webster 1996 cf. Fehr & Harasymchuk 2005). Easily angered individuals typically experience considerable distress or have significant impairment in their social relationships or as a wage earner, homemaker, or student. High levels of anger usually lead to limited problem solving ability, impulsive decisions, and foolish actions. It makes one less perceptive of the feelings and thoughts of others. Anger largely results from our irrational beliefs, expectations, and self-talk. Other people can trigger our anger only by activating or stimulating our irrational beliefs. Sometimes there is an immediate and pleasant, but brief, release of tension following a strong expression of anger. Anger provides us with a temporary feeling of strength,

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power, and control and covers up our feelings of hurt, rejection, helplessness, or insecurity or inadequacy. We feel that we are handling a practical problem (for example, getting a person who is behaving wrongfully to improve his behavior) when we express our anger. An individual’s only two choices regarding one’s anger is to express it or to hold it in. Two common sources of anger are low frustration tolerance and threats to one’s self-worth. Believing that one absolutely must get what he or she wants and if they don’t, it’s awful and they can’t-stand-it causes impatience, low frustration tolerance, heightened frustration, and anger. Distress tolerance strategies can be effective here by replacing the belief that a situation is awful or horrible with the belief that it’s inconvenient or a hassle. Individuals often respond with anger when they perceive that others are attempting to lower their self-worth, selfacceptance, or self-esteem, (Dryden 1990 cf. Finkel & Campbell 2001). The extent of their anger is usually proportional to the extent to which they doubt their own self-worth. Acceptance and Change strategies can be taught to hamper anger and clients can work on accepting themselves, and recognizing that their rising anger may be due to their feelings of self-worth being threatened. Acceptance is “the unqualified and nonjudgmental attitude to self and others, as well as an acknowledgment that what exists is bound to exist given the conditions that are present at the moment (Dryden and Neenan 1994 cf. Finkel and Campbell 2001).” Clients can be taught to strive for improvements, at the same time accepting themselves, others, and the world as fallible. Jealousy is often a destructive and refractory problem in relationships, sometimes resulting in the feared consequences it attempts to prevent. Jealousy is a multidimensional cognitive, emotional, behavioral and interpersonal phenomenon. It can be a destructive and often dangerous emotional and interpersonal response to threats to a valued relationship. Jealousy is a form of angry, agitated worry, whose goal is to anticipate and avoid surprise and betrayal. Personal Core Beliefs about jealousy—Jealousy is often related to core beliefs about the self and others. Problematic core beliefs include thoughts that one is unlovable, flawed, doomed, or entitled to special treatment. Beliefs about others may include thoughts that others are not trustworthy, rejecting, abandoning, manipulative, or inferior. Thus, the individual with a core belief that he is sexually undesirable would be more likely to be jealous (Dolan and Bishay 1996 cf. Vohs and Ciarocco 2004). DBT Strategies for dealing with Jealousy:1. Validate and Inquire: The therapist empathizes and validates the emotion of jealousy while questioning the degree, persistence, and the impact on pathological coping:

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It is one thing to feel jealous, but another thing to punish your partner. Validation can link jealousy to evolutionary theory (“natural instincts to protect yourself”), the value of commitment and honesty in relationships, and the desire to feel understood (Gilbert 1998; Leahy 2005a cf. Leahy and Tirch 2008). Validation is an essential component because the jealous person is often dismissed and criticized for his jealousy. Inquiry can examine the extremity of the response, while validating the right to have the emotion of jealousy. This sets up a dialectic —“You have feelings of jealousy, but the response may or may not be extreme” (Leahy 2001 cf. Leahy and Tirch 2008; Linehan 1993 cf). 2. Assess Motivation to Change: The therapist helps the patient evaluate the costs and benefits of jealousy—for example, the benefits may include not being surprised, avoiding the dissolution of the relationship and developing the motivation to either improve or leave the relationship. Costs may include anxiety, anger, helplessness and relationship conflict. Resistance to modifying jealousy may include the belief that feeling less jealous is “granting permission” to being hurt or may reduce one’s effective self-defense against betrayal and humiliation (Leahy 2005; Wells and Carter 2001). 3. Distress tolerance by diffusing thoughts and feelings: Metacognitive and acceptance-based interventions can assist the client in distancing from and de-literalizing thoughts and emotions that escalate the jealousy. Similar to worry and rumination, the patient may have heightened cognitive self-consciousness, believe that his jealousy protects him, view jealous thoughts as potentially out of control and requiring suppression, and believe that he will suffer negative consequences because of these thoughts. These beliefs are similar to metacognitive beliefs and strategies for worry, rumination and anger (Papageorgiou 2006; Papageorgiou and Wells 2001; Simpson and Papageorgiou 2003 cf, Segrin and Taylor 2007). Defusion techniques can serve to change the context in which these thoughts are experienced, thereby changing the function of the angry and agitated worries involved in problematic jealousy (Hayes et al. 2003). 4. Use Mindful Awareness: The therapist assists the patient in employing a mindful “observing” stance towards their experience of jealousy in the present moment. Such a strategy would involve the suspension of control-based strategies, urges to act upon emotions, and attempts at interpersonal manipulation. Rather than coercing or protesting, the patient can practice an intentional, non-judgmental, and accepting awareness of their internal responses to each participant’s behavior, and of events independent of the relationship (Segal et al. 2002). In such away, the client may learn to let go

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of habitual patterns of responding to perceived threats, and may begin to have the space and time to make more informed and reality based decisions regarding the relationship to jealousy and partner. 5. Practice Acceptance: This phase of treatment recognizes that uncertainty is part of any relationship and accepting uncertainty as inevitable does not mean giving up one’s rights. Furthermore, struggling to suppress the experience of jealousy and jealousy based predictions may paradoxically increase their frequency (Wenzlaff and Wegner 2000). The therapist assists the patient in recognizing that you cannot control the partner’s thoughts and actions and that you may not even be able to prevent the experience of jealous feelings or thoughts, but that you can choose ways to respond to jealousy (Hayes et al. 2003; Linehan 1993). 6. Teach Emotion Regulation Skills: Dialectical Behavior Therapy skills can assist the patient in managing the intensity of the emotion. This can include examining emotional myths, improving the moment, and stress reduction techniques (Linehan 1993). The patient can also be encouraged to use self-imposed “time-out” when jealousy and anger escalate, so that she can remove herself temporarily from interactions with the partner until she has used her emotion regulation skills. The patient and therapist clarified the aim of the treatment as involving the cultivation of an ability to notice, tolerate, and regulate the jealousy response rather than as an attempt to avoid any feelings of jealousy and apprehension altogether. Rather than pursuing a goal of “not being jealous,” the patient was taught to distinguish between “productive” and “nonproductive” jealousy based predictions, and the foundation for a flexible response strategy was put in place. 7. Build Relationship Enhancement Skills: Since many relationships can focus on jealousy to the exclusion of productive behavior, the therapist can assist the patient in decreasing destructive behavior (withholding, contempt, stone-walling, criticizing, labeling, and mindreading) and increasing positive behavior (positive tracking, reward, active listening skills, developing shared activities, and validating the partner that one’s jealousy has been damaging) Many young people are not yet developed enough to think in complex ways about a range of issues. Immature cognition often leads to simple solutions to problems, and a lack of ability to see things from other people’s perspectives. They are usually extreme at understanding things and situations. This type of thought is present-focused and tied to extremes. Mature adult thinking includes the ability to think in the abstract and to consider a number of solutions to a problem.

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Attainment of such thinking is not universal, even in adulthood. Many young people have difficulty with advanced thinking skills. Children who have been neglected or abused, for example, may have had less exposure to experiences that foster mature thinking. “Black and white thinking” is a common manifestation of immature thought; thinking that is rigid, stubborn and often extreme, with few ‘grey areas’. Black and white thinking creates dialectical dilemmas associated with interpersonal situations. This dilemma can be resolved by balancing or synthesizing the polarized opinions and finding a middle path through acceptance and change. Black and white thinking reflects the construct of “splitting” in psychological terms. Clients include dichotomous, rigid thinking and behavioral and emotional extremes, dialectical philosophy and strategies offer a means of reconciling differences so that conflicts in therapy are met with movement rather than with impasse. The black and white thinking is a kind of ‘all or nothing’ thinking where one is either right or wrong—either good or bad— there are no in-betweens, no shades of gray, and no middle ground. When we judge ourselves or others, or the situation based on these extremes, without seeing the shades of gray in-between, it can be very easy to feel negative emotions, such as disappointment, frustration, anger and anxiety and jealousy. A number of strategies are included in DBT that serve the function of keeping polarized positions from remaining polarized. The first of these is that core strategies are used to balance acceptance and change. Encourage the young person to explore their own thinking and whether it is serving them well in their relationships with their family and friends. Accept that some young people are simply not developmentally ready to think in other ways. Various strategies have been developed to help the client–therapist dyad manage the relationships with other clinicians and family members. DBT is weighted toward a consultation-to-the-client strategy that emphasizes change. The DBT therapist will intervene in the environment on the client’s behalf when the short-term gain is worth the longterm loss in learning. Other dialectical strategies include use of metaphor or assuming the position of devil’s advocate in order to prevent polarization. The dialectical tension is resolved by finding the synthesis, by seeking to find what is being left out of the thesis and antithesis (e.g., validating the need to relieve distress while helping the client utilize skills that function to reduce stress and the long-term negative consequences of repeated self-injury). The middle path approach of dialectics is an inherent feature of Zen, and DBT utilizes these principles in an effort to help clients behave more effectively and live more balanced lives.

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DBT as Problem Solving Whenever one of the targeted problem behaviors occurs, the therapist and the client conduct an in-depth analysis of events and situational factors before, during, and after that particular instance (or set of instances) of the targeted behavior. The goal of this chain analysis is to provide an accurate and reasonably complete account of the behavioral and environmental events associated with the problem behavior. As the therapist and the client discuss a chain of events, the therapist highlights dysfunctional behavior, focusing on emotions, and helps the client gain insight by recognizing the patterns between this and other instances of problem behavior. Together they identify where an alternative client response might have produced positive change and why that more skillful alternative did not happen. This process of identifying the problem and analyzing the chain of events moment to moment over time to determine which variables control/influence the behavior occurs for each targeted problem behavior as it occurs. The goal of the treatment approaches can be distilled down into the following process: the reduction of ineffective action tendencies linked with dysregulated emotions (Chapman and Linehan 2006 cf Linehan et al. 2006a, b). The primary goal of treatment is to help the patient to engage in functional, life-enhancing behavior, even when intense emotions are present. DBT is a flexible treatment that varies in its approach depending on the client’s current level of disorder.

Conclusion The client having interpersonal problems can begin to practice dialectical behavior therapy daily as a “preparatory” exercise for the applied mindfulness and acceptance techniques involved in coping with negative feelings. These techniques can be appealing to the patient, as he may greatly enjoy the “relaxation” and stress reducing effects found in a yoga class, which is similar in DBT. As the client had no history of acting out and also had sufficient insight to see that his anger and jealousy based cognitions and predictions are baseless and unproductive, this component of the intervention can be easily addressed. By examining the possibility of productive and unproductive cognitions and emotions, the client may reportedly feel further validated with regards to the legitimacy of his emotional response, while not feeling compelled to buy into his difficult and negative thoughts. Rather than engage in experiential avoidance or thought suppression through trying to “not be angry and jealous” the patient may actively engage with his emotions and cognitions in an adaptive way. Similarly, immature extreme thinking styles

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such as black and white thinking can effectively be dealt with mid-way path of acceptance and change. The complementary DBT techniques proposed in this article aim to: 1) provide clients an understanding of problems in relationships in a clear, nonjudgmental way; 2) give a clear picture of the clients’ thoughts and feelings that augment his difficulties in maintaining healthy relationships; 3) enhance the contributions and capabilities of clients to a mutually validating environment; and 4) address clients’ emotional and interpersonal skills deficits. Thus, relationship interventions in DBT may be considered: 1) as psychoeducation, to augment individual DBT; 2) as a treatment of the individuals per se, targeting improvement of interpersonal relationships and satisfaction; or 3) as both. The theoretical relevance of the results for treating interpersonal issues by dialectical behavior therapy is indicated, as well as implications of the findings for clinical practices are elaborated.

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