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tance and change: Content and context in psychothera]o' (pp. 175-197). nitive therapy prevent depressive relapse and why should atten-
Reno, N%1:Context Press. tional control (mindfulness) training help? BehaviourResean:h and
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a~ng high-risk behaviors. New York: Guilford Press. Teasdale, J. D., Segal, Z. V., Williams,J. M. G., Ridgewa); V. A., Soulsby,
Marlatt, G. A., Baez;J. S., Kivlahan, D. R., Dimeff, L. A., Larimel; M. E., J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in
Quigley, L. A., Somers,J. M., & Williams, E. (1998). Screening and m~:jor depression by mindfulness-based cognitive therapy. Journal
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W. R. Miller (Ed.), Integrating spirituality in treatment: Resourcesfor
practitioners (pp. 67-84). V~:ashington,DC: American Psychologi- Address correspondence to G. Alan Marlatt, Ph.D., University of
cal Association Books. Washington, Department of Psychology, Box 351525, Seattle, WA
Marlatt, G. A., & Marques, J. K. (1977). Meditation, selfcontrol, and
98195; e-mail: marlatt@u.washington.edu.
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Mazel. Received: January 10, 2000
Marlatt, G. A., Pagano, R. R., Rose, R. M., & Marques, J. K. (1984). Accepted: l~br'uary 20, 2001

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Zen Principles and M i n d f u l n e s s Practice in Dialectical Behavior Therapy


C l i v e J . R o b i n s , D u k e University

Dia&ctical behavior therapy (DBT; Linehan, 1993a) was developed as a treatment for borderline personality disorder (BPD). It in-
volves a dialectical synthesis of the change-oriented strateg4es of cognitive-behavioral therapy with more acceptance-oriented principles
and strategies adapted primarily Ji'om client-centered therapy and from Zen. In this p a p ~ I note both .similarities and contrasts be-
tween co~zitive-behavioral therapy and Zen. I then highlight the role of Zen principles in DBT's assumptions about patients, theory
of BPD, selection of treatment targets, and treatment strategies. Finally, the article describes the value of mindfulness practice for pa-
tients with BPD, how mindfulness skills are taught to patients in DBT, and benefits of mindfulness practice for therapists.

EHAVIOR THERAPY a n d B u d d h i s t t h o u g h t m i g h t ap- k n o w l e d g e , w h e r e a s B u d d h i s t t h o u g h t a n d m o s t o t h e r re-


p e a r to b e radically d i f f e r e n t , p e r h a p s e v e n c o n t r a - ligious t r a d i t i o n s have b e e n c o n c e r n e d p r i m a r i l y with
dictory, in t h e i r a p p r o a c h e s to u n d e r s t a n d i n g a n d c h a n g - m e n t a l a n d spiritual p h e n o m e n a a n d p r o p o s e a n e x p e r i -
i n g behavior. F o r e x a m p l e , b e h a v i o r t h e r a p y t r a d i t i o n a l l y e n t i a l p a t h to u n d e r s t a n d i n g a n d c h a n g i n g b e h a v i o r .
has f o c u s e d o n o v e r t b e h a v i o r a n d o t h e r o b s e r v a b l e vari- H o w e v e r , as this series attests, t h e r e is g r o w i n g i n t e r e s t
ables a n d t h e W e s t e r n scientific m e t h o d o f a d v a n c i n g among behavior therapists and cognitive behavior thera-
pists in t h e p o t e n t i a l c o n t r i b u t i o n s o f spiritual t r a d i t i o n s ,
particularly Buddhism.
Cognitive and Behavioral Practice 9, 50-57, 2002
A t least o n e f o r m o f b e h a v i o r t h e r a p y , d i a l e c t i c a l be-
1077-7229/02/50-5751.00/0
Copyright © 2002 by Association for Advancement of Behavior h a v i o r t h e r a p y (DBT; L i n e h a n , 1993a) f o r p e r s o n s diag-
Therapy. All right.s of reproduction in any form reserved. n o s e d with b o r d e r l i n e p e r s o n a l i t y d i s o r d e r (BPD), ex-
Mindfulness and Dialectical Behavior Therapy 51

plicitly integrates cognitive-behavioral principles a n d tempts at cognitive restructuring with BPD patients fre-
strategies with Zen Buddhist principles a n d mindfulness quently m e t objections such as, "So now y o u ' r e saying
practice. Several r a n d o m i z e d trials have f o u n d that DBT there's a n o t h e r thing wrong with me: I c a n ' t think right,"
has some efficacy for the t r e a t m e n t o f BPD (Koons et al., or "It's n o t my t h i n k i n g that makes m e upset. W h e n I get
2001; Linehan, Armstrong, Suarez, Allmon, & Heard, upset, I start to think like this a n d I a m n o t able to c h a n g e
1991; L i n e h a n et al., 1999). In this article, I will discuss it." These kinds o f difficulties led L i n e h a n to modify stan-
the historical d e v e l o p m e n t o f DBT a n d highlight why d a r d cognitive behavioral t r e a t m e n t to i n c l u d e a greater
Zen principles a n d practices have b e c o m e a defining as- emphasis on validating the patient's e x p e r i e n c e , even
p e c t of the t r e a t m e n t (for a m o r e c o m p r e h e n s i v e de- maladaptive behaviors, as m a k i n g sense given his o r h e r
scription of DBT as a whole, see Robins, Ivanoff, a n d history a n d the c u r r e n t context. T h e emphasis on accep-
L i n e h a n , 2001). I t h e n note some i m p o r t a n t ways in tance o f the patient c o u n t e r b a l a n c e s the emphasis on
which Buddhist t h o u g h t is c o m p a t i b l e with behavior c h a n g e associated with behavior therapy. In addition,
therapy, as well as differences between the two that sug- b o r d e r l i n e patients typically have great difficulty accept-
gest that Buddhist principles a n d mindfulness practice ing many things a b o u t themselves, o t h e r p e o p l e , a n d the
may provide behavior therapists b o t h with useful ways o f world in general. L i n e h a n , therefore, was also i n t e r e s t e d
conceptualizing patients a n d situations a n d with helpful in teaching these patients a m e t h o d for p r o m o t i n g a
t r e a t m e n t strategies. Following these i n t r o d u c t o r y com- greater capacity for a c c e p t a n c e a n d drew on h e r own ex-
ments, I discuss in m o r e detail some o f the ways in which p e r i e n c e with Zen mindfulness practice as well as the
Zen principles are reflected in various aspects o f DBT. Christian contemplative tradition.
These include its (a) assumptions a b o u t patients; (b) the- It is likely that most patients, regardless of diagnosis or
ory o f the d e v e l o p m e n t a n d m a i n t e n a n c e o f the behav- type o f behavioral p r o b l e m , benefit f r o m e x p e r i e n c i n g
iors, thoughts, a n d feelings c o m m o n in persons diag- their therapists as validating a n d a c c e p t i n g a n d from
n o s e d with BPD, (c) secondary targets o f t r e a t m e n t that l e a r n i n g how to be m o r e accepting o f themselves a n d
are functionally related to BPD criterion behaviors, a n d others. However, this n e e d p r o b a b l y is m u c h g r e a t e r for
(d) t r e a t m e n t strategies. Finally, I d e s c r i b e how m i n d - b o r d e r l i n e patients than for most others. O n e interesting
fulness practice is t a u g h t to patients as a core skill a n d finding that may illustrate the i m p o r t a n c e of a c c e p t a n c e
utilized by therapists themselves in the service o f com- by others is the large effect o n relapse rates in schizo-
passionate a n d effective t r e a t m e n t for m u l t i p r o b l e m pa- p h r e n i a (and some o t h e r disorders) as a function o f the
tients. I s h o u l d say at the o u t s e t that my own back- level o f expressed e m o t i o n (EE) o f their relatives with
g r o u n d k n o w l e d g e o f B u d d h i s m as a whole is relatively w h o m they live (Butzlaff & Hooley, 1998). Observational
limited. I a m aware that t h e r e are m a n y streams o f measures o f EE assess criticism, hostility, a n d e m o t i o n a l
t h o u g h t in B u d d h i s m , as t h e r e are in o t h e r world reli- overinvolvement. H o o l e y a n d Hiller (2000) r e p o r t e d that
gions. My focus h e r e will be o n the Zen t r a d i t i o n as it is high EE relatives o f s c h i z o p h r e n i a patients scored signifi-
r e f l e c t e d in DBT. cantly lower on tolerance, flexibility, a n d e m p a t h y on a
b r o a d - b a n d personality measure than d i d low EE rela-
tives. However, it was the low EE relatives who differed
Why Does DBT Include Zen Principles
most from normative samples on t o l e r a n c e (Hooley,
and Practice?
1998). Thus, it may be that an unusually high level o f ac-
DBT was d e v e l o p e d as a t r e a t m e n t for chronically sui- ceptance, p e r h a p s reflected in their explicit o r implicit
cidal a n d / o r self-injurious women, m a n y o f w h o m h a d expectations o f the patient, is helpful to the patient's clin-
BPD. L i n e h a n initially a t t e m p t e d to h e l p the patient ical progress.
c h a n g e such behaviors by using s t a n d a r d cognitive-
behavioral strategies: c o n d u c t i n g a behavioral analysis o f
particular incidents o f the behaviors a n d t h e n influenc- Compatibility of Buddhism
ing the variables that s e e m e d to maintain t h e m t h r o u g h and Cognitive-Behavioral Therapy
such p r o c e d u r e s as assertiveness training a n d cognitive A l t h o u g h B u d d h i s m frequently is viewed as a religion,
restructuring. She has r e p o r t e d that such attempts to ap- it also can be viewed as a psychology. This a r g u m e n t prob-
ply s t a n d a r d protocols were n o t very successful (Linehan, ably could be a d v a n c e d for o t h e r religions, b u t I believe
1993a, p. 77). Patients often e x p e r i e n c e d a sole focus on that it is particularly clear with Buddhism. T h e core
change p r o c e d u r e s as invalidating their levels o f distress, teachings o f B u d d h i s m involve the F o u r N o b l e Truths
o r even as b l a m i n g t h e m for their problems, m a k i n g it a n d the Eight-Fold Path, s u m m a r i z e d in this issue by Kn-
difficult for t h e m to use the skills taught in therapy. As a m a r (2002). T h e F o u r Noble Truths c o n c e r n the experi-
result, patients may r e s p o n d by attacking the therapist or ence of suffering a n d thus are relevant to behavior thera-
by leaving treatment. Prior to l e a r n i n g DBT, my own at- pists a n d to the field o f mental health in general. These
52 Robins

truths or principles state the following: (a) life is full of separation between the observer a n d the observed:
suffering, (b) the r o o t cause o f suffering is attachment, T h o u g h t s are n o t taken as literally "true" a n d to be acted
(c) it is possible to decrease o r even e n d suffering by let- upon. Similarly, in cognitive-behavioral therapy, o n e goal
ting go o f o n e ' s attachments, a n d (d) the m e t h o d for may be to h e l p the individual to gain distance from his o r
d o i n g so is to practice the Eight-Fold Path. T h e eight h e r thoughts, to n o t e x p e r i e n c e the thoughts as p a r t o f
parts o f this p a t h may be translated as right u n d e r s t a n d - themselves, b u t to e x p e r i e n c e the self as an object o f
ing, right thought, right speech, right action, right liveli- observation. We may, for example, accomplish this by ask-
hood, right effort, right mindfulness, a n d right concen- ing the patient to keep a r e c o r d o f thoughts that run
tration. T h e idea tla~ the solution to suffering is to t h r o u g h his or h e r m i n d when distressed o r in o t h e r situ-
decrease a t t a c h m e n t or craving is quite different from be- ations. T h e act of c o m p l e t i n g a daily t h o u g h t r e c o r d
havior therapy's emphasis on d e v e l o p i n g skills for attain- helps a person to stand back from his o r h e r thoughts in
ing one's goals. However, the idea that suffering results o r d e r to evaluate their truth value o r utility. Meditation
from things n o t b e i n g the way one strongly wants t h e m to can have a similar effect. At times, the thoughts, images,
b e is consistent with the principles u n d e r l y i n g cognitive- a n d o t h e r mental p h e n o m e n a that arise d u r i n g medita-
behavioral therapies, A l b e r t Ellis b e i n g perhaps the clear- tion may be distressing to the individual. T h e practice is
est e x p o n e n t of this viewpoint. n o t to a t t e m p t to suppress o r avoid such experiences b u t
T h e r e are a n u m b e r of interesting parallels between to notice t h e m a n d notice one's reaction to t h e m without
Buddhist p h i l o s o p h y a n d practice a n d behaviorism or j u d g m e n t . This practice can be viewed as similar to the
cognitive-behavioral therapy, some of which were arti- behavioral t r e a t m e n t strategy of e x p o s u r e to feared b u t
culated years ago by Mikulas (1978). Like behaviorism, n o n h a r m f u l stimuli.
Buddhist psychology has few, if any, abstract theoretical Mindfulness practice has b e e n i n t e g r a t e d with cogni-
concepts, b u t r a t h e r emphasizes observed p h e n o m e n a . tive therapy for the prevention o f relapse in depression.
A l t h o u g h behaviorism historically has c o n c e r n e d itself Teasdale et al. (2000) r e p o r t e d that a g r o u p mindfulness
mostly with overt o r external p h e n o m e n a that can be ob- intervention, in which participants e n g a g e d in mindful-
served a n d m e a s u r e d consensually, Buddhist practice ness practice with a goal o f increasing their ability to dis-
concerns n o t only n o n j u d g m e n t a l observation o f the out- engage from depressogenic thinking, significantly re-
side world b u t particularly o f one's internal experiences. d u c e d rates of relapse a n d r e c u r r e n c e a m o n g recovered
N e i t h e r behaviorism n o r B u d d h i s m describes a theorized d e p r e s s e d patients who h a d three or m o r e previous epi-
structure o f internal mental c o m p o n e n t s , such as is sodes of depression.
f o u n d in psychodynamic a n d some o t h e r a p p r o a c h e s to
mind. T h e r e also is a similarity in the d e g r e e o f focus on
Differences Between Buddhism
the p r e s e n t r a t h e r than on the past a n d how things devel-
and Cognitive-Behavioral Therapy
oped. F u r t h e r m o r e , unlike some religions, the Buddhist
c o n c e p t o f morality is n o t based in abstract notions o f A l t h o u g h B u d d h i s m a n d cognitive-behavioral therapy
g o o d a n d bad; instead, behaviors, including mental ones, are, in nay view, essentially c o m p a t i b l e a n d involve some
are d e s c r i b e d a n d evaluated in terms of their effective- interesting parallels, there are also some i m p o r t a n t dif-
ness in relation to goals. T h e r e is also the belief that ver- ferences. If this were n o t so, there would be little p o i n t in
bal insight alone does n o t p r o d u c e change, t h o u g h it behavior therapists e x a m i n i n g Buddhist t h o u g h t a n d
may at times be a useful p r e l i m i n a r y step. Buddhism also practice for innovations and i m p r o v e m e n t s in treatment.
assumes that the essential nature o f life involves constant O n e i m p o r t a n t principle o f Zen is that everything is as it
change a n d that all things are c o n n e c t e d a n d thus in should be at this m o m e n t : This is the essence of accept-
some way influence each other. Its c o n c e p t i o n o f h u m a n ing the world, oneself, a n d o t h e r people. Behavior ther-
behavior a n d its relation to the h u m a n e n v i r o n m e n t is apy, on the o t h e r hand, emphasizes c h a n g i n g behavior
thus m u c h m o r e similar to a behaviorist emphasis on the a n d the environment. It is n o t that B u d d h i s m is n o t at all
effects o f e n v i r o n m e n t a l c o n t e x t on behavior than it is to c o n c e r n e d with change. In fact, it would make no sense
personality trait theories o r psychoanalytic theory, which to practice meditation with a c o m p l e t e absence o f expec-
assume a m u c h greater d e g r e e o f cross-situational consis- tation that any c h a n g e would result, although, paradoxi-
tency o f behavior. cally, focusing on the goal of c h a n g e is i n c o m p a t i b l e with
Like cognitive-behavioral therapy, B u d d h i s m also em- the process of meditation. T h e B u d d h a initially was in-
phasizes self-observation or self-monitoring o f behaviors. spired to go off alone a n d meditate for a p r o l o n g e d pe-
Particularly i m p o r t a n t is the observation of one's t h o u g h t riod because o f the suffering that he saw a m o n g the
c o n t e n t a n d process. In some forms of mindfulness prac- people, a n d his teachings on the p a t h to e n d suffering
tice, the s t u d e n t observes a n d describes his o r h e r obviously h a d a goal that the p e r s o n following that p a t h
thoughts. In d o i n g so, the s t u d e n t begins to u n d e r s t a n d a would c h a n g e in particular ways.
Mindfulness and Dialectical Behavior Therapy 53

Behavior therapy's emphasis on the individual's learn- viewed from a holistic perspective in which everything is
ing history as an e x p l a n a t i o n for their c u r r e n t patterns o f c o n n e c t e d to everything else a n d objects o r individuals
behavior is also consistent with the Zen assumption that c a n n o t be u n d e r s t o o d in terms o f their parts b u t only by
things are as they should be at this m o m e n t . However, in considering the relationships a m o n g the parts. O u r sense
behavioral practice, we emphasize applying the technol- o f identity also is d e f i n e d largely in relation to others,
ogy o f c h a n g e strategies that have b e e n d e v e l o p e d over r a t h e r than the m o r e individualistic u n d e r s t a n d i n g o f
the past several decades r a t h e r than accepting what is. identity that is d o m i n a n t in o u r culture. T h e principle of
T h e Zen emphasis on acceptance leads m o r e naturally to polarity proposes that all things in n a t u r e consist o f op-
the strategy o f validation. In DBT, the therapist attempts posing forces a n d that the essence o f growth is in the
b o t h to validate behavior and, in some cases, to p r o b l e m c o m i n g t o g e t h e r o f these divisions. In the p h i l o s o p h y o f
solve with the p a t i e n t as to how to change the behavior. dialectics, these positions frequently are r e f e r r e d to as
Validation draws m o r e heavily o n client-centered a n d hu- the "thesis" a n d "antithesis," a n d their resultant integra-
manistic therapies than o n behavior therapy. tion the "synthesis," which o f course is itself a t e m p o r a r y
At times, p a t i e n t s - - i n d e e d , all o f u s - - w o u l d d o b e t t e r state o f affairs that gives rise to a new antithesis. Impor-
to accept that which they c a n n o t now change, as is well ar- tantly for therapy, this viewpoint suggests that, for any
ticulated in the serenity prayer. F o r example, we c a n n o t idea that has value, an i d e a that opposes it in some way
change the past, i n c l u d i n g things we have d o n e that we p r o b a b l y also has value. Consideration o f this o p p o s i n g
regret, hurts that have b e e n inflicted on us by others, the idea a n d the integration o f the two can be very useful.
failure to receive the e m o t i o n a l s u p p o r t o r l e a r n i n g expe- A m o n g o t h e r things, this suggests that even patients' mal-
riences that we n e e d e d as a child, a n d so on. Some as- adaptive behaviors serve a useful p u r p o s e o r in some
pects o f o u r c u r r e n t situation may n o t be i m m e d i a t e l y o t h e r way reflect wisdom. With r e g a r d to the p r i n c i p l e o f
changeable, such as one's physical a p p e a r a n c e , or the c o n t i n u o u s change, it follows from the first two prin-
costs of c h a n g i n g are too high, such as a very b a d mar- ciples that if everything is c o n n e c t e d a n d contains polari-
riage that is one's only potential source o f financial sup- ties that give rise to i n t e g r a t e d syntheses, than everything
p o r t in the n e a r future. In the latter case, acceptance may is continually in a state o f change. As o n e p e r s o n o r ob-
be "for now," while the p e r s o n works on the steps that j e c t influences another, it in turn is i n f l u e n c e d by the
will be necessary to make that change. Acceptance then will o t h e r in a transactional process.
be helpful because it reduces the suffering associated
with continually telling o n e s e l f that the relationship Assumptions About Patients
should n o t be this way. In fact, such lack o f acceptance Because most therapists, like others in the patient's
can even stand in the way o f change. F o r example, self- e n v i r o n m e n t , will at times feel irritated, stressed, o r
b l a m e a n d guilt over maladaptive behaviors like self- scared by the patient's behavior, it is helpful for the DBT
injury, substance abuse, o r binge eating d o n o t usually therapist to r e m i n d him- o r herself a b o u t certain assump-
lead directly to change, a n d the resulting e m o t i o n a l dys- tions that DBT makes a b o u t patients. Some o f these as-
regulation may lead to even less effective application o f sumptions, such as the i d e a that patients n e e d to learn
c h a n g e procedures. It is m o r e productive to describe the new behaviors in all relevant contexts, stem directly from
behaviors n o n j u d g m e n t a l l y to oneself a n d n o t e their dis- theory a n d research o n l e a r n i n g principles. O t h e r s owe
crepancy from behaviors that are m o r e effective for m o r e to the Zen tradition a n d humanistic ideas. F o r ex-
r e a c h i n g o n e ' s goals. In Buddhist thought, o n e still may ample, it is assumed that patients are d o i n g the best that
have goals a n d preferences; b u t a t t a c h m e n t to those they can a n d that they want to improve. T h e first assump-
goals and preferences leaves o n e vulnerable to suffering. tion is a variant o f the g e n e r a l idea that everything is as it
should be. T h e best that a p a t i e n t can d o now may be dif-
ferent than the best that they could do yesterday o r to-
How Zen Principles Are Reflected in DBT
morrow. T h e best they can d o in this m o m e n t is deter-
As K u m a r (2002) points out, the Buddhist p h i l o s o p h y m i n e d by all the internal a n d external variables that
views reality from a dialectical p o i n t o f view. Things are influence their effort. Because these patients usually
n o t viewed as having an i n d e p e n d e n t a n d e n d u r i n g iden- clearly n e e d to d o better, it b e c o m e s the therapist's j o b to
tity, b u t r a t h e r as having e m e r g e n t p r o p e r t i e s that arise d e t e r m i n e what variables would m a k e that m o r e likely. If
from the integration o f diverse elements, constantly patients d i d n o t want to improve, they would n o t c o m e
c h a n g i n g as they affect o t h e r things a n d are affected in for treatment. Borderline patients usually are so misera-
turn by them. L i n e h a n (1993a) discusses three character- ble that they desperately want things to be different. At
istics of a dialectical worldview: (a) the principle o f inter- times, it may a p p e a r that what they want to c h a n g e is the
relatedness a n d wholeness, (b) the principle o f polarity, outside world a n d n o t themselves, b u t when they are n o t
a n d (c) the principle o f c o n t i n u o u s change. T h e world is b e i n g defensive they usually recognize that their own be-
54 Robins

haviors create problems for themselves or others. This is ally in a radically different context. Consistent with this
consistent with the Zen idea of each person having wis- systemic view, roadblocks in t r e a t m e n t are n o t automati-
dom a n d i n n a t e potential toward positive growth. cally attributed to the patient but to some transaction
a m o n g the patient, therapist, the consultation team, the
Biosoeial Theory institutional e n v i r o n m e n t in which treatment occurs, a n d
O n e aspect of DBT that reflects a dialectical worldview the patient's h o m e e n v i r o n m e n t , any c o m b i n a t i o n of
is its theory of the etiology a n d m a i n t e n a n c e of BPD be- which may be targeted for intervention.
havior patterns, which L i n e h a n describes as a biosocial
theory. T h e theory contains two major elements, one bio- Treatment Targets
logical a n d the other social-environmental. Biologically, Dialectical thinking a n d the Zen c o n c e p t of the "mid-
an individual diagnosed with BPD may have a core diffi- dle way" also inform the t r e a t m e n t goals a n d targets in
culty with e m o t i o n regulation. The brain systems in- DBT in a n u m b e r of ways. At a general level, the behav-
volved in eliciting a n d m o d u l a t i n g emotions may be dif- iors, thoughts, a n d feelings of patients diagnosed with
ferent than those in the average person, possibly because BPD are often very nondialectical a n d polarized, think-
of genetics, events d u r i n g fetal development, or early life ing in terms of e i t h e r / o r rather than b o t h / a n d . For ex-
trauma, which research has shown can affect limbic sys- ample, the patient who makes a mistake a n d feels
tem development. The e n v i r o n m e n t a l aspect L i n e h a n re- ashamed may label him- or herself as completely worth-
fers to as the "invalidating e n v i r o n m e n t " is o n e in which less a n d view suicide as a reasonable option. The patient
the person's c o m m u n i c a t i o n s regarding their private ex- whose presence is not acknowledged by s o m e o n e they
periences frequently are m e t with responses that suggest know may conclude that the other person hates them or
they are invalid, faulty, or inappropriate, or that oversim- is a m e a n person. Similarly, patients may view positive
plify the ease of solving the problem. Unlike a diathesis- events a n d positive behaviors of others in equally ex-
stress model, in which the interaction of these two sets of treme terms to the p o i n t of overidealizing those persons
variables leads to disorder, L i n e h a n suggests that, in addi- or events. O n e overarching goal in DBT, therefore, is to
tion to such an interaction effect, there is a transaction help the patient to think more dialectically. This can in-
between the two, such that e m o t i o n dysregulation tends volve n o t only p o i n t i n g out the extreme nature of these
to lead to invalidation a n d vice versa. For example, the patterns a n d helping the person to think of a n d practice
emotional responses of the individual who is particularly alternatives, b u t also m o d e l i n g dialectical t h i n k i n g a n d
emotionally sensitive or vulnerable are likely to be puz- behavior on the part of the therapist. The goal is to help
zling to an individual who does n o t share this emotional- the patient see that a particular action or event is just o n e
ity. They may t h e n conclude that the person is faking e l e m e n t of a larger whole, that it is, for example, quite
their response in order to m a n i p u l a t e a situation, or is be- possible to be very angry with s o m e o n e a n d also still care
ing entirely u n r e a s o n a b l e a n d "crazy," or is n o t at all try- deeply about them.
ing to control his or her behavior. If this belief is commu- T h e r e are many areas in which b o r d e r l i n e patients
nicated, explicitly or implicitly, the sensitive individual is c o m m o n l y experience dialectical tensions that they usu-
likely to feel even more emotionally vulnerable. Further- ally resolve by going to one or the other extreme. These
more, if an individual's emotional state, their thoughts include accepting one's self versus improving one's self,
related to it, a n d their difficulty in c h a n g i n g their emo- tolerating feelings versus c h a n g i n g feelings, d e p e n d e n c e
tions are not taken seriously or are punished, a n d if this versus i n d e p e n d e n c e , trust versus mistrust, a n d self-
occurs d u r i n g the course of development, then the indi- blaine versus other-blame. The dialectical approach to
vidual may n o t learn how to accurately recognize or com- this, consistent with Zen principles, is n o t necessarily to
m u n i c a t e different emotions. Over time, as the individ- see the truth as something in between the two extremes,
ual's behavior becomes more extreme, either in attempts b u t to help the patient see the validity of both positions
to regulate e m o t i o n in the absence of more adaptive a n d find a useful synthesis. For example, an individual
skills, or in attempts to c o m m u n i c a t e , they are likely to who is mistrustful of the i n t e n t i o n s of others, a n d is there-
experience invalidation increasingly from their environ- fore generally g u a r d e d a n d secretive, may meet s o m e o n e
ment, i n c l u d i n g from the mental health system. Thus, in who treats them very nicely, thus deciding that this o n e
this transactional model, the individual a n d those in his person can in tiact be trusted. But if they become deeply
or her interpersonal e n v i r o n m e n t continuously change hurt in their relationship with this person, they may again
one another. Similarly, the individual is n o t viewed in decide that no one can be trusted. The task of the thera-
DBT as "having" a disorder, b u t as acting, at times, in dis- pist is to help the patient see trust as a c o n t i n u u m rather
o r d e r e d ways. It is this person in this particular situation than a dichotomy and to develop the skills necessary for
whose behavior is ineffective a n d dysfunctional. It is quite evaluating the degree of trust that is appropriate for each
possible that the individual might behave quite function- situation they encounter.
Mindfulness and Dialectical Behavior Therapy 55

Treatment Strategies ing a n d describing what is a n d participating in what is


Dialectics also inform the t r e a t m e n t strategies used in called for in this m o m e n t in a non-self-conscious way.
DBT. Most importantly, attention is paid to the balance of Similarly, patients learn distress-tolerance skills for situa-
strategies that primarily p r o m o t e a c c e p t a n c e a n d those tions o r feelings they c a n n o t change, simply to e n d u r e the
that primarily p r o m o t e change. P r o b l e m solving is bal- distress they are e x p e r i e n c i n g without relieving it by act-
a n c e d with validation. Balance does n o t m e a n that t h e r e ing in impulsive o r maladaptive w a y s - - i n o t h e r words,
should be 50% o f each. As the overall goal o f therapy is accepting o n e ' s c u r r e n t feeling state.
change, validation can be seen as in the service o f prob-
lem solving. Nonetheless, the spirit in which validation is Consultation Team
most effective is when it is d o n e purely to convey accep- DBT is p r o v i d e d within the framework o f a t r e a t m e n t
tance of the p a t i e n t o r to p r o m o t e self-acceptance by the team o f individual therapists a n d skills trainers who m e e t
patient, r a t h e r than with the idea that it will facilitate on a r e g u l a r basis for consultation, consistent with the as-
change. In a similar vein, o n e meditates because o n e has s u m p t i o n that n o o n e therapist is going to have the abso-
a goal for s o m e t h i n g to be different, yet completely d r o p s lute truth a b o u t the best way to p r o c e e d . Certain agree-
that goal d u r i n g meditation. And, paradoxically, an in- ments are m a d e a m o n g the m e m b e r s o f the team, some
somniac has a b e t t e r c h a n c e o f falling asleep if he or she of which reflect Zen philosophy. F o r e x a m p l e , team
does n o t focus on falling asleep. T h e i d e a o f thesis, an- m e m b e r s agree to accept a dialectical p h i l o s o p h y in
tithesis, a n d synthesis also leads the DBT therapist to which useful truths are seen as likely to e m e r g e from the
search for "what is left out" o f his o r h e r u n d e r s t a n d i n g o f transactions between o p p o s i n g ideas. T h e Zen principles
the case, particularly when progress stalls. T h e r e is an as- o f n o n j u d g m e n t a l observation a n d description o f behav-
s u m p t i o n that, in these situations, s o m e t h i n g has b e e n ior are a p p l i e d b o t h to the therapist's behavior a n d to the
o v e r l o o k e d or not a t t e n d e d to. Finally, in DBT it is impor- patient's behavior, so that nonpejorative, e m p a t h i c inter-
tant for the therapist to be able to move rapidly from one pretations o f b o t h are sought. Part o f the j o b o f the con-
strategy to another, from one target p r o b l e m to another, sultation team is to h e l p each therapist find "the m i d d l e
without losing track o f the overall goals o f the session. way" in the t r e a t m e n t o f a given patient. Several impor-
W h e n one strategy hits a brick wall, it can be helpful to tant therapist characteristics can be viewed in terms o f di-
switch to a dramatically different strategy. This is consis- alectical tensions. Most fundamentally, a therapist may be
tent with the idea that there is no o n e right way or truth. m o r e o r i e n t e d toward c h a n g e o r toward acceptance, a n d
this may even vary for the same therapist across patients
Skills Taught o r across time. T h e s o l u t i o n is n o t t h a t the c h a n g e -
DBT assumes that b o r d e r l i n e patients have b o t h capa- o r i e n t e d therapist should b e c o m e less c h a n g e - o r i e n t e d ,
bility deficits a n d difficulty motivating themselves to use b u t r a t h e r that he o r she also needs to work on b e c o m i n g
whatever capabilities they do possess. T h e d i c h o t o m y of m o r e o r i e n t e d to acceptance. L i n e h a n (1993a) describes
w h e t h e r o r n o t the p a t i e n t does n o t know how to behave two o t h e r therapist d i m e n s i o n s that are variants o f this
m o r e adaptively o r w h e t h e r she willfully chooses n o t to acceptance-change continuum: benevolent demanding-
behave m o r e adaptively is seen as a false dichotomy. Both ness versus nurturing, a n d unwavering c e n t e r e d n e s s re-
are true at times. Skills that frequently are deficient in g a r d i n g the t r e a t m e n t plan versus compassionate flexibil-
b o r d e r l i n e patients are taught in DBT, usually in the con- ity. A dialectical position sees the wisdom in b o t h poles
text o f a skills training group, whereas the motivational is- a n d the consultation team seeks the integration o f the
sues that interfere with the use o f skills, such as emo- two that is most a p p r o p r i a t e for each situation.
tional inhibitions, distorted cognitions, a n d u n h e l p f u l
r e i n f o r c e m e n t contingencies, are a d d r e s s e d in individual Why Mindfulness Is Taught in DBT
therapy. T h e dialectic o f a c c e p t a n c e versus change is re- Mindfulness may be d e f i n e d as n o n j u d g m e n t a l aware-
flected in the skills that are taught in the g r o u p (Line- ness o f o n e ' s e x p e r i e n c e as it unfolds m o m e n t by mo-
han, 1993b). Two m o d u l e s are c h a n g e - o r i e n t e d a n d two ment. In i n c o r p o r a t i n g mindfulness practice in treat-
are m o r e acceptance-oriented. I n t e r p e r s o n a l effective- ment, we are m a k i n g the assumption that the ability to
ness skills focus on how to ask for things from others, how n o n j u d g m e n t a l l y focus one's attention on a c h o s e n ob-
to say no, a n d how to negotiate. In o t h e r words, they are j e c t or event has clinically significant benefits a n d that
o r i e n t e d toward c h a n g i n g o n e ' s relationships. Emotion- this ability can be i m p r o v e d by particular practices. T h e r e
regulation skills, including identifying one's e m o t i o n a l are a n u m b e r o f potential benefits o f mindfulness. O n e
state, identifying a n d c h a l l e n g i n g negative cognitions, difficulty that many o f us experience, particularly at times
a n d e x p o s u r e a n d opposite action, are a i m e d at c h a n g i n g o f high e m o t i o n , is b e i n g "scattered." W h e n central cog-
o n e ' s e m o t i o n a l state. O n the o t h e r h a n d , mindfulness nitive processing resources are c a p t u r e d by every incom-
skills are n o t a b o u t c h a n g i n g anything, b u t simply observ- ing stimulus, the ability to stay focused may be dimin-
56 Robins

ished. A second type of attentional difficulty is in some interpersonal effectiveness). The core mindfulness skills
ways the reverse. Many patients r u m i n a t e at length about are taught over two to three sessions a n d t h e n reviewed
upsetting events a n d find it difficult to turn offthe stream again d u r i n g the first session of each succeeding module.
of thoughts a n d images or t u r n their attention to other In o u r clinic, each group session also begins with a brief
matters. In both cases, greater ability to direct one's focus mindfulness practice.
of attention would be helpful. For this p o p u l a t i o n partic- During the mindfulness skills module, the skills trainer
ularly, a potential benefit of mindfulness practice is that presents a n d discusses information about the goals of
greater awareness of action urges may help the individual mindfulness practice a n d also engages the participants in
to act less impulsively. A n o t h e r potential benefit is a n u m e r o u s practice exercises. Many of the practices de-
richer experience of life a n d an increased capacity for scribed in the skills training m a n u a l (Linehan, 1993b) are
joy. For example, o n e may be driving h o m e from work, adapted from the meditation m a n u a l written by the Viet-
t h i n k i n g a b o u t the o u t c o m e of a m e e t i n g earlier that day namese Buddhist m o n k Thich Nhat H a h n (1976). Partic-
or what needs to be accomplished that evening, arrive ipants are first asked to discuss times a n d ways in which
home, a n d have little recollection of the drive itself. If, in- they have n o t sufficiently felt in control of their mind.
stead, one becomes aware of not being focused on the These examples are then related to the goals of mindful-
present activity and brings the focus back to the present, he ness practice. The concept of "wise mind" is i n t r o d u c e d as
or she may notice, for example, the beauty of the scenery. the integration of "emotion mind," in which one's think-
O n e may distinguish between being mindful a n d ing a n d behavior are controlled by one's emotional state,
mindfulness practice. Mindfulness practice involves set- a n d "rational mind," which allows us to plan a n d evaluate
ting aside time regularly to practice b e i n g mindful. In the logically b u t does n o t address our desires or values. The
Zen tradition, the most c o m m o n basic practice involves group discusses the idea derived from Zen that all people
sitting comfortably with eyes closed, focusing o n the possess wise m i n d and that accessing it can, at times, be
breath, a n d noticing the thoughts, images, sensations, ac- difficult. Mindfulness practice is then i n t r o d u c e d as a
tion urges, a n d other mental p h e n o m e n a that arise in m e t h o d for allowing emotions a n d mental activity to settle
consciousness without j u d g i n g them, holding onto them, down e n o u g h to enable one to hear one's wise mind.
or trying to suppress them but allowing them to come a n d In mindfulness training, two sets of skills are distin-
go freely. O t h e r objects of focus may also be used, such as guished: (a) "what" skills (i.e., what to do) a n d (b) "how"
external objects, a particular idea or class of thoughts, or skills (i.e., how to do it). The three what skills are observ-
activities such as walking. Such practice frequently results ing, describing, a n d participating. O n e can simply ob-
in a more relaxed physical and mental state, which can al- serve one's sense experiences without describing them or
low one's wise j u d g m e n t to be more accessible than when doing anything about them. O n e can also describe what
strong emotions d o m i n a t e cognitive processes. However, one observes (i.e., "I am noticing an urge to move"). Fi-
we emphasize to patients that relaxation itself is not the nally, participating means acting in the world with full en-
primary goal of mindfulness practice. In fact, at times, g a g e m e n t a n d awareness. The ultimate goal, of course, is
mental p h e n o m e n a that arise d u r i n g mindfulness prac- to participate mindfully in life at all times. Practice in ob-
tice, or even the chosen object of focus itself, may be aver- serving a n d describing can be useful steps toward mind-
sive or lead to negative emotions. These are not to be ful participation.
avoided any more than pleasant experiences or emotions The how skills are nonjudgrnentally, one-mindfully, and
are to be sought after. Instead, the practice of n o t j u d g i n g effectively. One-mindfully refers to focusing o n one thing
or resisting such thoughts, images, or sensations may re- at a time with full awareness, rather than doing one thing
sult in desensitization to them. Because borderline pa- while thinking about another. Being nonjudgrnental is
tients tend to be j u d g m e n t a l of themselves a n d others, particularly important for describing. Judgments, such as
practicing the n o n j u d g m e n t a l attitude advocated in Zen good or bad, worthwhile or worthless, often lead to strong
practice can yield e n o r m o u s benefits. Over time, regular emotions. It is possible, however, to dislike the conse-
mindfulness practice may result in a greater awareness of quences of one's own or another's behavior a n d therefore
self. Patients may learn that their emotional states and ac- develop a plan to change it without j u d g i n g the behavior
tion urges come a n d go like the waves in an ocean, but or the person as "bad" in an absolute sense. The how skill of
that they, as observers, remain constant. effectiveness is related to the Zen concept of "skillful
means." It involves being clear about one's important goals
How Mindfulness Is Taught in DBT and then behaving (participating) in ways to bring one
Mindfulness skills are taught in DBT primarily in the closer to those goals, instead of focusing o n less important
skills training group. They are considered central or core goals. For example, threatening someone who has pro-
skills necessary for the p e r f o r m a n c e of skills in the other vided poor service may seem justified by the goal of prov-
three areas (distress tolerance, e m o t i o n regulation, a n d ing them wrong or h u r t i n g their feelings, but if one's more
Mindfulness and Dialectical Behavior Therapy 57

i m p o r t a n t goal is to receive b e t t e r service f r o m this p e r s o n o n tasks a n d in the p r e s e n t m o m e n t w h e n the p a t i e n t be-


in the future, that b e h a v i o r is unlikely to be effective. c o m e s t a n g e n t i a l o r o v e r w h e l m e d is essential in h e l p i n g
I n m y e x p e r i e n c e , several types o f p r o b l e m s c a n arise the p a t i e n t progress. M i n d f u l n e s s practice c a n also h e l p a
i n t e a c h i n g m i n d f u l n e s s to patients. A few patients have t h e r a p i s t regulate his o r h e r o w n e m o t i o n s d u r i n g ses-
o b j e c t e d to the exercises o n religious g r o u n d s . Generally, sions. M a i n t a i n i n g awareness of o n e ' s b r e a t h a n d o f shifts
we d o n o t discuss m i n d f u l n e s s practice i n the c o n t e x t o f i n o n e ' s e m o t i o n a l state e n a b l e s a therapist n o t to react
any p a r t i c u l a r r e l i g i o n a n d t e n d to use the word m i n d f u l - b u t to act in a m o r e p l a n f u l m a n n e r . A f o u r t h area i n
ness r a t h e r t h a n m e d i t a t i o n . F u r t h e r m o r e , it may be which m i n d f u l n e s s practice m a y b e n e f i t the t h e r a p i s t is
h e l p f u l to i n f o r m p a t i e n t s that the t r a d i t i o n s o f c o n t e m - in d e a l i n g with his o r h e r j u d g m e n t s a b o u t his o r h e r own
plative practice do o c c u r i n m o s t religions. S o m e patients c o m p e t e n c e . T h e therapist m u s t r e m e m b e r that, j u s t like
fear f o c u s i n g o n their private e x p e r i e n c e s o r allowing the the p a t i e n t , h e o r she is d o i n g the best work they c a n in
m i n d to focus o n the b r e a t h b e c a u s e u p s e t t i n g t h o u g h t s that m o m e n t : If d i f f e r e n t t h e r a p i s t b e h a v i o r o r i n t e r v e n -
a n d images c a n arise. A l t h o u g h in the l o n g r u n such ex- tion is likely to b e m o r e effective, the t h e r a p i s t c a n p l a n
p o s u r e m a y allow h a b i t u a t i o n to occur, it is o f t e n h e l p f u l the a p p r o p r i a t e c h a n g e w i t h o u t a n y j u d g m e n t o f the pre-
to i n s t r u c t p a t i e n t s to initially focus their a t t e n t i o n o n ex- vious behavior. Finally, it is essential for the t h e r a p i s t to
t e r n a l objects o r the physical s e n s a t i o n s associated with d e v e l o p a n a t t i t u d e o f n o n a t t a c h m e n t , striving to h e l p
t o u c h i n g a n o b j e c t o r e n g a g i n g in a n activity like walking. the p a t i e n t reach c e r t a i n goals, yet, at the same time, n o t
F o r p a t i e n t s with a history o f dissociation, it is h e l p f u l to b e i n g a t t a c h e d to those o u t c o m e s , t h e r e b y l e s s e n i n g his
p o i n t o u t that m i n d f u l n e s s is the opposite o f dissociation, o r h e r d e g r e e o f suffering if they are n o t yet achieved.
that it is b e i n g fully p r e s e n t a n d aware o f o n e ' s c u r r e n t
state. S o m e patients express b o r e d o m with m i n d f u l n e s s References
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for l o n g e r periods o n their own. We also e n c o u r a g e pa- Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A.
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sonality disorder.. New York: Guilford Press.
skills t r a i n i n g m o d u l e s . For e x a m p l e , for distress toler- Linehan, M. M. (1993b). Skills training manual for treating borderline per-
ance, o n e m i g h t choose a n object o f focus that can serve sonality disorder. New York: Guilford Press.
as a distraction f r o m the source o f distress. I n a t t e m p t i n g Linehan, M. M., Armstrong, H. E., Suarez, A., Mlmon, D., & Heard,
H. L. (1991). Cognitive-behavioral treatment of chronically suicidal
to regulate o n e ' s negative e m o t i o n s , the exercise o f adopt- borderline patients. Archives of General Psychiatry, 48, 1060-1064.
i n g a half smile a n d b e i n g m i n d f u l of the associated sensa- Linehan, M. M., Schmidt, H. I., Dimeff, L. A., Craft,J. C., Kanter, J., &
tions may result i n a shift toward a m o r e positive e m o t i o n . Comtois, K. A. (1999). Dialectical behavior therapy for patients
with borderline personality disorder and drug-dependence. Amer-
ican Journal on Addictions, 8, 279-292.
Mindfulness for the Therapist Mikulas, W. L. (1978). Four Noble Truths of Buddhism related to
I n o r d e r to teach m i n d f u l n e s s skills to patients, a n d behavior therapy. Psychological Record, 28, 59-67.
Robins, C.J., Ivanoff, A. M., & Linehan, M. M. (2001). Dialectical
particularly to address their questions, it is essential that behavior therapy. In W.J. Livesley (Ed.), Handbook of personality dis-
the therapist or skills t r a i n e r have e x p e r i e n c e with m i n d - orders: Theory, research, and treatment (pp. 117-139). NewYork: Guil-
ford Press.
fulness practice. A l o n g with b e n e f i t t i n g the life o f the
Teasdale,J. D., Segal, Z. V., Williams,J. M. G., Ridgeway,V. A., Soulsby,
therapist in g e n e r a l , r e g u l a r m i n d f u l n e s s practice can J. M., & Lau, M. A. (2000). Prevention of~relapse/recurrence in
also h e l p the therapist m a i n t a i n d i r e c t i o n t h r o u g h o u t major depression by mindfulness-basedcognitive therapy. Journal
of Consulting and Clinical Psychology, 68, 615-623.
the c h a l l e n g i n g course o f t r e a t m e n t that BPD patients
present. O n e b e n e f i t o f m i n d f u l n e s s is a n i n c r e a s e d abil- Address correspondence to CliveJ. Robins, Department of Psychiatry
ity to observe a n d describe the p a t i e n t ' s b e h a v i o r in ses- and Behavioral Sciences, Duke University Medical Center, Box 3362,
sion in a n o n j u d g m e n t a l m a n n e r , which c a n b e particu- Durham, NC 27710; e-mail: robin026@mc.duke.edu.
larly difficult w h e n o n e feels criticized o r is afraid that the Received: January 10, 2000
p a t i e n t m a y a t t e m p t suicide. T h e ability to stay focused Accepted: February 20, 2001

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