Journal of Personality Disorders. 1(4), 328-333.

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DIALECTICAL BEHAVIORAL THERAPY: A

COGNITIVE BEHAVIORAL APPROACH TO
PARASUICIDE

Marsha M. Linehan, PhD

particularly prevalent among individuals meeting criteria

Parasuieide, is
for borderline personality disorder (Clarkin, Widiger, Frances. Hurt, & Gil-
more, 1983). To date almost all published treatments for these individuals

have been psychoanalytic (Adler, 1985; Kernberg, 1984; Masterson, 1976).

Behavior therapy methods are also useful. Over the past several years, we
have developed and evaluated a comprehensive, behavioral treatment Dia
lectical Behavior Therapy (DBT) for chronically parasuicidal individuals.
DBT is based on a biosocial theory that views parasuieide as problem-

solving behavior emitted to cope with or ameliorate psychic distress brought

on by negative environmental events,
self-generated dysfunctional behav
iors, and individual temperamental characteristics. Three factors keep par
asuieide high in the individual's hierarchy of problem-solving responses:
(1) low distress tolerance, (2) inadequate functional coping resources, and
(3) parasuicidogenic expectancies. Low distress tolerance provides a pow
erful motivation for the individual to do something about the problem. Poor

coping responses include deficiencies in emotion regulation, interpersonal

problem solving, and self-management skills. Parasuicidogenic expectancies
include beliefs about the value and probability of consequences of suicidal
behavior. Parasuicidal behavior occurs when the individual believes that an

intolerable, inescapable life problem exists and that parasuieide is the only
or the best possible solution; that is, the parasuicidal act is regarded as a

potentially effective problem-solving behavior. A further review of the general

theory underpinning DBT and the empirical support for these propositions
is beyond the scope of this paper. The interested reader is referred to a
number of works by Linehan et al. (Linehan, 1981, 1987; Linehan, Chiles,

Egan, Devine, and Laffaw, 1986; Linehan, Chiles, Camper, Strosahl. and
Shearin, 1987).

TREATMENT GOALS

DBT involves simultaneous individual and group treatment. The group for
mat is psychoeducational, stressing acquisition of interpersonal effective
ness, emotion regulation, distress tolerance, and sell-management capa-

From the University of Washington Address reprint requests to the author at the Department
of Psychology, NI-25, University of Washington. Seattle. Washington 98195.

328
 SELF-MUTILATION: DIALECTICAL BEHAVIOR THERAPY 329

bilities. Treatment targets in individual DBT are hierarchically arranged as

follows: ( 1 ) suicidal behaviors, (2) behaviors interfering with the conduct of
therapy, (3) escape behaviors interfering with a reasonable life, (4) behav
ioral skillacquisition (emotion regulation, interpersonal effectiveness, dis
tress tolerance, self-management), and (5) other
goals the patient wishes to
focus on. Attention is shifted to a target earlier on the list when problems
in that area surface. Thus, is somewhat circular in that target focal
therapy
points revolve over time.
The first target of always high-risk suicidal behaviors, simply
DBT is
because psychotherapy is not effective with dead
patients. Although many
parasuieide methods (e.g., self-mutilation) are rarely lethal, their associa
tion with subsequent suicide and the potential for an accidental death
require immediate attention. Whenever parasuieide occurs, at least part of
the subsequent session is devoted to direct discussion of the behavior using
the problem-solving strategies described later. The goal is replacement of
parasuieide with more adaptive problem solutions. This approach has a
number of advantages. First, it increases the likelihood that parasuicidal

activity will be reduced (assuming one's treatment approach is effective).

Second, it communicates that we take the behavior very seriously. With
borderline patients this is a very important issue; it is in direct contrast to
the invalidating environments many of these patients are used to. Third,
it introduces a contingency for parasuicidal behaviors, one that quickly
becomes tiresome to patients; namely, they don't get to talk about other

topics.
The second target of patient behaviors that interfere with the
DBT is
conduct of therapy. Keeping patient alive is not sufficient; one must keep
a

both the therapist and the patient working together by dealing with the

patient's dissatisfaction, frequent session missing, demanding behaviors,

getting committed to hospitals excessively, lying, inability or refusal to work
in therapy, psychotic episodes, and continual interruptive crises.
The third target of DBT is other escape behaviors that, if not reduced,
threaten to destroy any chance for constructing a life worth living (e.g.,
substance addiction and abuse, repetitive antisocial patterns or child abuse,
or illness-producing behaviors). Often these behaviors strongly relate to both

of the previous targets. For example, several of our patients only self-injure
when drinking or taking drugs. As with parasuieide, part of sessions sub

sequent to therapy-interfering and escape behaviors is always devoted to

dealing with them. Problem-solving strategies are used, along with clear
communication of why we believe these behaviors must be changed. We are

explicit about what requisite behaviors for the conduct of effective

we view as

therapy, including those needed to safeguard the welfare and motivation of

the therapist. Regarding escape behaviors, our first goal is to increase aware
ness of the destructiveness of escape patterns.

The fourth target of individual therapy is the increase and integration

into daily life of the skills taught in group therapy: emotion regulation,

interpersonal effectiveness, distress tolerance, and

self-management. Be
cause of the instrumental value of these skills inachieving other targets,
we require all patients to participate in small-group skill training. Groups

are efficient and have the advantage of providing a framework in which

attention to skill building, rather than individual crises, is facilitated.

330 LINEHAN

Finally, we focus on specific patient goals such as building intimate re

lationships, getting off welfare, clarifying career directions, remedial int1
troublesome relationships with parents and siblings, or reducing the effects
of past traumas, such as childhood physical and sexual abuse.

TREATMENT STRATEGIES

DBT is defined by eight treatment strategies guiding the conduct of the

therapist. Strategies are combined to deal with specific problematic situa
tions that arise in the treatment of the borderline, parasuicidal individual.
Dialectical Strategies. Dialectical strategies permeate all aspects of treat
ment. The primary dialectic is that of
change in the context of acceptance
of reality as it is. The therapist change by highlighting both
facilitates
aspects of the dialectical oppositions that arise in sessions and in everyday

life, fostering their successive reconcilation and resolution at increasingly

more functional levels. Rigid adherence to either pole of the dialectic con

tributes to stagnation and increasing tension, and inhibits conciliation and

synthesis. The dialectical focus involves two levels of therapeutic behavior.
First, the therapist is alert to the dialectical balance occurring within the
treatment relationship itself. Second, the therapist teaches and models di
alectical thinking. Strategies include use of myth and paradox, nonreso-
lution of ambiguity, focus on reality as constant change, cognitive chal

lenging and restructuring, and support of intuitive, nonrational knowledge

bases.

Problem-Solving Strategies. The therapeutic task is twofold. First, the

problems precipitating suicidal and other maladaptive behaviors must be

identified, and, second, new solution behaviors must be generated and
learned. Identification of problems causing distress is often not easy. The
usual tactic is to teach the patient to use dysfunctional responses (including
parasuieide) as signals of a current problem to be solved. A
thorough be
havioral analysis is then conducted of these signal responses. The chain of
events, including the reciprocal interaction between the environment and
the patient's responses (cognitive, emotional, and behavioral), is examined
in minute detail. Every gap between one event and the next is explored as

thoroughly as possible. Hypotheses about variables influencing or control

ling the dysfunctional behaviors are generated and evaluated. Without fail,
this strategy is used for every instance of parasuieide reported by the patient
until, over time, insight is achieved into patterns of stimulus-response.
Next, alternate response chains, that is. adaptive solutions which could
have been made and could be made in the future, are generated and ana

lyzed. It often becomes clear that the individual does not have the requisite
response capabilities (skills) needed to cope effectively with the problem.
The therapist moves to the capability enhancement strategies. Sometimes,

problem solving requires the help of other professionals in the community

(e.g., for hospitalization, medication, or financial assistance). The therapist
moves to the consultant strategies. At other times it may be that the patient
has the requisite capabilities but is inaccurate in predicting current envi
ronmental response contingencies, or contigencies that are operating favor
dysfunctional over functional behaviors. The therapist moves to contingency
 SELF-MUTILATION: DIALECTICAL BEHAVIOR THERAPY 331

strategies. Finally, issues in the therapist-patient relationship may be the

source of the problem. Use of the
relationship strategies is in order.
Although it may seem obvious, it must be kept in mind that solving
problems requires first an acceptance of the existence of a problem- ther
apeutic change can only occur within the context of acceptance of what is.
In the case of borderline patients, problem solving is enormously compli
cated by their frequent tendency to view themselves in a negative manner
and by their inability to regulate the consequent emotional distress. On the
one pole, they often have
difficulty correctly identifying problems in their
environment, tending instead to view all problems as somehow self-gener
ated. On the other pole, viewing all problems as self-generated is so painful
that the patient often responds by inhibiting the process of self-reflection.
The irreverent communication and validation strategies are designed to
facilitate effective problem solving with these patients. In addition, both

strategies are aimed at responding to the patient's emotional pain without

at the same time reinforcing suicidal behaviors.
Irreverent Communication Strategy. The irreverent communication strat

egy in DBT requires the therapist to take a very matter-of-faet, rather ir

reverent attitude toward dysfunctional problem-solving attempts, including
suicidal behaviors, therapy-interfering behaviors, and other escape behav
iors. They accepted as normal consequences of individual learning his
are

tories and current operating factors in the individual's life. As will be seen

shortly, this is in sharp contrast to the validating strategies, where the

patient's suffering is never met with a matter-of-fact, indifferent attitude.
Consultant Strategies. The therapist role is consultant to the patient, not
to other treatment professionals interacting with the patient. Thus, the

therapist helps patients modify their own behavior so as to interact effec

tively with other community professionals. As a rule, the DBT therapist does
not assist other professionals in planning or modifying their behavior to be
effective with the patient. When asked directly, we advise these professionals
to follow normal procedures. We teach the patient interpersonal skills, not
the other professionals.
There are two exceptions to this rule. When substantial harm may come

to the patient from

professionals who
unwilling modify
are to their treatment
of the patient unless a high-power person intervenes, direct intervention is
called for. Involuntary commitment and public assistance are two systems
where intervention is often needed. The second exception is that the group
and the individual therapist are in constant contact. From the point of view
of DBT, the well-known phenomenon of staff splitting is seen as a problem
of the treatment professionals rather than as a patient problem. Treatment
staff are encouraged to use their interpersonal skills to work these problems
out as they arise.

Validation Strategies. The essence of the validation strategies is the active

acceptance of the patient by the therapist and the communication of this

acceptance to the patient. Validation involves three sequential steps. First,
the individual is helped to identify relevant response patterns. Second, the
therapist communicates accurate emotional empathy; understanding (but
not necessarily agreement) of beliefs, expectations, or
assumptions; and
recognition of behavioral patterns. Third, the therapist communicates that
these response patterns are understandable and that they make perfect
332 LINEHAN

sense in the context of the individual's life experiences to date even though
we often do not have access to the information needed to understand their
causes. This
strategy is absolutely essential to DBT. It requires a nonjudg-
mental therapeutic attitude. The therapist functions as the dialectically
opposing pole to the invalidating environments often experienced by the
patient.
Capability Enhancement Strategies. In contrast to the validation strat
egies, the focus here is on enhancement and change. Using these strategies,
the therapist acts as teacher, insisting at every point that the patient actively

engage in acquiring and practicing capabilities needed to cope with everyday

life. The parasuicidal person's passive problem-solving style is challenged
directly, forcefully, and repeatedly. Behavioral skill acquisition techniques
are used. These techniques are discussed at
length in behavior therapy
texts and in the DBT Treatment Manual (Linehan, 1983).
Relationship Strategies. There are four types of relationship strategies:
acceptance, enhancement, problem solving, and generalization. Relation
ship acceptance requires therapist acceptance of the current patient ther
apist relationship, including the stage of therapeutic progress or lack thereof,
at each successive moment. Patience; high tolerance for frustration, criti
cism, and hostile affect; and an ability a
nonjudgmental be
to maintain
havioral stance blaming the victim are necessary therapist char
not
acteristics. Relationship enhancement involves a direct attempt to create a

strong, positive patient therapist relationship. Generally, this is the focus

of the first few months of therapy with the borderline, parasuicidal patient.

Relationship problem solving is also called for whenever the interaction with
the therapist is a source of patient difficulty. Relationship problem solving
in DBT is done in the context of the therapeutic relationship as a "real"

relationship (Linehan, in press), and the therapist models how to work out
difficult interpersonal issues. This strategy is useful both to repair the pa
tienttherapist relationship and to improve via generalization the patient's
ability to successfully interact with others. Generalization from and to other
relationships, however, is not assumed. Instead, as in all behavior therapy,
generalization of behavior is an active focus of assessment and treatment.
Contingency Strategies. Contingency clarification and professor strate
gies involve giving the patient information about what can be reasonably
expected from the therapist and about the process and requirements of
therapy, as well as what factors are known to influence behavior in general,
and theories and data that might cast light on a particular patient's behavior

patterns. The contingency management strategy requires, as far as possible,

the arrangement of therapist responses to reinforce adaptive, nonsuicidal
behaviors and to extinguish suicidal behaviors. Due to the life-threatening
nature of suicidal behavior, therapist necessarily walks a dialectical
the

tightrope, neither reinforcing suicidal responses excessively nor ignoring

them in such a manner that the patient escalates to a
life-threatening level.
The DBT therapist takes some short-term risk in order to enhance long-
term advantage.
Conclusion There are no published empirical studies demonstrating the
effectiveness of any psychotherapy with this population. Nor are there any
available data indicating that hospitalization is effective at reducing suicidal
risk. Results of pharmacotherapy studies with inpatient borderlines are
 SELF-MUTILATION: DIALECTICAL BEHAVIOR THERAPY 333

somewhat hopeful. However, the risk of medication abuse and lethal over

dose is so
high that, with very few exceptions, outpatient pharmacotherapy
in ingestible form is simply not justified at this time with suicidal and

parasuicidal individuals. With several I currently in the midst

colleagues, am

of a randomized outcome DBT to treatment-as-usual in

study comparing
the community. To date, results are very encouraging.

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