1 Dialectical Theory Part I Dialectical Theory Part I

2 Structure the Philosophy of Care DBT requires a consistent philosophy of care DBT requires a consistent philosophy of care

3 Behavioral Science Zen Practice Dialectical Philosophy Dialectical Philosophy Philosophical Assumptions

4 Dialectical Philosophy of Treatment Dialectics As Persuasion Persuasion World View World View Dialectics As Persuasion Persuasion World View World View

5 Dialectics as Persuasion A method of logic or argumentation by disclosing the contradictions (antithesis) in an opponent’s argument (thesis) and overcoming them (synthesis).

6 The universe is so constructed that the opposite of a true statement is a false statement, but the opposite of a profound truth is usually another profound truth. N. Bohr, quoted in K. Wilber, 1977 The universe is so constructed that the opposite of a true statement is a false statement, but the opposite of a profound truth is usually another profound truth. N. Bohr, quoted in K. Wilber, 1977

7 Appearance is the process of arising and being and passing away again, a process that itself does not arise and pass away, but is per se, and constitutes reality and the life- movement of truth… [thus] the truth of the process is not to be found in any of its single phases, but in its totality (which is no mere plurality), the rational rhythm of the organic whole" Hegel Appearance is the process of arising and being and passing away again, a process that itself does not arise and pass away, but is per se, and constitutes reality and the life- movement of truth… [thus] the truth of the process is not to be found in any of its single phases, but in its totality (which is no mere plurality), the rational rhythm of the organic whole" Hegel

8 Three Types of Adult Thinking (Michael Basseches, 1984) Universal Formal Universal Formal Relativistic Relativistic Dialectical Dialectical Universal Formal Universal Formal Relativistic Relativistic Dialectical Dialectical

9 (Basseches, 1984) Truth is fixed and unchanging Truth is fixed and unchanging The Universe is ordered The Universe is ordered Some individuals have the Truth and others do not Some individuals have the Truth and others do not It is the therapist’s job to help the client arrive at the unfixed, stable TRUTH It is the therapist’s job to help the client arrive at the unfixed, stable TRUTH Truth is fixed and unchanging Truth is fixed and unchanging The Universe is ordered The Universe is ordered Some individuals have the Truth and others do not Some individuals have the Truth and others do not It is the therapist’s job to help the client arrive at the unfixed, stable TRUTH It is the therapist’s job to help the client arrive at the unfixed, stable TRUTH

10 (Basseches, 1984) Truth is entirely relative and varies from person to person, culture to culture. Truth is entirely relative and varies from person to person, culture to culture. No one person’s viewpoint is superior or inferior to another’s. No one person’s viewpoint is superior or inferior to another’s. There is no universal order and no Truth. There is no universal order and no Truth. It is the therapist’s job to help the client determine what values and opinions are most comfortable or useful to her or him It is the therapist’s job to help the client determine what values and opinions are most comfortable or useful to her or him Truth is entirely relative and varies from person to person, culture to culture. Truth is entirely relative and varies from person to person, culture to culture. No one person’s viewpoint is superior or inferior to another’s. No one person’s viewpoint is superior or inferior to another’s. There is no universal order and no Truth. There is no universal order and no Truth. It is the therapist’s job to help the client determine what values and opinions are most comfortable or useful to her or him It is the therapist’s job to help the client determine what values and opinions are most comfortable or useful to her or him

11 (Basseches, 1984) Elements of Universal Formal and Relativistic Thinking Elements of Universal Formal and Relativistic Thinking Rejects relativistic stance of not striving to find and create more powerful truths. Rejects relativistic stance of not striving to find and create more powerful truths. Also rejects universalist notion that an “all inclusive truth” is possible. Also rejects universalist notion that an “all inclusive truth” is possible. Elements of Universal Formal and Relativistic Thinking Elements of Universal Formal and Relativistic Thinking Rejects relativistic stance of not striving to find and create more powerful truths. Rejects relativistic stance of not striving to find and create more powerful truths. Also rejects universalist notion that an “all inclusive truth” is possible. Also rejects universalist notion that an “all inclusive truth” is possible.

12 (Basseches, 1984) There is Truth and Truth evolves over time. There is Truth and Truth evolves over time. Process of arriving at Truth involves discovering what is left out of existing truths and creating new truths or orderings that include or embrace what is left out. Process of arriving at Truth involves discovering what is left out of existing truths and creating new truths or orderings that include or embrace what is left out. It is the therapist’s job to help the client synthesize polarities, to search for what is left out, to both arrive at truth and be willing to let it go. It is the therapist’s job to help the client synthesize polarities, to search for what is left out, to both arrive at truth and be willing to let it go. There is Truth and Truth evolves over time. There is Truth and Truth evolves over time. Process of arriving at Truth involves discovering what is left out of existing truths and creating new truths or orderings that include or embrace what is left out. Process of arriving at Truth involves discovering what is left out of existing truths and creating new truths or orderings that include or embrace what is left out. It is the therapist’s job to help the client synthesize polarities, to search for what is left out, to both arrive at truth and be willing to let it go. It is the therapist’s job to help the client synthesize polarities, to search for what is left out, to both arrive at truth and be willing to let it go.

13 Search for “what is left out” Weave a “web of logic” Emphasis on speed, movement, flow Search for “what is left out” Weave a “web of logic” Emphasis on speed, movement, flow Dialectically-Informed Treatment Strategies of Persuasion

14 Dialectical Philosophy of Treatment Dialectics As Persuasion Persuasion World View World View Dialectics As Persuasion Persuasion World View World View

15 Dialectics as Process of Change The process of change whereby an idea or event (Thesis ) generates and is transformed into its opposite (Antithesis ) and is preserved and fulfilled by it, leading to a reconciliation of opposites ( Synthesis ) The process of change whereby an idea or event (Thesis ) generates and is transformed into its opposite (Antithesis ) and is preserved and fulfilled by it, leading to a reconciliation of opposites ( Synthesis )

16 Functions of Dialectical Philosophy Guides assumptions about the nature of reality Guides assumptions about the nature of reality Provides foundation of biosocial etiology Provides foundation of biosocial etiology Balances treatment goals Balances treatment goals Balances treatment strategies Balances treatment strategies Guides assumptions about the nature of reality Guides assumptions about the nature of reality Provides foundation of biosocial etiology Provides foundation of biosocial etiology Balances treatment goals Balances treatment goals Balances treatment strategies Balances treatment strategies

17 Dialectics as a World View: Assumptions Holistic, connected, and in relationship Complex, oppositional, and in polarity Change is continual Change is transactional Identity is relational and in continuous change Holistic, connected, and in relationship Complex, oppositional, and in polarity Change is continual Change is transactional Identity is relational and in continuous change

18 Change Core Problem Solving Problem Solving Acceptance V alidation Team Consultation Team Consultation ReciprocalReciprocal Environmental Intervention Environmental Intervention Consultation- to-the-Patient Consultation- to-the-Patient IrreverentIrreverent

19 Translating a Dialectical World View into Treatment Provides foundation of biosocial etiology 1.Transactional development and maintenance 2.Systemic disorder Dialectically informs treatment strategies 1.Balance of Acceptance vs. Change 2.Search for "what is left out" 3.Emphasis on speed, movement, flow Dialectically informs treatment goals 1.Emotion regulation 2.Interpersonal effectiveness 3.Mindfulness 4.Distress tolerance Provides foundation of biosocial etiology 1.Transactional development and maintenance 2.Systemic disorder Dialectically informs treatment strategies 1.Balance of Acceptance vs. Change 2.Search for "what is left out" 3.Emphasis on speed, movement, flow Dialectically informs treatment goals 1.Emotion regulation 2.Interpersonal effectiveness 3.Mindfulness 4.Distress tolerance

20 Dialectical View of Disorder Foundation of Foundation of biosocial etiology – Transactional model of development and maintenance – Systemic disorder Foundation of Foundation of biosocial etiology – Transactional model of development and maintenance – Systemic disorder

21 BPD results from transaction of biological vulnerability with invalidation over time A1 B1 A1 B1 A2 B2 A2 B2 A i B i A i B i A1 B1 A1 B1 A2 B2 A2 B2 A i B i A i B i

22 Systemic Disorder Defined Defines disorder with respect to normal functioning Defines disorder with respect to normal functioning Assumes continuity between health and disorder Assumes continuity between health and disorder Assumes disorder results from multiple rather than single causes Assumes disorder results from multiple rather than single causes Defines disorder with respect to normal functioning Defines disorder with respect to normal functioning Assumes continuity between health and disorder Assumes continuity between health and disorder Assumes disorder results from multiple rather than single causes Assumes disorder results from multiple rather than single causes

23 Dialectically-Informed Treatment Goals ACCEPTANCEACCEPTANCE CHANGE CHANGE Distress Tolerance Interpersonal Effectiveness BALANCES BALANCES Emotion Regulation Emotion Regulation Mindfulness Mindfulness Linda Dimeff: MML: I think the skills listing at bottom is confusing in that distress tolerance and emotion regulation contain within them change and acceptance strategies. Linda Dimeff: MML: I think the skills listing at bottom is confusing in that distress tolerance and emotion regulation contain within them change and acceptance strategies.

24 The Overarching DBT Target is... The Overarching DBT Target is... Dialectical Synthesis

25 Dialectical Synthesis the “middle path” Dialectical Analyses Truth is sought through efforts to discover what is left out of current ways of ordering events of ordering events Dialectical Lifestyle walking the “middle path” with balanced behavior patterns Balanced Actions, Emotions and Cognition Balanced Actions, Emotions and Cognition Dialectical Analyses Truth is sought through efforts to discover what is left out of current ways of ordering events of ordering events Dialectical Lifestyle walking the “middle path” with balanced behavior patterns Balanced Actions, Emotions and Cognition Balanced Actions, Emotions and Cognition

26 Goals of Treatment by Level of Disorder Goals of Treatment by Level of Disorder Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control

27 Decrease Decrease – Life-threatening behaviors – Therapy-interfering behaviors – Quality-of-life interfering behaviors Increase behavioral skills Increase behavioral skills Core Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation Self-Management Decrease Decrease – Life-threatening behaviors – Therapy-interfering behaviors – Quality-of-life interfering behaviors Increase behavioral skills Increase behavioral skills Core Mindfulness Distress Tolerance Interpersonal Effectiveness Emotion Regulation Self-Management Stage 1 Primary Targets Dialectical Synthesis Severe Behavioral Dyscontrol Behavioral Control Stage 1 Primary Targets Dialectical Synthesis Severe Behavioral Dyscontrol Behavioral Control

28 Structure the Secondary Targets of Treatment DBT selects secondary targets by their positions and functions on the chain analyses of problem behaviors

29 BiologicalSocialBiologicalSocial Emotional Vulnerability Emotional Vulnerability Active Passivity Active Passivity Unrelenting Crises Self-Invalidation Inhibited Experiencing Inhibited Experiencing Apparent Competence

30 DBT Secondary Targets Increase 1.Emotional Modulation 2.Self-Validation 3.Realistic Judgment 4.Emotional Experiencing 5.Active Problem- solving 6.Accurate Expression Increase 1.Emotional Modulation 2.Self-Validation 3.Realistic Judgment 4.Emotional Experiencing 5.Active Problem- solving 6.Accurate Expression Decrease 1.Emotional Reactivity 2.Self-Invalidation 3.Crises Generating Behaviors 4.Grief Inhibition 5.Active-Passivity 6.Apparent-only Competence

31 Goals of Treatment by Level of Disorder Goals of Treatment by Level of Disorder Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing

32 STAGE 2 Dialectical Synthesis Quiet Desperation Emotional Experiencing Primary Targets – Decrease Post-Traumatic Stress Responses Distortion/denial of facts of trauma Distortion/denial of facts of trauma Stigmatization, self-invalidation Stigmatization, self-invalidation Denial/avoidance of traumatic cues Denial/avoidance of traumatic cues Dichotomous response style Dichotomous response styleGoals – Non-traumatizing Emotional Experiencing – Connection to the Environment Primary Targets – Decrease Post-Traumatic Stress Responses Distortion/denial of facts of trauma Distortion/denial of facts of trauma Stigmatization, self-invalidation Stigmatization, self-invalidation Denial/avoidance of traumatic cues Denial/avoidance of traumatic cues Dichotomous response style Dichotomous response styleGoals – Non-traumatizing Emotional Experiencing – Connection to the Environment

33 Goals of Treatment by Level of Disorder Goals of Treatment by Level of Disorder Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness

34 STAGE 3 Dialectical Synthesis Problems in Living Ordinary Happiness & Unhappiness Primary Targets – Increase Respect for Self – Decrease Individual Problems in Living Goals – Self Respect Mastery, self-efficacy Mastery, self-efficacy Sense of morality Sense of morality – Acceptable Quality of Life Primary Targets – Increase Respect for Self – Decrease Individual Problems in Living Goals – Self Respect Mastery, self-efficacy Mastery, self-efficacy Sense of morality Sense of morality – Acceptable Quality of Life

35 Goals of Treatment by Level of Disorder Goals of Treatment by Level of Disorder Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Level 4: Incompleteness Capacity for Joy and Freedom Capacity for Joy and Freedom Dialectical Synthesis Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Level 4: Incompleteness Capacity for Joy and Freedom Capacity for Joy and Freedom

36 STAGE 4 Dialectical Synthesis Incompleteness Capacity for Sustained Joy Expanded Awareness Expanded Awareness – Self – Past to Present – Self to Other Peak Experiences/Flow Peak Experiences/Flow Spiritual Fulfillment Spiritual Fulfillment Expanded Awareness Expanded Awareness – Self – Past to Present – Self to Other Peak Experiences/Flow Peak Experiences/Flow Spiritual Fulfillment Spiritual Fulfillment

37 Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Level 4: Incompleteness Capacity for Joy Capacity for Joy Level 1: Severe Behavioral Dyscontrol Behavioral Control Behavioral Control Level 2: Quiet Desperation Emotional Experiencing Emotional Experiencing Level 3: Problems in Living Ordinary Happiness & Unhappiness Ordinary Happiness & Unhappiness Level 4: Incompleteness Capacity for Joy Capacity for Joy Stages of Treatment Commitment and Agreement Pre-Treatment Goals:

38 Biological Social Biological Social Emotional Vulnerability ( Emotional agony, Falling into the abyss, Loss of control, task impossibility) Emotional Vulnerability ( Emotional agony, Falling into the abyss, Loss of control, task impossibility) Self-Invalidation (Self-directed hate & contempt; Dismissal of pain & difficulty; Unrealistic expectations) Self-Invalidation (Self-directed hate & contempt; Dismissal of pain & difficulty; Unrealistic expectations)

39 BiologicalSocialBiologicalSocial Emotional Vulnerability Emotional Vulnerability Active Passivity Active Passivity Unrelenting Crises Self-Invalidation Inhibited Experiencing Inhibited Experiencing Apparent Competence