Marsha Linehan developed DBT to help suicidal individuals get out of emotional hell and to help them build lives worth living. As it turns out, the therapeutic action of the treatment seems to depend on helping the patient gain the capacity to regulate emotions more effectively, relying heavily on learning and applying skills. But think about it. We all suffer, at least at times, from emotional dysregulation. We all encounter rough patches, stress-induced dysregulation. When I lost my best friend to her eleven-year battle with cancer, I suffered and grieved. I needed skills. The parents whose teenage child, or adult child, struggles with substance abuse, suffers, as does the kid. They all need skills. The individual dealing with chronic pain and disability, or a dementing condition, needs skills, as does the person who is caring for him or her. Life deals us some painful cards, some agonizing dilemmas, again and again. Companies encounter periods of decline, or chaos, or conflict, in which nearly every employee suffers. Leaders of companies and other organizations are challenged again and again to adjust to stressful environmental conditions or difficulties with employees. The point is obvious: everyone gets dysregulated from time to time, every organization goes through its own versions of hell, and everyone needs skills. Of course we have a lot of the skills already, and you can find them in all kinds of guides and manuals for living. But I haven’t found a better set of principles, each of which brings very specific and concrete “tools,” than what exists within DBT. And it is reassuring that these arise as part of an evidence-based treatment program designed to get people out of emotional and behavioral hell.

This is what I want to explore in this blog. In today’s blog post and in the next two, I will lay out the three paradigms and the fifteen principles of DBT, as these are the basic building blocks from which I will draw in all future entries, which will take the form of a series “case studies.” Once we begin to look at examples of getting ourselves out of hell—loss, injury, illness, unrelenting conflict, relationship stalemates, “family hell,” organizational dysfunction, etc.—we will see how DBT’s paradigms and principles give rise to specific tools–strategies and skills—that give us so many more options than what we thought. In addition to exploring this principle- and skill-based way of coping with life’s hells, I think there is another application. The individual who is not in hell but is reaching for the stars, trying to take his or her “game,” whatever it may be, to the highest level, I believe that the same paradigms, the same principles, and the same skills, apply. I hope to look at the athlete or performer looking to maximize his or her potential, the student or worker trying to maximize his or her performance, and the family looking to establish the most trusting and nurturant atmosphere for all family members. DBT provides a program for effective and compassionate living. But I get way ahead of where I am; let me tell you about the paradigms today, and move on to the principles in the next two entries.
I will be as clear as I can be in laying out the paradigms and principles, but if you want to read about them in more detail and with case examples, as applied to the practice of psychotherapy, you can check out my book, DBT Principles in Action: Acceptance, Change, and Dialectics (Guilford Press, 2016). When we search to get out of hell or to reach the sky, we can be overwhelmed with the number of suggestions, the number of solutions, everywhere we turn. If you are raising an infant who is having trouble of some kind, you will find no lack of advice from experts, books, magazines, friends, family members, and sometimes even strangers on the street. Even within the DBT treatment manuals, the therapist has access to more than 85 strategies and more than 100 skills, as well as several protocols. How to proceed? What to do? Who wants to be entertaining almost 200 options at a moment of distress and uncertainty. But here is the good news: from another perspective, the individual drawing from DBT makes a choice between three directions, and having made one of those choices other options open up. What are those choices? We either choose 1) to change the problem confronting us, 2) to accept the predicament we encounter and the feelings that go with it, or 3) by locating the opposing positions at the center of our dilemma, find the wisdom on both sides, and move toward a synthesis of those two “wisdoms,” maintaining movement instead of grinding to a depressing halt.

I had a friend who was very important to me even though we did not see each other frequently. Circumstances arose in which one of my children needed a certain kind of help with which this friend could assist. I contacted him, asked him if he would help, and he graciously and willingly did so. I was grateful. Two months later a similar need arose, regarding the same child, and I asked him again for his help. He helped again. I thanked him again. But after that, he never returned any emails or calls from me, most of which were simply friendly gestures on my part. Long story short: an important bond between us seems to have snapped, but no matter what I did I couldn’t get him to respond. I became quite upset about it, with urgent feelings about getting it fixed as soon as I could. I felt his absence and his non-response as a big loss. And on top of that, I felt that I had asked too much of him, that it was not reciprocal in that he had asked for nothing from me. I felt guilty. Looking back on it, I realize that my distress may have been out of proportion with an objective assessment of the level of trouble from which it rose. But, nevertheless, it was awful for me, and it preoccupied me.

When I thought about what to do, I asked which of the three directions to take. 1) Should I push for a solution, pursuing him yet again, trying to get more creative or even a bit intrusive? Maybe I should reach out to mutual friends, or his family members. 2) Should I accept the predicament, at least for the time being, accept his non-response, accept my level of distress and preoccupation, while suspending any problem solving activities? As the Beatles said, maybe I should just “let it be.” 3) Or should I take a thoughtful look at the situation, trying to locate the nature of the opposition at the center of it, find the opposing sides, and find the wisdom on both sides before moving forward? I found it incredibly helpful to lay out my initial choices in this way. I realized that I didn’t really have to choose only one direction, but still it clarified matters for me. Sometimes when you find yourself in some version of hell small or large, it is so helpful just to have a way to stepping back and breaking down your choices. Intuitively, I concluded that I should leave him alone for the time being, accept his non-response without knowing for sure what it meant. If I could simply step back into myself, acknowledging the impasse, accepting that I could remain in the dark, that I could wait, that things could change and probably would, and let it settle, I would arrive at a “wiser” place in myself. There was nothing that I had to do.

From this path of “acceptance,” I moved easily into considering what might have gone wrong between us, what could be the opposition between us. I then remembered that this friend had fairly recently felt neglected by me when I came to the town where he lived to visit someone else. He heard about my visit and I heard through someone else that he was feeling hurt. I figured that he might now resent that episode, after which I twice asked him for help. I was able to imagine that his non-response may have been a way to protect himself against another slight or a feeling of being exploited. It may also have served as a silent way to communicate to me that he felt unhappy with me. As for my side, perhaps I had inadvertently exploited our friendship, and I knew that I wanted contact with him to express my gratitude and to reassure myself that things were all right between us. His response, or non-response, probably made complete sense, my inadvertent “exploitation” of him was understandable, my desire to re-connect made sense, and we were momentarily at odds. Thinking of it that way led me to a possible synthesis: to simply send him a thank you gift for the help he gave to my son, delivered without warning and without any expectation of hearing back from him in the near future. It “felt right” as a solution. I sent him a box of fruits, cheeses, and snacks with a thank you note. About a month later he wrote me an email thanking me for the gift and wondering if I’d like to get together.

These three directions are associated with the three paradigms, the three philosophies, providing the bases of DBT as a treatment. They are pivotal in translating this evidence-based treatment approach, developed to help a certain suffering patient population, to a guide for all of us in coping with our own hells and maximizing our own potentials. The first is the Change Paradigm, based on Cognitive-Behavioral Therapy approaches, and represented in DBT in problem-solving strategies. The second is the Acceptance Paradigm, based in Mindfulness principles and practices, and represented in DBT in the form of mindfulness practices and validation strategies. The third is the Dialectical Paradigm, based in Dialectical Philosophy and represented in DBT in the form of dialectical strategies. In the next blog entry I will spell out these three paradigms, and the five principles of each, more clearly.