Just What Is "Dialectical" About Dialectical Behavior Therapy?

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See reply by Goodman and Hazlett and article by Goodman et al

Just What Is “Dialectical” About Dialectical Behavior Therapy?

To the Editor: Regarding the recent study published in the Journal by Goodman et al,1 one possible explanation for the failure of dialectical behavior therapy (DBT) to demonstrate significant improvement is criterion deficiency resulting from a misapplication of the term dialectic. Using fancy words like dialectic is inherently suspicious, particularly in unexpected, anomalous contexts—such as psychotherapy. When asked to explain what it means, most DBT clinicians will make odd gestures with their hands and say something about “validating the client” while simultaneously “pushing for change.” As a result of which, presumably, they get better. This certainly is the emphasis of Dr Marsha Linehan’s most sustained reflections on the topic.2

The problem is that this has nothing to do with the concept of dialectics, which envisions a state transition from thesis to antithesis to synthesis. Thesis and antithesis are contradictory; they result in a new, inconsistent state of affairs—synthesis—which then develops its own internal contradictions.3 The antithesis renounces the thesis, and then the synthesis renounces both. They are mutually incomprehensible. In logical notation, this looks like:

Whereas Linehan’s concept of dialectics looks like:

Contemporary understanding of dialectics initially is based on the work of the German philosopher G. W. F. Hegel.4 Hegel believed that the ultimate expression of history was something he called “spirit,” which is a form of something else he called “absolute mind,” both of which are terms that have no discernible referents (and appear to have been adopted uncritically by DBT). Dialectics was then picked up by the social theorist Karl Marx, who hypothesized that late-stage industrial capitalism, when juxtaposed against worker dehumanization and alienation, would result in utopian communism.5 It since has proliferated to numerous other contexts, many involving psychiatry; for example, the migration from psychoanalysis to behaviorism to cognitive therapy is dialectical.

This is not what happens with DBT. The antithesis of “validation” is “rejection,” not “change.” Validation and change aren’ t true opposites, because clients aren’ t required to abandon the former in order to experience the latter. They don’ t have to repudiate their past, nor should they be required to do so. DBT correctly characterizes this process as “both/and,” not “either/or.”6

Their synthesis in turn is not a valid recombination. Clients often get better (or do not) for reasons that have nothing to do with acceptance or change. They don’ t move forward toward an outcome. Rather, the process of therapy is evolutionary—a “random walk”7 incorporating (nonexclusively) flexible thinking, adaptive behavior, and emotional awareness. “Change” is a description of what happens, not a maneuver within a collection of procedures. Its mechanism of action is diachronic (ateleological movement through time) or a set comprising a nondeterministic longitudinal series of synchronic moments (discrete points in time). As Wittgenstein might have said, there is no such thing as progress in psychology. Despite this, DBT still prescribes a rigorous initiation into what it incorrectly calls “dialectical thinking.” DBT is a good thing; however, it is not dialectical.

This confusion permeates DBT as applied, and is incomprehensible to clients, especially concrete ones (like many in the Veterans Administration). Holding two opposing thoughts in your mind at the same time is far more effortful than holding two complementary ones. Clinicians should divest themselves of the concept of “dialectic” and focus instead on emotional regulation, which is DBT’s most important theoretical contribution. It also is what most clearly distinguishes it from cognitive behavioral therapy; DBT is CBT’s counterpart, and it really should be called “emotional behavioral therapy” (EBT), abandoning any tenuous and misleading ties to “dialectics.” I suspect that DBT would have resulted in significantly more improved outcomes in this study, had emotional regulation been the focus of therapy.

References

1. Goodman M, Banthin D, Blair NJ, et al. A randomized trial of dialectical behavior therapy in high-risk suicidal veterans. J Clin Psychiatry. 2016;77(12):e1591-e1600. PubMed doi:10.4088/JCP.15m10235

2. Linehan MM, Schmidt H. The dialectics of effective treatment of borderline personality disorder. In: O’ Donohue WO, Krasner L, eds. Theories in Behavior Therapy. Washington, DC: American Psychological Association; 1995:443-484. doi:10.1037/10169-020

3. Priest G, Tanaka K, Weber Z. Paraconsistent logic. Stanford Encyclopedia of Philosophy. Stanford.edu website. http://plato.stanford.edu/entries/logic-paraconsistent/. 2016. Accessed January 15, 2017.

4. Hegel GWF. The Phenomenology of Spirit. Miller AV, trans. Oxford, UK: Oxford University Press; 1976.

5. Marx K. Das Kapital: A Critique of Political Economy. Fowkes B, trans. London, UK: Penguin Books Ltd; 1976.

6. Linehan MM. DBT Skills Training Manual, 2nd ed. New York, NY: Guilford Press; 2015:285-294.

7. Molenaar PCM. Note on optimization of individual psychotherapeutic processes. J Math Psychol. 2010;54:208-213. doi:10.1016/j.jmp.2009.04.003

David Kronemyer, PhDa

dkronemyer@mednet.ucla.edu

aDepartment of Psychiatry, University of California, Los Angeles

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2017;78(3):e310

https://doi.org/10.4088/JCP.16lr11394

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