Dialectical Behavior Therapy: What Is A Dialectic?

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Allan Schwartz, LCSW, Ph.D. was in private practice for more than thirty years. He is a Licensed Clinical Social Worker in the states ...Read More

Have you ever been in a situation in which you are angry at someone despite the fact that you know the other person was unable to be helpful to you even though they wanted to? Here is an example:

Hypothetical Case:


A female patient sees me for psychotherapy because she is extremely depressed. She is taking anti depressant medications that hep her feel better. During the first several months of therapy she appears to be doing very nicely. She is socializing more, going to work without absences for illness, she has stopped drinking and is feeling much better.

Suddenly, she becomes very silent during sessions and appears to be very angry. When the therapist asks her what her thoughts are and what has been going on she is reluctant to speak but begins to admit she has been f eeling very angry. Slowly and patiently, the therapist gently asks her to talk about what is troubling her, reminding her that the therapeutic office is a safe place. Finally and with tears in her eyes, she begins to reveal her feelings towards the therapist and fears that she will be thought of as ridiculous.

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She has encountered some of the therapist’s other patients. She notices that some of these patients are very a ttractive females. She comes to think that the therapist prefers them to her and that the therapist wishes she would leave and no longer "annoy him." Slowly and with great pain, the patient’s romantic feelings towards the therapist emerge as well as the hurt and rejected feelings she has always experienced from the time she was a small child until the present. In her family of origin, she was rejected by both of her parents who were professional people and had no time for her.

She understands that she is in psychotherapy and that the therapist does care about her and her development as a human being. Alongside of this knowlege, she harbors the resentment that she is not the preferred child or patient and she is furious about it. She tells herself that if the therapist really cared he would make love to her, leave his wife, marry her and they would live "happily ever after." Her explanation for why her fantasy wishes cannot come true is that she is worthless, unwanted and undesirable. The emotions that spring from these thoughts of jealously make her so angry, and she feels so rejected that she wants to quit therapy.

This is not an unusual scenario for a patient and therapist. In terms of psychoanalysis the thoughts and emotions of the therapist are called transference. Patient and therapist would work through the transferential thoughts and feelings so that the patient would gain insight into her feelings of rejection. The transference of this patient would be viewed in terms of her childhood relationship to and experience with her father and mother. Unlike traditional Cognitive Behavior Therapy, transference issues are an important part of Dialectical Behavior Therapy. In dialectical behavior therapy, the patient and therapist work on understanding the complex and conflicting issues that motivate the therapist.

According to Marsha Linehan, the psychologist and founder of Dialectical Behavior Therapy, dialectical thinking is a middle ground between two opposite ways of thinking and acting. One way of thinking is in terms of absolutes. This is called Univeralistic thinking and it means that the belief is that, in an argument or discussion, one person is right and the other is wrong.

In the case above, the patient became convinced that the therapist did not care about her and really preferred the other female patients. To prove that her view was right she would point out how the therapist would smile when talking to other females but would never smile at her. When challenged on this she would retreat and state that "the only reason the therapist was evening seeing her in treatment was because she payed him."

Relativistic thinking, according to Linehan, assumes that there is no universal truth and that in an argument truth is in the "eye of the beholder."

Linehan then reports that dialectical thinking requires that the thinker transcend polarities. The thinker must look at each of the polarities and ask about what may have been left out of each argument. In terms of dialectical behavior therapy the goal becomes that the patient comes to accept the existence of two poles and many details. In these terms it means that the patient come to understand and accept that both black and white exist. Therefore, it is not necessary to abandon one way of thinking or one point of view.

The patient in the hypothetical case above came close to dialectical thinking when she realized that the therapist can care about her but in a professional way. In the professional caring the therapist is not rejecting the patient but helping her to become an autonomous individual who does not need to bind herself to the therapist in order to feel good about herself.

This is complicated and I may not be the best translator of Linehan and DBT. However, what is most important to me is to get across the idea that thinking in dialectical terms is liberating because it become possible to take in many truths, many realities without rejecting any persons who hold to these opposite or varied opinions, views and realities. For the patient above one goal of therapy might have been for her to come to see that the therapist can care about her but that he is constrained by two things: one is his professional obligations and the second is that to have satiated her romantic fantasies he would have harmed her autonomy and this would have done damage to his intent as her therapist.

My reason for writing this posting about dialectical thinking is to make the point that we all need to look at what is missing when we deal with issues and conflicts and, in doing so, we need to remember that there there can be conflicting absolutes. It is not that I am right and you are wrong. It is that you and I are driven by many poles, many truths and many points of view.

So, what is the point of all of this? The point is that we can spare ourselves a lot of stress, anger and anguish by not getting stuck in one way of thinking.

What Do You Think??

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