zen principles and mindfulness practice in dialectical behavior therapy

5 0 R o b i n s

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Dimeff, L. A., Baer, J. S., Kivlahan, D. R., & Marlatt, G. A. (1999). Brief Alcohol Screwing and Intervention fi)r College Students (BASICS): A ha~vn reduction approach. New York: Guilford Press.

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Levine, M. (2000). The positive psycholo~ of Buddhism and yoga. Mahwah, NJ: Lawrence Erlbaum.

Marlatt, G. A. (1985). Lifestyle modification. In G. A, Martatt &J. R. Gordon (Eds.), Relapse prevention (pp. 280-348). New York: Guil- ford Press.

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Marlatt, G. A., & gJ'istellei; J. (1999). Mindfulness and meditation. In W. R. Miller (Ed.), Integrating spirituality in treatment: Resources for practitioners (pp. 67-84). V~:ashington, DC: American Psychologi- cal Association Books.

Marlatt, G. A., & Marques, J. K. (1977). Meditation, self control, and alcohol use. Ill R. B. Stuart (Ed.), Behavioral self-management: Strat- egies, techniques, and outcomes (pp. 117-153). New York: Brunner/ Mazel.

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Effects of meditation and relaxation training upon alcohol use in male social drinkers. In D. H. Shapiro & R. N. Walsh (Eds.), Med- itation: Classic and eontemporary perspectives (pp. 105-120). New York: Aldine Press.

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Murphy, T.J., Pagano, R. R., & Marlatt, G. A. (1986). Lifestyle modification with hea~T alcohol drinkers: Effects of aerobic exercise and meditation. Addictive Behaviors, 11, 175-186.

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Teasdale,J. D., Segal, Z. V., & Williams,J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should atten- tional control (mindfulness) training help? BehaviourResean:h and Therapy, 33, 25-39.

Teasdale, J. D., Segal, Z. V., Williams,J. M. G., Ridgewa); V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of relapse/recurrence in m~:jor depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623.

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Address correspondence to G. Alan Marlatt, Ph.D., University of Washington, Department of Psychology, Box 351525, Seattle, WA 98195; e-mail: [email protected].

Received: January 10, 2000 Accepted: l~br'uary 20, 2001

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Zen Principles and Mindfulness Practice in Dialectical Behavior Therapy

C l i v e J . R o b i n s , D u k e University

Dia&ctical behavior therapy (DBT; Linehan, 1993a) was developed as a treatment for borderline personality disorder (BPD). It involves a dialectical synthesis of the change-oriented strateg4es of cognitive-behavioral therapy with more acceptance-oriented principles and strategies adapted primarily Ji'om client-centered therapy and from Zen. In this pap~ I note both .similarities and contrasts between co~zitive-behavioral therapy and Zen. I then highlight the role of Zen principles in DBT's assumptions about patients, theory of BPD, selection of treatment targets, and treatment strategies. Finally, the article describes the value of mindfulness practice for patients with BPD, how mindfulness skills are taught to patients in DBT, and benefits of mindfulness practice for therapists.

EHAVIOR THERAPY a n d B u d d h i s t t h o u g h t m i g h t ap-

p e a r to be radically d i f fe ren t , p e r h a p s even con t ra -

dictory, in t he i r a p p r o a c h e s to u n d e r s t a n d i n g a n d chang-

ing behavior . For e x a m p l e , b e h a v i o r t he r apy t radi t ional ly

has f o c u s e d on over t behav io r a n d o t h e r observable vari-

ables a n d the Wes t e rn scientif ic m e t h o d o f a d v a n c i n g

C o g n i t i v e a n d B e h a v i o r a l P r a c t i c e 9 , 5 0 - 5 7 , 2 0 0 2

1077-7229/02/50-5751.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy. All right.s of reproduction in any form reserved.

knowledge , w h e r e a s B u d d h i s t t h o u g h t a n d m o s t o t h e r re-

l igious t rad i t ions have b e e n c o n c e r n e d pr imar i ly with

m e n t a l a n d spir i tual p h e n o m e n a a n d p r o p o s e an exper i -

ent ia l p a t h to u n d e r s t a n d i n g a n d c h a n g i n g behavior .

However , as this series attests, t h e r e is g ro wing i n t e r e s t

a m o n g b eh av i o r the rap i s t s a n d cogni t ive b e h a v i o r thera -

pists in the po t en t i a l c o n t r i b u t i o n s o f spir i tual t rad i t ions ,

par t icu lar ly B u d d h i s m .

At least o n e f o r m o f b eh av i o r therapy, d ia lect ica l be-

hav ior t h e r ap y (DBT; L i n e h a n , 1993a) fo r p e r s o n s diag-

n o s e d with b o r d e r l i n e pe r sona l i ty d i s o r d e r (BPD), ex-

Mindfulness and Dialectical Behavior Therapy 51

plicitly integrates cognit ive-behavioral pr inciples and strategies with Zen Buddhis t pr inciples and mindfulness practice. Several r andomized trials have found that DBT has some efficacy for the t r ea tment of BPD (Koons et al., 2001; Linehan, Armstrong, Suarez, Al lmon, & Heard, 1991; L inehan et al., 1999). In this article, I will discuss the historical deve lopmen t of DBT and highl ight why Zen principles and practices have become a def ining as- pec t of the t rea tment (for a more comprehens ive de- script ion of DBT as a whole, see Robins, Ivanoff, and Linehan, 2001). I then note some impor t an t ways in which Buddhis t thought is compat ib le with behavior therapy, as well as differences between the two that suggest that Buddhis t pr inciples and mindfulness pract ice may provide behavior therapists both with useful ways of conceptual iz ing pat ients and situations and with helpful t r ea tment strategies. Following these in t roductory com- ments, I discuss in more detail some of the ways in which Zen pr inciples are ref lected in various aspects of DBT. These include its (a) assumptions about patients; (b) theory of the deve lopmen t and main tenance of the behaviors, thoughts, and feelings c o m m o n in persons diagnosed with BPD, (c) secondary targets of t r ea tment that are functionally re la ted to BPD cr i ter ion behaviors, and (d) t r e a tmen t strategies. Finally, I descr ibe how mindfulness pract ice is t aught to pat ients as a core skill and ut i l ized by therapists themselves in the service o f com- passionate and effective t r ea tmen t for mul t ip rob lem patients. I should say at the outse t that my own back- g r o u n d knowledge of Buddh i sm as a whole is relatively l imited. I am aware that there are many streams of t hough t in Buddhism, as there are in o the r world religions. My focus here will be on the Zen t rad i t ion as it is re f lec ted in DBT.

Why Does DBT Include Zen Principles and Practice?

DBT was deve loped as a t r ea tment for chronical ly suicidal a n d / o r self-injurious women, many of whom had BPD. L inehan initially a t t empted to he lp the pat ient change such behaviors by using s tandard cognitive- behavioral strategies: conduc t ing a behavioral analysis of par t icular incidents of the behaviors and then influenc- ing the variables that seemed to mainta in them th rough such p rocedures as assertiveness t ra in ing and cognitive restructuring. She has r epo r t ed that such at tempts to ap- ply s tandard protocols were not very successful (Linehan, 1993a, p. 77). Patients often expe r i enced a sole focus on change procedures as invalidating their levels of distress, or even as b laming them for their problems, making it difficult for them to use the skills taught in therapy. As a result, pat ients may r e spond by at tacking the therapis t or by leaving t reatment . Pr ior to lea rn ing DBT, my own at-

tempts at cognitive res t ructur ing with BPD pat ients frequently met object ions such as, "So now you ' r e saying there 's ano the r th ing wrong with me: I can ' t th ink right," or "It's not my th inking that makes me upset. W h e n I get upset, I start to th ink like this and I am no t able to change it." These kinds of difficulties led L inehan to modify stan- dard cognitive behavioral t r ea tment to inc lude a greater emphasis on validating the pat ient ' s exper ience , even maladapt ive behaviors, as making sense given his o r he r history and the cur ren t context . The emphasis on acceptance of the pat ient counterba lances the emphasis on change associated with behavior therapy. In addi t ion , bo rde r l ine pat ients typically have great difficulty accepting many things about themselves, o the r people , and the world in general . Linehan, therefore , was also in teres ted in teaching these pat ients a m e t h o d for p romot ing a greater capacity for acceptance and drew on he r own exper ience with Zen mindfulness pract ice as well as the Christ ian contemplat ive tradi t ion.

It is likely that most patients, regardless of diagnosis or type of behavioral p roblem, benef i t f rom exper ienc ing their therapists as validating and accept ing and f rom learn ing how to be more accept ing o f themselves and others. However, this need probably is much grea ter for bo rde r l ine patients than for most others. One in teres t ing f inding that may illustrate the impor tance of acceptance by others is the large effect on relapse rates in schizo- phren ia (and some o the r disorders) as a funct ion of the level of expressed emot ion (EE) of thei r relatives with whom they live (Butzlaff & Hooley, 1998). Observat ional measures of EE assess criticism, hostility, and emot iona l overinvolvement. Hooley and Hil ler (2000) r epo r t ed that high EE relatives of schizophrenia pat ients scored significantly lower on tolerance, flexibility, and empathy on a b road-band personal i ty measure than d id low EE relatives. However, it was the low EE relatives who differed most f rom normat ive samples on to lerance (Hooley, 1998). Thus, it may be that an unusually high level of acceptance, perhaps ref lected in their explici t or implici t expectat ions of the pat ient , is helpful to the pat ient ' s clinical progress.

Compatibility of Buddhism and Cognitive-Behavioral Therapy

Although Buddhism frequent ly is viewed as a rel igion, it also can be viewed as a psychology. This a rgumen t probably could be advanced for o the r religions, bu t I believe that it is part icular ly clear with Buddhism. The core teachings of Buddhism involve the Four Noble Truths and the Eight-Fold Path, summar ized in this issue by Kn- mar (2002). The Four Noble Truths conce rn the experience of suffering and thus are relevant to behavior therapists and to the field of menta l heal th in general . These

52 Robins

truths or pr inciples state the following: (a) life is full of suffering, (b) the root cause of suffering is a t tachment , (c) it is possible to decrease or even end suffering by let- t ing go of one ' s a t tachments , and (d) the me thod for do ing so is to practice the Eight-Fold Path. The eight parts o f this pa th may be t ranslated as r ight unders tand- ing, r ight thought , r ight speech, r ight action, r ight liveli- hood, r ight effort, r ight mindfulness, and r ight concen- tration. The idea t la~ the solut ion to suffering is to decrease a t t achment or craving is quite different f rom behavior therapy's emphasis on developing skills for attain- ing one 's goals. However, the idea that suffering results from things not be ing the way one strongly wants them to b e is consistent with the principles under ly ing cognitive- behavioral therapies, Alber t Ellis be ing perhaps the clear- est e x p o n e n t of this viewpoint.

There are a n u m b e r of in teres t ing parallels between Buddhis t ph i losophy and practice and behaviorism or cognitive-behavioral therapy, some of which were arti- culated years ago by Mikulas (1978). Like behaviorism, Buddhis t psychology has few, if any, abstract theoret ical concepts, bu t ra ther emphasizes observed phenomena . Al though behaviorism historically has conce rned itself mostly with overt or external p h e n o m e n a that can be observed and measured consensually, Buddhis t practice concerns no t only non judgmen ta l observation of the outside world but part icularly of one 's in ternal experiences. Nei ther behaviorism nor Buddhism describes a theor ized structure of internal menta l components , such as is found in psychodynamic and some o ther approaches to mind. There also is a similarity in the degree of focus on the presen t ra ther than on the past and how things developed. Fur the rmore , unl ike some religions, the Buddhis t concept of moral i ty is not based in abstract not ions of good and bad; instead, behaviors, inc luding mental ones, are descr ibed and evaluated in terms of their effectiveness in relat ion to goals. There is also the bel ief that ver- bal insight a lone does not p roduce change, though it may at times be a useful pre l iminary step. Buddhism also assumes that the essential na ture of life involves constant change and that all things are connec ted and thus in some way inf luence each other. Its concept ion of human behavior and its relat ion to the h u m a n env i ronment is thus much more similar to a behaviorist emphasis on the effects of envi ronmenta l context on behavior than it is to personali ty trait theories or psychoanalytic theory, which assume a much greater degree of cross-situational consis- tency of behavior.

Like cognitive-behavioral therapy, Buddhism also emphasizes self-observation or self-monitoring of behaviors. Particularly impor t an t is the observation of one 's thought con ten t and process. In some forms of mindfulness practice, the s tudent observes and describes his or he r thoughts. In do ing so, the s tudent begins to under s t and a

separat ion between the observer and the observed: Thoughts are not taken as literally "true" and to be acted upon. Similarly, in cognitive-behavioral therapy, one goal may be to he lp the individual to gain distance from his or her thoughts, to not exper ience the thoughts as par t of themselves, but to exper ience the self as an object of observation. We may, for example , accomplish this by ask- ing the pat ient to keep a record of thoughts that run th rough his or he r mind when distressed or in o ther situations. The act of comple t ing a daily thought record helps a person to s tand back f rom his or he r thoughts in o rde r to evaluate their truth value or utility. Medi ta t ion can have a similar effect. At times, the thoughts, images, and o the r menta l p h e n o m e n a that arise dur ing medita- t ion may be distressing to the individual. The practice is not to a t t empt to suppress or avoid such exper iences but to notice them and notice one 's react ion to them without j udgmen t . This practice can be viewed as similar to the behavioral t r ea tment strategy of exposure to feared but nonharmfu l stimuli.

Mindfulness practice has been in tegra ted with cognitive therapy for the prevent ion of relapse in depression. Teasdale et al. (2000) r epor t ed that a g roup mindfulness intervent ion, in which part ic ipants engaged in mindfulness practice with a goal of increasing their ability to dis- engage f rom depressogenic thinking, significantly re- duced rates of relapse and recur rence among recovered depressed patients who had three or more previous epi- sodes of depression.

Differences Between Buddhism and Cognitive-Behavioral Therapy

Although Buddhism and cognitive-behavioral therapy are, in nay view, essentially compat ib le and involve some interest ing parallels, there are also some impor t an t differences. If this were no t so, there would be little po in t in behavior therapists examin ing Buddhis t thought and practice for innovations and improvements in t rea tment . One impor tan t pr inciple of Zen is that everything is as it should be at this moment : This is the essence of accepting the world, oneself, and o the r people . Behavior therapy, on the o ther hand, emphasizes changing behavior and the environment . It is not that Buddhism is not at all conce rned with change. In fact, it would make no sense to practice medi ta t ion with a comple te absence of expec- tation that any change would result, a l though, paradoxically, focusing on the goal of change is incompat ib le with the process of medi ta t ion. The Buddha initially was in- spired to go off a lone and medi ta te for a p ro longed pe- r iod because of the suffering that he saw among the people , and his teachings on the pa th to end suffering obviously had a goal that the person following that pa th would change in par t icular ways.


Behavior therapy's emphasis on the individual 's learn- ing history as an explanat ion for thei r cur ren t pat terns of behavior is also consistent with the Zen assumption that things are as they should be at this moment . However, in behavioral practice, we emphasize applying the technol- ogy o f change strategies that have been deve loped over the past several decades ra ther than accept ing what is. The Zen emphasis on acceptance leads more naturally to the strategy of validation. In DBT, the therapis t a t tempts bo th to validate behavior and, in some cases, to p rob lem solve with the pa t ien t as to how to change the behavior. Validation draws more heavily on cl ient-centered and hu- manistic therapies than on behavior therapy.

At times, p a t i e n t s - - i n d e e d , all of u s - - w o u l d do be t te r to accept that which they cannot now change, as is well ar- t iculated in the serenity prayer. For example , we cannot change the past, inc luding things we have done that we regret , hurts that have been infl icted on us by others, the failure to receive the emot iona l suppor t or learn ing expe- r iences that we n e e d e d as a child, and so on. Some aspects of our cur ren t si tuation may no t be immedia te ly changeable , such as one 's physical appearance , or the costs of changing are too high, such as a very bad mar- riage that is one 's only potent ia l source of financial suppor t in the near future. In the lat ter case, acceptance may be "for now," while the person works on the steps that will be necessary to make that change. Acceptance then will be helpful because it reduces the suffering associated with cont inual ly tel l ing onese l f that the re la t ionship should no t be this way. In fact, such lack of acceptance can even s tand in the way of change. For example , self- b lame and guilt over maladapt ive behaviors like self- injury, substance abuse, or b inge eat ing do no t usually lead directly to change, and the result ing emot iona l dys- regula t ion may lead to even less effective appl icat ion of change procedures . It is more product ive to describe the behaviors nonjudgmenta l ly to onesel f and note their dis- crepancy from behaviors that are more effective for reaching one ' s goals. In Buddhis t thought , one still may have goals and preferences; but a t t achment to those goals and preferences leaves one vulnerable to suffering.

How Zen Principles Are Reflected in DBT

As Kumar (2002) points out, the Buddhis t ph i losophy views reality from a dialectical po in t of view. Things are no t viewed as having an i n d e p e n d e n t and endur ing iden- tity, but ra ther as having emergen t proper t ies that arise from the in tegrat ion of diverse elements , constantly changing as they affect o ther things and are affected in turn by them. L inehan (1993a) discusses three character- istics of a dialectical worldview: (a) the pr inciple of inter- re latedness and wholeness, (b) the pr incip le of polarity, and (c) the pr incip le of cont inuous change. The world is

viewed from a holistic perspect ive in which everything is connec ted to everything else and objects or individuals canno t be unde r s tood in terms of their parts bu t only by consider ing the relat ionships a m o n g the parts. O u r sense of identi ty also is def ined largely in relat ion to others, ra ther than the more individualist ic unde r s t and ing of identi ty that is d o m i n a n t in our culture. The pr incip le of polari ty proposes that all things in na ture consist of op- posing forces and that the essence of growth is in the coming toge ther of these divisions. In the phi losophy of dialectics, these posi t ions f requent ly are re fer red to as the "thesis" and "antithesis," and their resul tant integra- t ion the "synthesis," which of course is itself a t emporary state of affairs that gives rise to a new antithesis. Impor- tantly for therapy, this viewpoint suggests that, for any idea that has value, an idea that opposes it in some way probably also has value. Considera t ion of this oppos ing idea and the in tegrat ion of the two can be very useful. A m o n g o the r things, this suggests that even pat ients ' mal- adaptive behaviors serve a useful purpose or in some o ther way reflect wisdom. With regard to the pr inc ip le of cont inuous change, it follows from the first two principles that if everything is connec ted and contains polari- ties that give rise to in tegra ted syntheses, than everything is cont inual ly in a state of change. As one person or ob- j ec t inf luences another , it in turn is in f luenced by the o ther in a t ransact ional process.

Assumptions About Patients Because most therapists, like others in the pat ient ' s

envi ronment , will at t imes feel i rr i tated, stressed, or scared by the pat ient ' s behavior, it is helpful for the DBT therapis t to r emind him- or herself about cer tain assumptions that DBT makes about patients. Some of these assumptions, such as the idea that pat ients need to learn new behaviors in all relevant contexts, stem directly f rom theory and research on learn ing principles. Others owe more to the Zen t radi t ion and humanis t ic ideas. For example, it is assumed that pat ients are do ing the best that they can and that they want to improve. The first assumption is a variant of the genera l idea that everything is as it should be. The best that a pa t ien t can do now may be different than the best that they could do yesterday or to- morrow. The best they can do in this m o m e n t is deter- mined by all the in ternal and external variables that inf luence their effort. Because these pat ients usually clearly need to do better, it becomes the therapis t ' s j o b to de te rmine what variables would make that more likely. If pat ients d id not want to improve, they would no t come for t rea tment . Border l ine patients usually are so misera- ble that they desperate ly want things to be different. At times, it may appea r that what they want to change is the outside world and not themselves, bu t when they are no t be ing defensive they usually recognize that their own be-

54 Robins

haviors create problems for themselves or others. This is consistent with the Zen idea of each person having wisdom and innate potential toward positive growth.

Biosoeial Theory One aspect of DBT that reflects a dialectical worldview

is its theory of the etiology and main tenance of BPD behavior patterns, which Linehan describes as a biosocial theory. The theory contains two major elements, one bio- logical and the other social-environmental. Biologically, an individual diagnosed with BPD may have a core difficulty with emot ion regulation. The brain systems in- volved in eliciting and modula t ing emotions may be different than those in the average person, possibly because of genetics, events dur ing fetal development, or early life trauma, which research has shown can affect limbic system development. The envi ronmenta l aspect L inehan refers to as the "invalidating envi ronment" is one in which the person's communica t ions regarding their private experiences frequently are met with responses that suggest they are invalid, faulty, or inappropriate, or that oversim- plify the ease of solving the problem. Unlike a diathesis- stress model, in which the interact ion of these two sets of variables leads to disorder, Linehan suggests that, in addi- tion to such an interact ion effect, there is a transaction between the two, such that emot ion dysregulation tends to lead to invalidation and vice versa. For example, the emotional responses of the individual who is particularly emotionally sensitive or vulnerable are likely to be puz- zling to an individual who does not share this emotional- ity. They may then conclude that the person is faking their response in order to manipulate a situation, or is being entirely unreasonable and "crazy," or is not at all trying to control his or her behavior. If this belief is commu- nicated, explicitly or implicitly, the sensitive individual is likely to feel even more emotionally vulnerable. Further- more, if an individual 's emotional state, their thoughts related to it, and their difficulty in changing their emotions are not taken seriously or are punished, and if this occurs dur ing the course of development, then the individual may not learn how to accurately recognize or communicate different emotions. Over time, as the individual's behavior becomes more extreme, either in attempts to regulate emot ion in the absence of more adaptive skills, or in attempts to communicate , they are likely to experience invalidation increasingly from their environment , inc luding from the mental health system. Thus, in this transactional model, the individual and those in his or her interpersonal env i ronment continuously change one another. Similarly, the individual is not viewed in DBT as "having" a disorder, but as acting, at times, in dis- ordered ways. It is this person in this particular situation whose behavior is ineffective and dysfunctional. It is quite possible that the individual might behave quite function-

ally in a radically different context. Consistent with this systemic view, roadblocks in t reatment are not automati- cally attr ibuted to the patient but to some transaction among the patient, therapist, the consultat ion team, the institutional env i ronment in which t reatment occurs, and the patient 's home environment , any combinat ion of which may be targeted for intervention.

Treatment Targets Dialectical thinking and the Zen concept of the "mid-

dle way" also inform the t reatment goals and targets in DBT in a n u m b e r of ways. At a general level, the behaviors, thoughts, and feelings of patients diagnosed with BPD are often very nondialectical and polarized, thinking in terms of e i the r /o r rather than b o t h / a n d . For example, the patient who makes a mistake and feels ashamed may label him- or herself as completely worthless and view suicide as a reasonable option. The patient whose presence is not acknowledged by someone they know may conclude that the other person hates them or is a mean person. Similarly, patients may view positive events and positive behaviors of others in equally extreme terms to the point of overidealizing those persons or events. One overarching goal in DBT, therefore, is to help the patient to think more dialectically. This can involve not only point ing out the extreme nature of these patterns and helping the person to think of and practice alternatives, but also model ing dialectical th inking and behavior on the part of the therapist. The goal is to help the pat ient see that a particular action or event is just one e lement of a larger whole, that it is, for example, quite possible to be very angry with someone and also still care

deeply about them. There are many areas in which border l ine patients

commonly experience dialectical tensions that they usually resolve by going to one or the other extreme. These include accepting one's self versus improving one's self, tolerating feelings versus changing feelings, dependence versus independence , trust versus mistrust, and self- blaine versus other-blame. The dialectical approach to this, consistent with Zen principles, is not necessarily to see the truth as something in between the two extremes, but to help the patient see the validity of both positions and find a useful synthesis. For example, an individual who is mistrustful of the intent ions of others, and is therefore generally guarded and secretive, may meet someone who treats them very nicely, thus deciding that this one person can in tiact be trusted. But if they become deeply hurt in their relationship with this person, they may again decide that no one can be trusted. The task of the therapist is to help the pat ient see trust as a c on t i nuum rather than a dichotomy and to develop the skills necessary for evaluating the degree of trust that is appropriate for each situation they encounter .


Treatment Strategies Dialectics also inform the t r ea tment strategies used in

DBT. Most importantly, a t tent ion is paid to the balance of strategies that pr imari ly p romo te acceptance and those that pr imari ly p romo te change. P rob lem solving is bal- anced with validation. Balance does not mean that there should be 50% of each. As the overall goal of therapy is change, validation can be seen as in the service of problem solving. Nonetheless , the spiri t in which validation is most effective is when it is done purely to convey acceptance of the pa t ien t or to p romo te self-acceptance by the patient , ra ther than with the idea that it will facilitate change. In a similar vein, one medi ta tes because one has a goal for someth ing to be different, yet complete ly drops that goal dur ing medi ta t ion. And, paradoxically, an in- somniac has a be t te r chance of fall ing asleep if he or she does not focus on fall ing asleep. The idea of thesis, antithesis, and synthesis also leads the DBT therapis t to search for "what is left out" of his or he r under s t and ing of the case, part icularly when progress stalls. There is an assumpt ion that, in these situations, someth ing has been over looked or not a t t ended to. Finally, in DBT it is important for the therapis t to be able to move rapidly f rom one strategy to another , f rom one target p rob l em to another , without losing track of the overall goals of the session. When one strategy hits a br ick wall, it can be helpful to switch to a dramatical ly different strategy. This is consistent with the idea that there is no one r ight way or truth.

Skills Taught DBT assumes that bo rde r l ine pat ients have both capa-

bility deficits and difficulty motivat ing themselves to use whatever capabil i t ies they do possess. The d icho tomy of whether or no t the pa t ien t does no t know how to behave more adaptively or whether she willfully chooses not to behave more adaptively is seen as a false dichotomy. Both are true at times. Skills that f requent ly are deficient in borde r l ine patients are taught in DBT, usually in the context of a skills t ra ining group, whereas the motivat ional is- sues that interfere with the use of skills, such as emo- t ional inhibi t ions, d is tor ted cognit ions, and unhelpfu l r e in fo rcement contingencies, are addressed in individual therapy. The dialectic of acceptance versus change is re- f lected in the skills that are taught in the group (Line- han, 1993b). Two modules are change-or ien ted and two are more acceptance-or iented. In te rpersona l effectiveness skills focus on how to ask for things from others, how to say no, and how to negotiate. In o the r words, they are o r i en ted toward changing one ' s relat ionships. Emotion- regula t ion skills, inc luding identifying one 's emot iona l state, identifying and chal lenging negative cognit ions, and exposure and opposi te action, are a imed at changing one ' s emot iona l state. On the o the r hand, mindfulness skills are not about changing anything, bu t simply observ-

ing and descr ibing what is and par t ic ipat ing in what is called for in this m o m e n t in a non-self-conscious way. Similarly, patients learn distress-tolerance skills for situations or feelings they cannot change, simply to endure the distress they are expe r i enc ing without rel ieving it by acting in impulsive o r maladapt ive w a y s - - i n o the r words, accept ing one ' s cu r ren t feel ing state.

Consultation Team DBT is provided within the f ramework of a t r ea tment

team of individual therapists and skills t rainers who mee t on a regular basis for consultat ion, consis tent with the assumpt ion that no one therapis t is going to have the absolute t ruth about the best way to proceed . Certain agree- ments are made a m o n g the members of the team, some of which reflect Zen philosophy. For example , team member s agree to accept a dialectical ph i losophy in which useful truths are seen as likely to emerge f rom the transact ions between oppos ing ideas. The Zen pr inciples of non judgmenta l observat ion and descr ip t ion o f behavior are app l ied both to the therapist ' s behavior and to the pat ient ' s behavior, so that nonpejorat ive , empath ic inter- pre ta t ions of both are sought. Part of the j o b of the consultation team is to he lp each therapis t f ind "the middle way" in the t rea tment of a given pat ient . Several important therapis t characterist ics can be viewed in terms of dialectical tensions. Most fundamental ly, a therapis t may be more o r i en ted toward change or toward acceptance, and this may even vary for the same therapis t across pat ients or across t ime. The so lu t ion is no t tha t the change- o r ien ted therapis t should become less change-or iented , but ra ther that he or she also needs to work on b e c o m i n g more o r i en ted to acceptance. L inehan (1993a) describes two o the r therapis t d imensions that are variants of this a c c e p t a n c e - c h a n g e cont inuum: benevolen t demand ing- ness versus nur tur ing, and unwavering centeredness regard ing the t rea tment plan versus compass ionate flexibility. A dialectical posi t ion sees the wisdom in bo th poles and the consul ta t ion team seeks the in tegra t ion of the two that is most appropr ia t e for each situation.

Why Mindfulness Is Taught in DBT Mindfulness may be def ined as non judgmen ta l aware-

ness of one ' s exper ience as it unfolds m o m e n t by moment. In incorpora t ing mindfulness pract ice in treatment , we are making the assumpt ion that the ability to non judgmenta l ly focus one 's a t tent ion on a chosen ob- j ec t or event has clinically significant benefi ts and that this ability can be improved by par t icular practices. There are a n u m b e r of potent ia l benefits of mindfulness . One difficulty that many of us exper ience , part icular ly at t imes of high emot ion , is be ing "scattered." When central cognitive processing resources are cap tured by every incom- ing stimulus, the ability to stay focused may be dimin-

56 Robins

ished. A second type of at tentional difficulty is in some ways the reverse. Many patients ruminate at length about upsett ing events and find it difficult to turn off the stream of thoughts and images or turn their a t tent ion to other matters. In both cases, greater ability to direct one's focus of a t tent ion would be helpful. For this populat ion particularly, a potential benefi t of mindfulness practice is that greater awareness of action urges may help the individual to act less impulsively. Another potential benefit is a richer experience of life and an increased capacity for joy. For example, one may be driving home from work, th inking about the outcome of a meet ing earlier that day or what needs to be accomplished that evening, arrive home, and have little recollection of the drive itself. If, instead, one becomes aware of not being focused on the present activity and brings the focus back to the present, he or she may notice, for example, the beauty of the scenery.

One may distinguish between being mindful and mindfulness practice. Mindfulness practice involves set- ting aside time regularly to practice being mindful. In the Zen tradition, the most common basic practice involves sitting comfortably with eyes closed, focusing on the breath, and noticing the thoughts, images, sensations, action urges, and other mental p h e n o m e n a that arise in consciousness without judg ing them, holding onto them, or trying to suppress them but allowing them to come and go freely. Other objects of focus may also be used, such as external objects, a particular idea or class of thoughts, or activities such as walking. Such practice frequently results in a more relaxed physical and mental state, which can allow one's wise j u d g m e n t to be more accessible than when strong emotions dominate cognitive processes. However, we emphasize to patients that relaxation itself is not the primary goal of mindfulness practice. In fact, at times, mental p h e n o m e n a that arise dur ing mindfulness practice, or even the chosen object of focus itself, may be aver- sive or lead to negative emotions. These are not to be avoided any more than pleasant experiences or emotions are to be sought after. Instead, the practice of not judg ing or resisting such thoughts, images, or sensations may result in desensitization to them. Because borderl ine patients tend to be judgmenta l of themselves and others, practicing the nonjudgmenta l attitude advocated in Zen practice can yield enormous benefits. Over time, regular mindfulness practice may result in a greater awareness of self. Patients may learn that their emotional states and action urges come and go like the waves in an ocean, but that they, as observers, remain constant.

How Mindfulness Is Taught in DBT Mindfulness skills are taught in DBT primarily in the

skills t ra ining group. They are considered central or core skills necessary for the performance of skills in the other three areas (distress tolerance, emot ion regulation, and

interpersonal effectiveness). The core mindfulness skills are taught over two to three sessions and then reviewed again dur ing the first session of each succeeding module. In our clinic, each group session also begins with a brief mindfulness practice.

During the mindfulness skills module, the skills trainer presents and discusses information about the goals of mindfulness practice and also engages the participants in numerous practice exercises. Many of the practices de- scribed in the skills training manual (Linehan, 1993b) are adapted from the meditat ion manual written by the Viet- namese Buddhist monk Thich Nhat Hahn (1976). Partic- ipants are first asked to discuss times and ways in which they have not sufficiently felt in control of their mind. These examples are then related to the goals of mindfulness practice. The concept of "wise mind" is int roduced as the integration of "emotion mind," in which one's thinking and behavior are controlled by one's emotional state, and "rational mind," which allows us to plan and evaluate logically but does not address our desires or values. The group discusses the idea derived from Zen that all people possess wise mind and that accessing it can, at times, be difficult. Mindfulness practice is then introduced as a method for allowing emotions and mental activity to settle down enough to enable one to hear one's wise mind.

In mindfulness training, two sets of skills are distin- guished: (a) "what" skills (i.e., what to do) and (b) "how" skills (i.e., how to do it). The three what skills are observing, describing, and participating. One can simply observe one's sense experiences without describing them or doing anything about them. One can also describe what one observes (i.e., "I am noticing an urge to move"). Fi- nally, participating means acting in the world with full en- gagement and awareness. The ultimate goal, of course, is to participate mindfully in life at all times. Practice in observing and describing can be useful steps toward mindful participation.

The how skills are nonjudgrnentally, one-mindfully, and effectively. One-mindfully refers to focusing on one thing at a time with full awareness, rather than doing one thing while thinking about another. Being nonjudgrnental is particularly important for describing. Judgments, such as good or bad, worthwhile or worthless, often lead to strong emotions. It is possible, however, to dislike the conse- quences of one's own or another 's behavior and therefore develop a plan to change it without judg ing the behavior or the person as "bad" in an absolute sense. The how skill of effectiveness is related to the Zen concept of "skillful means." It involves being clear about one's important goals and then behaving (participating) in ways to bring one closer to those goals, instead of focusing on less important goals. For example, threatening someone who has provided poor service may seem justified by the goal of prov- ing them wrong or hurt ing their feelings, but if one's more


i m p o r t a n t goal is to receive be t te r service f rom this pe rson in the future, that behavior is unl ikely to be effective.

In my exper ience , several types of p r o b l e m s can arise in t each ing mind fu l n e s s to pat ients . A few pat ients have objec ted to the exercises o n rel igious g rounds . Generally, we do n o t discuss m i n d fu l n e s s pract ice in the con tex t o f any par t icu la r re l ig ion a n d t e n d to use the word mindfu l - ness ra the r t han med i t a t ion . F u r t h e r m o r e , it may be he lpfu l to i n f o r m pat ients that the t rad i t ions of con tem- plative pract ice do occur in mos t rel igions. Some pat ients fear focus ing o n the i r private exper iences or al lowing the m i n d to focus o n the b rea th because upse t t ing though t s a n d images can arise. A l t h o u g h in the l ong r u n such exposure may allow hab i t u a t i o n to occur, it is o f t en he lpful to ins t ruc t pa t ien ts to init ial ly focus the i r a t t en t i o n o n ex- te rna l objects o r the physical sensa t ions associated with t o u c h i n g an objec t o r e n g a g i n g in an activity like walking. For pa t ients with a history of dissociat ion, it is he lpfu l to p o i n t ou t that m ind fu l n e s s is the opposi te of dissociat ion, tha t it is b e i n g fully p r e s en t a n d aware of one ' s c u r r e n t state. Some pat ients express b o r e d o m with mindfu lness exercises a n d impa t i ence for t hem to be over. Discuss whe the r this reflects their m o r e genera l t e n d e n c y to al- ways be active a n d whe the r it would be he lpful for t hem to develop a grea ter capacity for s imply b e i n g a n d observing.

Given the above difficulties that some pat ients have with mindfu lness practice, we genera l ly keep practices in the g roup qui te short, usually only a few minutes . Pat ients who f ind this helpful can t h e n be e n c o u r a g e d to practice for l onge r per iods o n the i r own. We also en co u rage pa- t ients to identify activities that they do regularly that they could practice do in g mindfully, such as walking back to the i r car after g roup or washing the dishes. In addi t ion , specific mindfu lness practices are suggested d u r i n g o the r skills t r a in ing modules . For example , for distress tolerance, one migh t choose an object o f focus that can serve as a dis t ract ion f rom the source of distress. In a t t empt ing to regulate one ' s negat ive emot ions , the exercise of adopt- ing a hal f smile a n d b e i n g mi n d fu l of the associated sensa- t ions may result in a shift toward a m o r e positive emot ion .

Mindfulness for the Therapist In o rde r to teach mi n d fu l n e s s skills to pat ients , a n d

par t icular ly to address the i r quest ions , it is essential tha t the therapis t or skills t r a ine r have expe r i ence with m ind - fulness practice. A l o n g with bene f i t t i ng the life o f the therapis t in genera l , regular m i n d fu l n e s s pract ice can also he lp the therapis t m a i n t a i n d i rec t ion t h r o u g h o u t the cha l l eng ing course of t r e a t m e n t that BPD pat ients present . O n e benef i t o f mind fu lnes s is an increased ability to observe a n d descr ibe the pa t ien t ' s behav io r in ses- s ion in a n o n j u d g m e n t a l ma n n e r , which can be part icularly difficult w h e n o n e feels cri t icized or is afraid that the pa t i en t may a t t emp t suicide. Th e abili ty to stay focused

o n tasks a n d in the p r e s e n t m o m e n t w h e n the pa t i en t becomes t angen t ia l o r ove rwhe lmed is essential in h e l p i n g the pa t i en t progress. Mindfu lness pract ice can also he lp a therapis t regula te his o r he r own emot ions d u r i n g sessions. M a i n t a i n i n g awareness of one ' s b r ea th a n d o f shifts in one ' s e m o t i o n a l state enab les a therapis t n o t to react b u t to act in a m o r e p lanfu l m anne r . A four th area in which m i n d f u l n e s s pract ice may benef i t the therapis t is in dea l ing with his o r h e r j u d g m e n t s a b o u t his o r he r own com pe tence . The therapis t mus t r e m e m b e r that, j u s t like the pa t ient , he or she is d o i n g the best work they can in that m o m e n t : If d i f fe ren t therapis t behav io r or in te rven- t ion is likely to be m o r e effective, the therapis t can p l an the appropr i a t e change wi thou t any j u d g m e n t of the previous behavior. Finally, it is essential for the therapis t to develop an a t t i tude of n o n a t t a c h m e n t , s tr iving to he lp the pa t i en t reach cer ta in goals, yet, at the same t ime, n o t b e i n g a t t ached to those ou tcomes , the reby lessen ing his o r he r degree o f suffer ing if they are n o t yet achieved.

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Robins, C.J., Ivanoff, A. M., & Linehan, M. M. (2001). Dialectical behavior therapy. In W.J. Livesley (Ed.), Handbook of personality disorders: Theory, research, and treatment (pp. 117-139). NewYork: Guil- ford Press.

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Address correspondence to Clive J. Robins, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Box 3362, Durham, NC 27710; e-mail: [email protected].

Received: January 10, 2000 Accepted: February 20, 2001

zen principles and mindfulness practice in dialectical behavior therapy

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