Dialectical Behaviour Therapy (DBT) and the Buddhist Philosophy

Ruwan M Jayatunge M.D.

Dialectical behavior therapy (DBT) is a modified form of cognitive behavioral therapy (CBT) that was developed in late 1970s by Marsha M. Linehan a psychology researcher at the University of Washington (Linehan, 1993). DBT is an empirically supported treatment for suicidal individuals (Linehan et al., 2015). It can be adapted to treat borderline personality disorder patients with comorbid substance-abuse disorder (Koerner & Linehan, 2000) and depressed elderly clients with personality disorders (Lynch et al., 2003). DBT addresses deficits in emotion regulation, distress tolerance and interpersonal relationship.

The patients with borderline personality disorder have faulty schemas and splitting in the patient’s relations to others. They have frantic efforts to avoid real or imagined abandonment. Often they have pattern of unstable and intense interpersonal relationships, impulsivity, emotional instability and recurrent suicidal behavior. In addition they are impacted by chronic feelings of emptiness. Borderline personality disorder is treated with psychotherapy and medication. Dialectical Behavior Therapy and Buddhist Psychotherapy are effective in treating borderline personality disorder.

The basis for DBT is stemming from the mindfulness practice of the Buddhist teachings and the philosophy of dialectics. Mindfulness according to the Buddhism is bare attention a sort of non-judgmental, non-discursive attending to the moment-to-moment flow of consciousness (Sharf, 2015). Mindfulness meditation has three overarching purposes: knowing the mind; training the mind; and freeing the mind (Fronsdal, 2006). As described by Palmer (2002) developing the capacity for being mindful and living in the moment allows a greater potential for feeling appropriately in charge of the self.

DBT combines mindful awareness largely derived from Buddhist meditative practice. Kirmayer (2015) concluded that Mindfulness meditation and other techniques drawn from Buddhism have increasingly been integrated into forms of psycho-therapeutic intervention. Since the 1990s, mindfulness meditation has been applied to multiple mental and physical health conditions, and has received much attention in psychological research (Tang & Posner, 2013). Mindfulness has been described as a practice of learning to focus attention on moment-by moment experience with an attitude of curiosity, openness, and acceptance (Marchand, 2012) Schmidt (2004) states that mindfulness is strongly related to compassion, and it is compassion that serves as a source for all healing intentionality. Both mindfulness and self-compassion involve promoting an attitude of curiosity and non-judgment towards one’s experiences (Raab, 2014). The core mindfulness skills (focus, compassion, curiosity, inner calm, balance, and awareness) lead to serenity.

Chafos and Economou (2014) highlighted the efficacy of mindfulness-based interventions in borderline personality disorder. They further stated that mindfulness helped to improve impulsivity, emotional irregularity and relationship instability in clients. Mindfulness shapes individuals’ personality and self-concept toward more healthy profiles (Crescentini & Capurso, 2015). Shorey and colleagues (2014) elucidate that mindfulness meditation may help to prevent relapse to substance use.

Mindfulness practices as well as the Buddhist philosophy help the patients to gain growth promotion. Buddhist doctrine and practices can be considered as a psychotherapeutic method (de Zoysa, 2011) and Buddhist psychology is increasingly informing psychotherapeutic practice in the western world (Kelly, 2008). In Mahāsatipaṭṭhāna Sutta the Buddha described the practice of meditation in detail. The Mahāsatipaṭṭhāna Sutta or the great discourse on the establishing of awareness is considered as the discourse on the foundations of mindfulness. It is generally regarded as the canonical Buddhist text with the fullest instructions on the system of meditation unique to the Buddha’s own dispensation (Soma, 1998). Mahāsatipaṭṭhāna Sutta describes contemplation of the body, contemplation of feeling, contemplation of mind and contemplation of mind-objects.

The word dialectical” in DBT comes from its focus on providing motivation for change in behavior while simultaneously validating the client’s thoughts and feelings ( DeVylder, 2010).The ‘dialectical’ in DBT refers to the way in which it uses a broad way of thinking that emphasizes the limitations of linear ideas about causation (Palmer, 2002). The dialectical philosophy serves as the backbone for DBT. Dialectics is a complex concept that has its roots in philosophy and science. Dialectics involves several assumptions about the nature of reality: everything is connected to everything else, change is constant and inevitable and opposites can be integrated to form a closer approximation to the truth. Dialectical thinking provides the ability to view issues from multiple perspectives.

The elements of dialectics are found in Buddhism. Dialectics is an integral part of the foundation of world philosophy. The word dialectics meant, on the one hand, the search for truth by conversations, which were carried out through the formulation of questions and the methodical search for answers to them. On the other hand, dialectics means the capability of vision and reflection by means of notions of the opposite facets of nature. Dialectics represents a synthesis of the best achievements of both materialism and idealism and it is the ground for understanding of the material-ideal essence of the world. (Shpenkov, 2013). Dialectical thought emphasizes the wholeness and inter-connectedness of the world and the potential for the reconciliation of opposites (Palmer, 2002). According to Charles H. Elliott- Clinical Psychologist dialectics are one of the important unifying concepts that reflect how the mind fundamentally understands and perceives most core concepts and ideas.The dialectical aspects of Buddhism connected with impermanence.

The idea of interdependence is central to Buddhist teaching. The interdependent arising (pratitya samutpada) describes that human life is a continuous process of change, rising and falling through interdependence with numerous other processes” (Koller, 2002). Dr. Alfred Bloom, Emeritus Professor of Religion, University of Hawai’ states that the central concept of Buddhism is generally termed Interdependent Co-arising or Dependent Co-origination. The emptiness is based in the principle of Interdependent Co-arising.

The DBT suggests that change is an inevitable and welcome part of life. Change according to Buddhism is a constant phenomenon. Change is the focal point for Buddhist insight and change is built into the nature of things, nothing is inherently fixed (Thanissaro, 2004). Everything in human life, all objects nothing lasts and everything is changing and inconstant. The Buddha described the world as an unending flux of becoming. All is changeable, continuous transformation, ceaseless mutation, and a moving stream. Everything exists from moment to moment. Everything is a recurring rotation of coming into being and then passing out of existence (Sri Dhammananda, 2003).

The Buddha taught that all compounded things are impermanent. The Doctrine of Impermanence or Annicca is an undeniable and inescapable fact of human existence. According to Buddhism, everything is the product of the antecedent causes and therefore of dependent origination. These causes themselves are not ever lasting and static, but simply antecedent aspects of the same ceaseless becoming. Every event is the result of a concatenation of dynamic processes (Karunadasa, 1998).

The Buddhism teaches that the ultimate nature of all things is in fact just this absence (Newland, 2015). The dialectical monism is described in Buddhism in following terms. “Form is emptiness; emptiness also is form. Emptiness is no other than form; form is no other than emptiness.”It is not a nihilistic view. Emptiness or Sunyata is the true nature of things and events. The doctrine of non-attachment relates to the concept of emptiness and impermanence. It is the knowledge of the ultimate reality of all objects, material and phenomenal.

DBT promotes non-judgmental thinking and view their environment non-judgmentally. Practicing mindfulness helps to release judgment. Nonjudgmental attitude helps to open in to new experiences. Some experts believe that judging causes emotional mind to increase in intensity. The Buddha believed that self-imposed suffering stemming from judgmental thought.

According to Buddhist philosophy, the identification with a static concept of ‘self’ causes psychological distress. Dis-identification from such a static self-concept results in the freedom to experience a more genuine way of being (Tang, et al., 2015). In Buddhism, the term anattā or refers to the doctrine of “non-self”. According to the mainstream view, anatta means the denial of a permanent self-entity, both at the microcosmic and the macrocosmic levels (Karunadasa, 1994). Furthermore the Budistic nonself-cultivating process aims to minimize or extinguish the self and avoid desires, leading to egolessness or selflessness (Shiah ,2016).

Borderline personality disorder is a hurtful label for real suffering (Kulkarni, 2015). Suffering is an inevitable component of human existence. According to Buddhism, existence is suffering (dukkha). Dukkha is an important Buddhist concept, commonly translated as “suffering”, “pain” or “unsatisfactoriness” (Huxter, 2016). The Buddhist concept of duhkha, often translated as ‘‘suffering,’’ is not simply an unpleasant feeling. Rather, it refers most deeply to a basic vulnerability to suffering and pain due to misapprehending the nature of reality (Ekman et al., 2005). The Buddha presented Noble Eight fold Path as a way to extinguish the suffering. The Noble Eight fold Path are right views, right resolve/aspiration, right speech, right action/conduct, right livelihood, right effort right mindfulness and right concentration.

Hoffman and colleagues (1999) hypothesized that borderline patients’ behavioral patterns are thought to result from a lifelong transaction between emotional vulnerability and invalidating features of the social and familial environment. Many patients with borderline personality disorder (BPD) experience difficulties in empathizing with others and are sensitive to social exclusion (Flasbeck, Enzi & Brüne, 2017). They often become disconnected from the society. Isolation and alienation affect their wellbeing. The cultivation of disciplined reflection with mindfulness helps the patients to combat social exclusion. The deeper awareness provides to enhance sense of fulfillment and individual happiness. Buddhism is a pragmatic teaching promotes inclusion. Inclusion is spiritual and growth promotional.

Emotion regulation is essential for adaptive behavior and mental health (Kinner et al., 2017). Buddhists and psychologists alike believe that emotions strongly influence people’s thoughts, words, and actions and that, at times, they help people in their pursuit of transient pleasures and satisfaction (Ekman et al., 2005). DBT deals with intense and labile emotions. There is a connection between mindfulness and emotion regulation. Mindfulness facilitates adaptive emotion regulation. Mindfulness improves emotion regulation by influencing people’s awareness of their emotional experiences (Hill & Updegraff, 2012).

In DBT clinician attempts to motivate the client towards change in behavior while simultaneously validating existing thoughts and feelings (DeVylder, 2010). DBT provides dialectical strategies to help clients get unstuck” from rigid ways of thinking or viewing the world. Along with non-aggression and non-attachment help the patients to view their world as a non hostile entity. In Buddhist doctrine Equanimity is promoted as a self discipline to combat rigid ways of thinking. According to the psychologists equanimity is a state of psychological stability and composure which is undisturbed by experience of or exposure to emotions, pain, or other phenomena that may cause others to lose the balance of their mind. In Buddhstic view Upekkha or equanimity is to have a clear-minded tranquil state of mind – not being overpowered by delusions, mental dullness or agitation. It is a steady conscious realization of reality’s transience.

According to Linehan (2000) DBT, therapists have five main tasks. They work to expand client capabilities, motivate the client to engage in new behaviors, generalize the use of the new behaviors, establish a treatment environment that reinforces progress, and maintain capable and motivated therapists. The ultimate goal of DBT is to aid patients in their efforts to build a life worth living.

Acknowledgement; Sheri Van Dijk MSW RSW DBT Therapist -Toronto Canada

References

Chafos, V.H., Economou, P.(2014).Beyond borderline personality disorder: the mindful brain.Soc Work. t;59(4):297-302.

Crescentini, C. , Capurso, V.(2015).Mindfulness meditation and explicit and implicit indicators of personality and self-concept changes.Front Psychol. 29;6:44.

DeVylder, J.E. (2010). Dialectical Behavior Therapy for the Treatment of Borderline Personality Disorder: An Evaluation of the Evidence International Journal of Psychosocial Rehabilitation. Vol 15(1) 61-70.

de Zoysa, P.(2011).The use of Buddhist mindfulness meditation in psychotherapy: a case report from Sri Lanka. Transcult Psychiatry. ;48(5):675-83.

Ekman, P., Davidson, R. J., Ricard, M., & Wallace, B. A. (2005). Buddhist and Psychological Perspectives on Emotions and Well-Being. Current Directions in Psychological Science, 14(2), 59-63.

Flasbeck, V., Enzi, B., Brüne, M. (2017).Altered Empathy for Psychological and Physical Pain in Borderline Personality Disorder.J Pers Disord. doi: 10.1521/pedi_2017_31_276.

Fronsdal,G.(2006). Mindfulness Meditation as a Buddhist Practice. Retrieved from http://www.insightmeditationcenter.org/books-articles/articles/mindfulness-meditation-as-a-buddhist-practice/

Hill, C. L. M., Updegraff, J. A. (2012). Mindfulness and Its Relationship to Emotional Regulation. Emotion, 12, 81-90.

Hoffman, P. D., Fruzzetti, A. E. and Swenson, C. R. (1999). Dialectical behavior therapy: Family skills training. Family Process, 38: 399–414.

Huxter, M. (2016). Healing the Heart and Mind with Mindfulness: Ancient Path, Present Moment. Routledge.

Karunadasa, Y.(1994).The Buddhist Doctrine of Non-Self, and the Problem of the Over-Self. Retrieved from http://www.andrew-may.com/zendynamics/nonself.htm

Karunadasa,Y. (1998).The Buddhist Doctrine of Annicca or Impermanence, and the Soul Theory http://maithri.com/links/articles/anicca1.htm

Kelly,B.D.(2008).Buddhist psychology, psychotherapy and the brain: a critical introduction.Transcult Psychiatry. ;45(1):5-30.

Kinner, V.L. , Kuchinke, L. , Dierolf, A.M. , Merz, C.J. , Otto, T.1., Wolf, O.T. (2017).What our eyes tell us about feelings: Tracking pupillary responses during emotion regulation processes. Psychophysiology. doi: 10.1111/psyp.12816.

Kirmayer, L.J. (2015).Mindfulness in cultural context.Transcult Psychiatry. ;52(4):447-69.

Koerner, K. , Linehan, M.M.(2000).Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatr Clin North Am. ;23(1):151-67.

Koller, J. M. (2002). Asian Philosophies. Upper Saddle River, NJ: Prentice Hall.

Kulkarni,J.(2015).Borderline personality disorder is a hurtful label for real suffering – time we changed it. . Retrieved from

http://www.monash.edu/news/opinions/borderline-personality-disorder-is-a-hurtful-label-for-real-suffering-time-we-changed-it

Linehan, M. M. (1993) Cognitive–Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.

Linehan, M. (2000). Commentary on innovations in Dialectical Behavior Therapy. Cognitive and Behavioral Practice, 7, 478-481.

Linehan, M.M., Korslund, K.E. , Harned, M.S. , Gallop, R.J ., Lungu ,A. , Neacsiu, A.D. , McDavid, J. , Comtois, K.A. , Murray-Gregory, A.M. (2015).Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry. ;72(5):475-82.

Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behavior therapy for depressed older adults. American Journal of Geriatric Psychiatry, 11, 33–45.

Marchand, W.R.(2012).Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression, anxiety, pain, and psychological distress.J Psychiatr Pract. ;18(4):233-52.

Palmer,R.L.(2002). Dialectical behaviour therapy for borderline personality disorder. Advances in Psychiatric Treatment. 8 (1) 10-16.

Raab, K.(2014).Mindfulness, self-compassion, and empathy among health care professionals: a review of the literature.J Health Care Chaplain. ;20(3):95-108.

Schmidt, S.(2004).Mindfulness and healing intention: concepts, practice, and research evaluation.J Altern Complement Med. ;10 Suppl 1:S7-14.

Sharf RH.(2015).Is mindfulness Buddhist? (and why it matters).Transcult Psychiatry. ;52(4):470-84.

Shiah YJ.(2016).From Self to Nonself: The Nonself Theory.Front Psychol. 4;7:124.

Shorey RC , Brasfield H, Anderson S, Stuart GL.(2014).Differences in trait mindfulness across mental health symptoms among adults in substance use treatment. Subst Use Misuse. ;49(5):595-600.

Shpenkov, G.P. (2013). Dialectical View of the World: The Wave Model (Selected Lectures). Volume I: Philosophical and Mathematical Background. URL: http://shpenkov.janmax.com/Vol.1.Dialectics.pdf

Soma. (1998).The Way of Mindfulness The Satipatthana Sutta and Its Commentary. Retrieved from http://www.accesstoinsight.org/lib/authors/soma/wayof.html

Sri Dhammananda, K. (2003).Everything is Changeable. Retrieved from http://www.budsas.org/ebud/whatbudbeliev/85.htm

Tang, Y.-Y., Posner, M. I. (2013).Theory and method in mindfulness neuroscience. Soc. Cogn. Affect. Neurosci. 8, 118–120.

Tang, Y.-Y., Hölzel, B. K. & Posner, M. I. (2015).The neuroscience of mindfulness meditation. Nat. Rev. Neurosci. 16, 213–225.

Thanissaro. (2004).All About Change. Retrieved from http://www.accesstoinsight.org/lib/authors/thanissaro/change.html