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Denning, E (2000). Practicing harm reduction psychothoapy/. New York: Guilford Press. Dimeff, L. A., Baer, J. S., Kivlahan, D. R., & Marlatt, G. A. (1999). Brief

Effects of meditation and relaxation training upon alcohol use in male social drinkers. In D. H. Shapiro & R. N. Walsh (Eds.), Meditation: Classic and eontemporary perspectives (pp. 105-120). New York: Aldine Press. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change. New York: Guilford Press. 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. O'Connell, D. E, & Alexander, C. N. (Eds.). (1994). Self-recovery: 7?eat-

Alcohol Screwing and Intervention fi)r College Students (BASICS): A ha~vn reduction approach. New York: Guilford Press. Groves, E, & Farmer, R. (1994). Buddhism and addictions. Addiction Reseatch, 2, 183-194. Kumar, S. M. (2002). An introduction to Buddhism for the cognitivebeha~ioral therapist. Cognitive and Behavioral Practice, 9, 40-43. 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: Guilford Press. Marlatt, G. A. (1994). Addiction, mindfulness, and acceptance. In S. C. Hayes, N. S.Jacobson, V. M. Folette, & M.J. Dougher (Eds.), Acceptance and change: Content and context in psychothera]o' (pp. 175-197). Reno, N%1:Context Press. Marlatt, G. A. (Ed.). (1998). Harm reduction: PragmaticstmtegiesJbr mana~ng high-risk behaviors. New York: Guilford Press. Marlatt, G. A., Baez;J. S., Kivlahan, D. R., Dimeff, L. A., Larimel; M. E., Quigley, L. A., Somers,J. M., & Williams, E. (1998). Screening and brief intezwention for high-risk college student drinkers: Results from a two-year tollow-up assessment. Journal of Consulting and Clinical Psychology, 66, 604-615. Marlatt, G. A., & gJ'istellei; J. (1999). Mindfulness and meditation. In W. R. Miller (Ed.), Integrating spirituality in treatment: Resourcesfor practitioners (pp. 67-84). V~:ashington,DC: American Psychological Association Books. Marlatt, G. A., & Marques, J. K. (1977). Meditation, selfcontrol, and alcohol use. Ill R. B. Stuart (Ed.), Behavioral self-management: Strategies, techniques, and outcomes (pp. 117-153). New York: Brunner/ Mazel. Marlatt, G. A., Pagano, R. R., Rose, R. M., & Marques, J. K. (1984).

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ing addictions using 7?anscendental Meditation and Maharishi AyuT: Veda. New York: Haworth Press. Prochaska,J. O., DiClemente, C. C., & Norcross,J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114. Teasdale,J. D., Segal, Z. V., & Williams,J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentional 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. Thoreson, C. G., & Mahoney, M. H. (1974). Behavioralself-control. New York: Holt, Rinehart & Winston. Trungpa, C. (1968). Meditation in action. Boston: Shambhala. 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 M i n d f u l n e s s 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 p a p ~ 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 app e a r to b e radically d i f f e r e n t , p e r h a p s e v e n c o n t r a dictory, in t h e 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 c h a n g i n g behavior. F o r e x a m p l e , b e h a v i o r t h e r a p y t r a d i t i o n a l l y has f o c u s e d o n o v e r t b e h a v i o r a n d o t h e r o b s e r v a b l e variables a n d t h e W e s t e r n scientific m e t h o d o f a d v a n c i n g

k n o w l e d g e , 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 religious t r a d i t i o n s have b e e n c o n c e r n e d p r i m a r i l y with m e n t a l a n d spiritual p h e n o m e n a a n d p r o p o s e a n e x p e r i e n t i a 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 b e h a v i o r . H o w e v e r , as this series attests, t h e r e is g r o w i n g i n t e r e s t among behavior therapists and cognitive behavior therapists in t h e p o t e n t i a l c o n t r i b u t i o n s o f spiritual t r a d i t i o n s ,

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particularly Buddhism. A t least o n e f o r m o f b e h a v i o r t h e r a p y , d i a l e c t i c a l beh a v i o r t h e r a p y (DBT; L i n e h a n , 1993a) f o r p e r s o n s diagn o s e d with b o r d e r l i n e p e r s o n a l i t y d i s o r d e r (BPD), ex-

Mindfulness and Dialectical Behavior Therapy plicitly integrates cognitive-behavioral principles a n d strategies with Zen Buddhist principles a n d mindfulness practice. Several r a n d o m i z e d trials have f o u n d that DBT has some efficacy for the t r e a t m e n t o f BPD (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; L i n e h a n et al., 1999). In this article, I will discuss the historical d e v e l o p m e n t o f DBT a n d highlight why Zen principles a n d practices have b e c o m e a defining asp e c t of the t r e a t m e n t (for a m o r e c o m p r e h e n s i v e description of DBT as a whole, see Robins, Ivanoff, a n d L i n e h a n , 2001). I t h e n note some i m p o r t a n t ways in which Buddhist t h o u g h t is c o m p a t i b l e with behavior therapy, as well as differences between the two that suggest that Buddhist principles a n d mindfulness practice may provide behavior therapists b o t h with useful ways o f conceptualizing patients a n d situations a n d with helpful t r e a t m e n t strategies. Following these i n t r o d u c t o r y comments, I discuss in m o r e detail some o f the ways in which Zen principles are reflected in various aspects o f DBT. These include its (a) assumptions a b o u t patients; (b) theory o f the d e v e l o p m e n t a n d m a i n t e n a n c e o f the behaviors, thoughts, a n d feelings c o m m o n in persons diagn o s e d with BPD, (c) secondary targets o f t r e a t m e n t that are functionally related to BPD criterion behaviors, a n d (d) t r e a t m e n t strategies. Finally, I d e s c r i b e how m i n d fulness practice is t a u g h t to patients as a core skill a n d utilized by therapists themselves in the service o f compassionate a n d effective t r e a t m e n t for m u l t i p r o b l e m patients. I s h o u l d say at the o u t s e t that my own backg r o u n d k n o w l e d g e o f B u d d h i s m as a whole is relatively limited. I a m aware that t h e r e are m a n y streams o f t h o u g h t in B u d d h i s m , as t h e r e are in o t h e r world religions. My focus h e r e will be o n the Zen t r a d i t i o n as it is r e f l e c t e d in DBT.

Why Does DBT Include Zen Principles and Practice? DBT was d e v e l o p e d as a t r e a t m e n t for chronically suicidal a n d / o r self-injurious women, m a n y o f w h o m h a d BPD. L i n e h a n initially a t t e m p t e d to h e l p the patient c h a n g e such behaviors by using s t a n d a r d cognitivebehavioral strategies: c o n d u c t i n g a behavioral analysis o f particular incidents o f the behaviors a n d t h e n influencing the variables that s e e m e d to maintain t h e m t h r o u g h such p r o c e d u r e s as assertiveness training a n d cognitive restructuring. She has r e p o r t e d that such attempts to apply s t a n d a r d protocols were n o t very successful (Linehan, 1993a, p. 77). Patients often e x p e r i e n c e d a sole focus on change p r o c e d u r e s as invalidating their levels o f distress, o r even as b l a m i n g t h e m for their problems, m a k i n g it difficult for t h e m to use the skills taught in therapy. As a result, patients may r e s p o n d by attacking the therapist or by leaving treatment. Prior to l e a r n i n g DBT, my own at-

tempts at cognitive restructuring with BPD patients frequently m e t objections such as, "So now y o u ' r e saying there's a n o t h e r thing wrong with me: I c a n ' t think right," or "It's n o t my t h i n k i n g that makes m e upset. W h e n I get upset, I start to think like this a n d I a m n o t able to c h a n g e it." These kinds o f difficulties led L i n e h a n to modify stand a r d cognitive behavioral t r e a t m e n t to i n c l u d e a greater emphasis on validating the patient's e x p e r i e n c e , even maladaptive behaviors, as m a k i n g sense given his o r h e r history a n d the c u r r e n t context. T h e emphasis on acceptance o f the patient c o u n t e r b a l a n c e s the emphasis on c h a n g e associated with behavior therapy. In addition, b o r d e r l i n e patients typically have great difficulty accepting many things a b o u t themselves, o t h e r p e o p l e , a n d the world in general. L i n e h a n , therefore, was also i n t e r e s t e d in teaching these patients a m e t h o d for p r o m o t i n g a greater capacity for a c c e p t a n c e a n d drew on h e r own exp e r i e n c e with Zen mindfulness practice as well as the Christian contemplative tradition. It is likely that most patients, regardless of diagnosis or type o f behavioral p r o b l e m , benefit f r o m e x p e r i e n c i n g their therapists as validating a n d a c c e p t i n g a n d from l e a r n i n g how to be m o r e accepting o f themselves a n d others. However, this n e e d p r o b a b l y is m u c h g r e a t e r for b o r d e r l i n e patients than for most others. O n e interesting finding that may illustrate the i m p o r t a n c e of a c c e p t a n c e by others is the large effect o n relapse rates in schizop h r e n i a (and some o t h e r disorders) as a function o f the level o f expressed e m o t i o n (EE) o f their relatives with w h o m they live (Butzlaff & Hooley, 1998). Observational measures o f EE assess criticism, hostility, a n d e m o t i o n a l overinvolvement. H o o l e y a n d Hiller (2000) r e p o r t e d that high EE relatives o f s c h i z o p h r e n i a patients scored significantly lower on tolerance, flexibility, a n d e m p a t h y on a b r o a d - b a n d personality measure than d i d low EE relatives. However, it was the low EE relatives who differed most from normative samples on t o l e r a n c e (Hooley, 1998). Thus, it may be that an unusually high level o f acceptance, p e r h a p s reflected in their explicit o r implicit expectations o f the patient, is helpful to the patient's clinical progress.

Compatibility of Buddhism and Cognitive-Behavioral Therapy A l t h o u g h B u d d h i s m frequently is viewed as a religion, it also can be viewed as a psychology. This a r g u m e n t probably could be a d v a n c e d for o t h e r religions, b u t I believe that it is particularly clear with Buddhism. T h e core teachings o f B u d d h i s m involve the F o u r N o b l e Truths a n d the Eight-Fold Path, s u m m a r i z e d in this issue by Knm a r (2002). T h e F o u r Noble Truths c o n c e r n the experience of suffering a n d thus are relevant to behavior therapists a n d to the field o f mental health in general. These

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Robins truths or principles state the following: (a) life is full of suffering, (b) the r o o t cause o f suffering is attachment, (c) it is possible to decrease o r even e n d suffering by letting go o f o n e ' s attachments, a n d (d) the m e t h o d for d o i n g so is to practice the Eight-Fold Path. T h e eight parts o f this p a t h may be translated as right u n d e r s t a n d ing, right thought, right speech, right action, right livelihood, right effort, right mindfulness, a n d right concentration. T h e idea tla~ the solution to suffering is to decrease a t t a c h m e n t or craving is quite different from behavior therapy's emphasis on d e v e l o p i n g skills for attaining one's goals. However, the idea that suffering results from things n o t b e i n g the way one strongly wants t h e m to b e is consistent with the principles u n d e r l y i n g cognitivebehavioral therapies, A l b e r t Ellis b e i n g perhaps the clearest e x p o n e n t of this viewpoint. T h e r e are a n u m b e r of interesting parallels between Buddhist p h i l o s o p h y a n d practice a n d behaviorism or cognitive-behavioral therapy, some of which were articulated years ago by Mikulas (1978). Like behaviorism, Buddhist psychology has few, if any, abstract theoretical concepts, b u t r a t h e r emphasizes observed p h e n o m e n a . A l t h o u g h behaviorism historically has c o n c e r n e d itself mostly with overt o r external p h e n o m e n a that can be observed a n d m e a s u r e d consensually, Buddhist practice concerns n o t only n o n j u d g m e n t a l observation o f the outside world b u t particularly o f one's internal experiences. N e i t h e r behaviorism n o r B u d d h i s m describes a theorized structure o f internal mental c o m p o n e n t s , such as is f o u n d in psychodynamic a n d some o t h e r a p p r o a c h e s to mind. T h e r e also is a similarity in the d e g r e e o f focus on the p r e s e n t r a t h e r than on the past a n d how things developed. F u r t h e r m o r e , unlike some religions, the Buddhist c o n c e p t o f morality is n o t based in abstract notions o f g o o d a n d bad; instead, behaviors, including mental ones, are d e s c r i b e d a n d evaluated in terms of their effectiveness in relation to goals. T h e r e is also the belief that verbal insight alone does n o t p r o d u c e change, t h o u g h it may at times be a useful p r e l i m i n a r y step. Buddhism also assumes that the essential nature o f life involves constant change a n d that all things are c o n n e c t e d a n d thus in some way influence each other. Its c o n c e p t i o n o f h u m a n behavior a n d its relation to the h u m a n e n v i r o n m e n t is thus m u c h m o r e similar to a behaviorist emphasis on the effects o f e n v i r o n m e n t a l c o n t e x t on behavior than it is to personality trait theories o r psychoanalytic theory, which assume a m u c h greater d e g r e e o f cross-situational consistency o f behavior. Like cognitive-behavioral therapy, B u d d h i s m also emphasizes self-observation or self-monitoring o f behaviors. Particularly i m p o r t a n t is the observation of one's t h o u g h t c o n t e n t a n d process. In some forms of mindfulness practice, the s t u d e n t observes a n d describes his o r h e r thoughts. In d o i n g so, the s t u d e n t begins to u n d e r s t a n d a

separation between the observer a n d the observed: T h o u g h t s are n o t taken as literally "true" a n d to be acted upon. Similarly, in cognitive-behavioral therapy, o n e goal may be to h e l p the individual to gain distance from his o r h e r thoughts, to n o t e x p e r i e n c e the thoughts as p a r t o f themselves, b u t to e x p e r i e n c e the self as an object o f observation. We may, for example, accomplish this by asking the patient to keep a r e c o r d o f thoughts that run t h r o u g h his or h e r m i n d when distressed o r in o t h e r situations. T h e act of c o m p l e t i n g a daily t h o u g h t r e c o r d helps a person to stand back from his o r h e r thoughts in o r d e r to evaluate their truth value o r utility. Meditation can have a similar effect. At times, the thoughts, images, a n d o t h e r mental p h e n o m e n a that arise d u r i n g meditation may be distressing to the individual. T h e practice is n o t to a t t e m p t to suppress o r avoid such experiences b u t to notice t h e m a n d notice one's reaction to t h e m without j u d g m e n t . This practice can be viewed as similar to the behavioral t r e a t m e n t strategy of e x p o s u r e to feared b u t n o n h a r m f u l stimuli. Mindfulness practice has b e e n i n t e g r a t e d with cognitive therapy for the prevention o f relapse in depression. Teasdale et al. (2000) r e p o r t e d that a g r o u p mindfulness intervention, in which participants e n g a g e d in mindfulness practice with a goal o f increasing their ability to disengage from depressogenic thinking, significantly red u c e d rates of relapse a n d r e c u r r e n c e a m o n g recovered d e p r e s s e d patients who h a d three or m o r e previous episodes of depression.

Differences Between Buddhism and Cognitive-Behavioral Therapy A l t h o u g h B u d d h i s m a n d cognitive-behavioral therapy are, in nay view, essentially c o m p a t i b l e a n d involve some interesting parallels, there are also some i m p o r t a n t differences. If this were n o t so, there would be little p o i n t in behavior therapists e x a m i n i n g Buddhist t h o u g h t a n d practice for innovations and i m p r o v e m e n t s in treatment. O n e i m p o r t a n t principle o f Zen is that everything is as it should be at this m o m e n t : This is the essence of accepting the world, oneself, a n d o t h e r people. Behavior therapy, on the o t h e r hand, emphasizes c h a n g i n g behavior a n d the environment. It is n o t that B u d d h i s m is n o t at all c o n c e r n e d with change. In fact, it would make no sense to practice meditation with a c o m p l e t e absence o f expectation that any c h a n g e would result, although, paradoxically, focusing on the goal of c h a n g e is i n c o m p a t i b l e with the process of meditation. T h e B u d d h a initially was inspired to go off alone a n d meditate for a p r o l o n g e d period because o f the suffering that he saw a m o n g the people, a n d his teachings on the p a t h to e n d suffering obviously h a d a goal that the p e r s o n following that p a t h would c h a n g e in particular ways.

Mindfulness and Dialectical Behavior Therapy Behavior therapy's emphasis on the individual's learning history as an e x p l a n a t i o n for their c u r r e n t patterns o f behavior is also consistent with the Zen assumption that things are as they should be at this m o m e n t . However, in behavioral practice, we emphasize applying the technology o f c h a n g e strategies that have b e e n d e v e l o p e d over the past several decades r a t h e r than accepting what is. T h e Zen emphasis on acceptance leads m o r e naturally to the strategy o f validation. In DBT, the therapist attempts b o t h to validate behavior and, in some cases, to p r o b l e m solve with the p a t i e n t as to how to change the behavior. Validation draws m o r e heavily o n client-centered a n d humanistic therapies than o n behavior therapy. At times, p a t i e n t s - - i n d e e d , all o f u s - - w o u l d d o b e t t e r to accept that which they c a n n o t now change, as is well articulated in the serenity prayer. F o r example, we c a n n o t change the past, i n c l u d i n g things we have d o n e that we regret, hurts that have b e e n inflicted on us by others, the failure to receive the e m o t i o n a l s u p p o r t o r l e a r n i n g experiences that we n e e d e d as a child, a n d so on. Some aspects o f o u r c u r r e n t situation may n o t be i m m e d i a t e l y changeable, such as one's physical a p p e a r a n c e , or the costs of c h a n g i n g are too high, such as a very b a d marriage that is one's only potential source o f financial supp o r t in the n e a r future. In the latter case, acceptance may be "for now," while the p e r s o n works on the steps that will be necessary to make that change. Acceptance then will be helpful because it reduces the suffering associated with continually telling o n e s e l f that the relationship should n o t be this way. In fact, such lack o f acceptance can even stand in the way o f change. F o r example, selfb l a m e a n d guilt over maladaptive behaviors like selfinjury, substance abuse, o r binge eating d o n o t usually lead directly to change, a n d the resulting e m o t i o n a l dysregulation may lead to even less effective application o f c h a n g e procedures. It is m o r e productive to describe the behaviors n o n j u d g m e n t a l l y to oneself a n d n o t e their discrepancy from behaviors that are m o r e effective for r e a c h i n g o n e ' s goals. In Buddhist thought, o n e still may have goals a n d preferences; b u t a t t a c h m e n t to those goals and preferences leaves o n e vulnerable to suffering.

How Zen Principles Are Reflected in DBT As K u m a r (2002) points out, the Buddhist p h i l o s o p h y views reality from a dialectical p o i n t o f view. Things are n o t viewed as having an i n d e p e n d e n t a n d e n d u r i n g identity, b u t r a t h e r as having e m e r g e n t p r o p e r t i e s that arise from the integration o f diverse elements, constantly c h a n g i n g as they affect o t h e r things a n d are affected in turn by them. L i n e h a n (1993a) discusses three characteristics of a dialectical worldview: (a) the principle o f interrelatedness a n d wholeness, (b) the principle o f polarity, a n d (c) the principle o f c o n t i n u o u s change. T h e world is

viewed from a holistic perspective in which everything is c o n n e c t e d to everything else a n d objects o r individuals c a n n o t be u n d e r s t o o d in terms o f their parts b u t only by considering the relationships a m o n g the parts. O u r sense o f identity also is d e f i n e d largely in relation to others, r a t h e r than the m o r e individualistic u n d e r s t a n d i n g o f identity that is d o m i n a n t in o u r culture. T h e principle of polarity proposes that all things in n a t u r e consist o f opposing forces a n d that the essence o f growth is in the c o m i n g t o g e t h e r o f these divisions. In the p h i l o s o p h y o f dialectics, these positions frequently are r e f e r r e d to as the "thesis" a n d "antithesis," a n d their resultant integration the "synthesis," which o f course is itself a t e m p o r a r y state o f affairs that gives rise to a new antithesis. Importantly for therapy, this viewpoint suggests that, for any idea that has value, an i d e a that opposes it in some way p r o b a b l y also has value. Consideration o f this o p p o s i n g idea a n d the integration o f the two can be very useful. A m o n g o t h e r things, this suggests that even patients' maladaptive behaviors serve a useful p u r p o s e o r in some o t h e r way reflect wisdom. With r e g a r d to the p r i n c i p l e o f c o n t i n u o u s change, it follows from the first two principles that if everything is c o n n e c t e d a n d contains polarities that give rise to i n t e g r a t e d syntheses, than everything is continually in a state o f change. As o n e p e r s o n o r obj e c t influences another, it in turn is i n f l u e n c e d by the o t h e r in a transactional process.

Assumptions About Patients Because most therapists, like others in the patient's e n v i r o n m e n t , will at times feel irritated, stressed, o r scared by the patient's behavior, it is helpful for the DBT therapist to r e m i n d him- o r herself a b o u t certain assumptions that DBT makes a b o u t patients. Some o f these assumptions, such as the i d e a that patients n e e d to learn new behaviors in all relevant contexts, stem directly from theory a n d research o n l e a r n i n g principles. O t h e r s owe m o r e to the Zen tradition a n d humanistic ideas. F o r example, it is assumed that patients are d o i n g the best that they can a n d that they want to improve. T h e first assumption is a variant o f the g e n e r a l idea that everything is as it should be. T h e best that a p a t i e n t can d o now may be different than the best that they could do yesterday o r tomorrow. T h e best they can d o in this m o m e n t is determ i n e d by all the internal a n d external variables that influence their effort. Because these patients usually clearly n e e d to d o better, it b e c o m e s the therapist's j o b to d e t e r m i n e what variables would m a k e that m o r e likely. If patients d i d n o t want to improve, they would n o t c o m e for treatment. Borderline patients usually are so miserable that they desperately want things to be different. At times, it may a p p e a r that what they want to c h a n g e is the outside world a n d n o t themselves, b u t when they are n o t b e i n g defensive they usually recognize that their own be-

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haviors create problems for themselves or others. This is consistent with the Zen idea of each person having wisdom a n d i n n a t e potential toward positive growth.

Biosoeial Theory O n e aspect of DBT that reflects a dialectical worldview is its theory of the etiology a n d m a i n t e n a n c e of BPD behavior patterns, which L i n e h a n describes as a biosocial theory. T h e theory contains two major elements, one biological a n d the other social-environmental. Biologically, an individual diagnosed with BPD may have a core difficulty with e m o t i o n regulation. The brain systems involved in eliciting a n d m o d u l a t i n g emotions may be different than those in the average person, possibly because of genetics, events d u r i n g fetal development, or early life trauma, which research has shown can affect limbic system development. The e n v i r o n m e n t a l aspect L i n e h a n refers to as the "invalidating e n v i r o n m e n t " is o n e in which the person's c o m m u n i c a t i o n s regarding their private experiences frequently are m e t with responses that suggest they are invalid, faulty, or inappropriate, or that oversimplify the ease of solving the problem. Unlike a diathesisstress model, in which the interaction of these two sets of variables leads to disorder, L i n e h a n suggests that, in addition to such an interaction effect, there is a transaction between the two, such that e m o t i o n dysregulation tends to lead to invalidation a n d vice versa. For example, the emotional responses of the individual who is particularly emotionally sensitive or vulnerable are likely to be puzzling to an individual who does n o t share this emotionality. They may t h e n conclude that the person is faking their response in order to m a n i p u l a t e a situation, or is being entirely u n r e a s o n a b l e a n d "crazy," or is n o t at all trying to control his or her behavior. If this belief is communicated, explicitly or implicitly, the sensitive individual is likely to feel even more emotionally vulnerable. Furthermore, if an individual's emotional state, their thoughts related to it, a n d their difficulty in c h a n g i n g their emotions are not taken seriously or are punished, a n d if this occurs d u r i n g the course of development, then the individual may n o t learn how to accurately recognize or comm u n i c a t e different emotions. Over time, as the individual's behavior becomes more extreme, either in attempts to regulate e m o t i o n in the absence of more adaptive skills, or in attempts to c o m m u n i c a t e , they are likely to experience invalidation increasingly from their environment, i n c l u d i n g from the mental health system. Thus, in this transactional model, the individual a n d those in his or her interpersonal e n v i r o n m e n t continuously change one another. Similarly, the individual is n o t viewed in DBT as "having" a disorder, b u t as acting, at times, in diso r d e r e d ways. It is this person in this particular situation whose behavior is ineffective a n d 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 r e a t m e n t are n o t automatically attributed to the patient but to some transaction a m o n g the patient, therapist, the consultation team, the institutional e n v i r o n m e n t in which treatment occurs, a n d the patient's h o m e e n v i r o n m e n t , any c o m b i n a t i o n of which may be targeted for intervention.

Treatment Targets Dialectical thinking a n d the Zen c o n c e p t of the "middle way" also inform the t r e a t m e n t goals a n d targets in DBT in a n u m b e r of ways. At a general level, the behaviors, thoughts, a n d feelings of patients diagnosed with BPD are often very nondialectical a n d polarized, thinking in terms of e i t h e r / o r rather than b o t h / a n d . For example, the patient who makes a mistake a n d feels ashamed may label him- or herself as completely worthless a n d view suicide as a reasonable option. The patient whose presence is not acknowledged by s o m e o n e they know may conclude that the other person hates them or is a m e a n person. Similarly, patients may view positive events a n d positive behaviors of others in equally extreme terms to the p o i n t of overidealizing those persons or events. O n e overarching goal in DBT, therefore, is to help the patient to think more dialectically. This can involve n o t only p o i n t i n g out the extreme nature of these patterns a n d helping the person to think of a n d practice alternatives, b u t also m o d e l i n g dialectical t h i n k i n g a n d behavior on the part of the therapist. The goal is to help the patient see that a particular action or event is just o n e e l e m e n t of a larger whole, that it is, for example, quite possible to be very angry with s o m e o n e a n d also still care deeply about them. T h e r e are many areas in which b o r d e r l i n e patients c o m m o n l y 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 c h a n g i n g feelings, d e p e n d e n c e versus i n d e p e n d e n c e , trust versus mistrust, a n d selfblaine versus other-blame. The dialectical approach to this, consistent with Zen principles, is n o t necessarily to see the truth as something in between the two extremes, b u t to help the patient see the validity of both positions a n d find a useful synthesis. For example, an individual who is mistrustful of the i n t e n t i o n s of others, a n d is therefore generally g u a r d e d a n d secretive, may meet s o m e o n e who treats them very nicely, thus deciding that this o n e 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 patient see trust as a c o n t i n u u m rather than a dichotomy and to develop the skills necessary for evaluating the degree of trust that is appropriate for each situation they encounter.

Mindfulness and Dialectical Behavior Therapy

Treatment Strategies Dialectics also inform the t r e a t m e n t strategies used in DBT. Most importantly, attention is paid to the balance of strategies that primarily p r o m o t e a c c e p t a n c e a n d those that primarily p r o m o t e change. P r o b l e m solving is bala n c e d with validation. Balance does n o t m e a n that t h e r e should be 50% o f each. As the overall goal o f therapy is change, validation can be seen as in the service o f problem solving. Nonetheless, the spirit in which validation is most effective is when it is d o n e purely to convey acceptance of the p a t i e n t o r to p r o m o t e self-acceptance by the patient, r a t h e r than with the idea that it will facilitate change. In a similar vein, o n e meditates because o n e has a goal for s o m e t h i n g to be different, yet completely d r o p s that goal d u r i n g meditation. And, paradoxically, an insomniac has a b e t t e r c h a n c e o f falling asleep if he or she does n o t focus on falling asleep. T h e i d e a o f thesis, antithesis, a n d synthesis also leads the DBT therapist to search for "what is left out" o f his o r h e r u n d e r s t a n d i n g o f the case, particularly when progress stalls. T h e r e is an ass u m p t i o n that, in these situations, s o m e t h i n g has b e e n o v e r l o o k e d or not a t t e n d e d to. Finally, in DBT it is important for the therapist to be able to move rapidly from one strategy to another, from one target p r o b l e m to another, without losing track o f the overall goals o f the session. W h e n one strategy hits a brick wall, it can be helpful to switch to a dramatically different strategy. This is consistent with the idea that there is no o n e right way or truth.

Skills Taught DBT assumes that b o r d e r l i n e patients have b o t h capability deficits a n d difficulty motivating themselves to use whatever capabilities they do possess. T h e d i c h o t o m y of w h e t h e r o r n o t the p a t i e n t does n o t know how to behave m o r e adaptively o r w h e t h e r she willfully chooses n o t to behave m o r e adaptively is seen as a false dichotomy. Both are true at times. Skills that frequently are deficient in b o r d e r l i n e patients are taught in DBT, usually in the context o f a skills training group, whereas the motivational issues that interfere with the use o f skills, such as emotional inhibitions, distorted cognitions, a n d u n h e l p f u l r e i n f o r c e m e n t contingencies, are a d d r e s s e d in individual therapy. T h e dialectic o f a c c e p t a n c e versus change is reflected in the skills that are taught in the g r o u p (Linehan, 1993b). Two m o d u l e s are c h a n g e - o r i e n t e d a n d two are m o r e acceptance-oriented. I n t e r p e r s o n a l effectiveness skills focus on how to ask for things from others, how to say no, a n d how to negotiate. In o t h e r words, they are o r i e n t e d toward c h a n g i n g o n e ' s relationships. Emotionregulation skills, including identifying one's e m o t i o n a l state, identifying a n d c h a l l e n g i n g negative cognitions, a n d e x p o s u r e a n d opposite action, are a i m e d at c h a n g i n g o n e ' s e m o t i o n a l state. O n the o t h e r h a n d , mindfulness skills are n o t a b o u t c h a n g i n g anything, b u t simply observ-

ing a n d describing what is a n d participating 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 o r feelings they c a n n o t change, simply to e n d u r e the distress they are e x p e r i e n c i n g without relieving it by acting in impulsive o r maladaptive w a y s - - i n o t h e r words, accepting o n e ' s c u r r e n t feeling state.

Consultation Team DBT is p r o v i d e d within the framework o f a t r e a t m e n t team o f individual therapists a n d skills trainers who m e e t on a r e g u l a r basis for consultation, consistent with the ass u m p t i o n that n o o n e therapist is going to have the absolute truth a b o u t the best way to p r o c e e d . Certain agreements are m a d e a m o n g the m e m b e r s o f the team, some of which reflect Zen philosophy. F o r e x a m p l e , team m e m b e r s agree to accept a dialectical p h i l o s o p h y in which useful truths are seen as likely to e m e r g e from the transactions between o p p o s i n g ideas. T h e Zen principles o f n o n j u d g m e n t a l observation a n d description o f behavior are a p p l i e d b o t h to the therapist's behavior a n d to the patient's behavior, so that nonpejorative, e m p a t h i c interpretations o f b o t h are sought. Part o f the j o b o f the consultation team is to h e l p each therapist find "the m i d d l e way" in the t r e a t m e n t o f a given patient. Several important therapist characteristics can be viewed in terms o f dialectical tensions. Most fundamentally, a therapist may be m o r e o r i e n t e d toward c h a n g e o r toward acceptance, a n d this may even vary for the same therapist across patients o r across time. T h e s o l u t i o n is n o t t h a t the c h a n g e o r i e n t e d therapist should b e c o m e less c h a n g e - o r i e n t e d , b u t r a t h e r that he o r she also needs to work on b e c o m i n g m o r e o r i e n t e d to acceptance. L i n e h a n (1993a) describes two o t h e r therapist d i m e n s i o n s that are variants o f this acceptance-change continuum: benevolent demandingness versus nurturing, a n d unwavering c e n t e r e d n e s s reg a r d i n g the t r e a t m e n t plan versus compassionate flexibility. A dialectical position sees the wisdom in b o t h poles a n d the consultation team seeks the integration o f the two that is most a p p r o p r i a t e for each situation.

Why Mindfulness Is Taught in DBT Mindfulness may be d e f i n e d as n o n j u d g m e n t a l awareness o f o n e ' s e x p e r i e n c e as it unfolds m o m e n t by moment. In i n c o r p o r a t i n g mindfulness practice in treatment, we are m a k i n g the assumption that the ability to n o n j u d g m e n t a l l y focus one's attention on a c h o s e n obj e c t or event has clinically significant benefits a n d that this ability can be i m p r o v e d by particular practices. T h e r e are a n u m b e r o f potential benefits o f mindfulness. O n e difficulty that many o f us experience, particularly at times o f high e m o t i o n , is b e i n g "scattered." W h e n central cognitive processing resources are c a p t u r e d by every incoming stimulus, the ability to stay focused may be dimin-

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ished. A second type of attentional difficulty is in some ways the reverse. Many patients r u m i n a t e at length about upsetting events a n d find it difficult to turn offthe stream of thoughts a n d images or t u r n their attention to other matters. In both cases, greater ability to direct one's focus of attention would be helpful. For this p o p u l a t i o n particularly, a potential benefit of mindfulness practice is that greater awareness of action urges may help the individual to act less impulsively. A n o t h e r potential benefit is a richer experience of life a n d an increased capacity for joy. For example, o n e may be driving h o m e from work, t h i n k i n g a b o u t the o u t c o m e of a m e e t i n g earlier that day or what needs to be accomplished that evening, arrive home, a n d 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. O n e may distinguish between being mindful a n d mindfulness practice. Mindfulness practice involves setting aside time regularly to practice b e i n g mindful. In the Zen tradition, the most c o m m o n basic practice involves sitting comfortably with eyes closed, focusing o n the breath, a n d noticing the thoughts, images, sensations, action urges, a n d other mental p h e n o m e n a that arise in consciousness without j u d g i n g them, holding onto them, or trying to suppress them but allowing them to come a n d go freely. O t h e r 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 d o m i n a t e 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 d u r i n g mindfulness practice, or even the chosen object of focus itself, may be aversive 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 n o t j u d g i n g or resisting such thoughts, images, or sensations may result in desensitization to them. Because borderline patients tend to be j u d g m e n t a l of themselves a n d others, practicing the n o n j u d g m e n t a l attitude advocated in Zen practice can yield e n o r m o u s 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 a n d 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 training group. They are considered central or core skills necessary for the p e r f o r m a n c e of skills in the other three areas (distress tolerance, e m o t i o n regulation, a n d

interpersonal effectiveness). The core mindfulness skills are taught over two to three sessions a n d t h e n reviewed again d u r i n g the first session of each succeeding module. In o u r clinic, each group session also begins with a brief mindfulness practice. During the mindfulness skills module, the skills trainer presents a n d discusses information about the goals of mindfulness practice a n d also engages the participants in n u m e r o u s practice exercises. Many of the practices described in the skills training m a n u a l (Linehan, 1993b) are adapted from the meditation m a n u a l written by the Vietnamese Buddhist m o n k Thich Nhat H a h n (1976). Participants are first asked to discuss times a n d ways in which they have n o t sufficiently felt in control of their mind. These examples are then related to the goals of mindfulness practice. The concept of "wise mind" is i n t r o d u c e d as the integration of "emotion mind," in which one's thinking a n d behavior are controlled by one's emotional state, a n d "rational mind," which allows us to plan a n d evaluate logically b u t does n o t address our desires or values. The group discusses the idea derived from Zen that all people possess wise m i n d and that accessing it can, at times, be difficult. Mindfulness practice is then i n t r o d u c e d as a m e t h o d for allowing emotions a n d mental activity to settle down e n o u g h to enable one to hear one's wise mind. In mindfulness training, two sets of skills are distinguished: (a) "what" skills (i.e., what to do) a n d (b) "how" skills (i.e., how to do it). The three what skills are observing, describing, a n d participating. O n e can simply observe one's sense experiences without describing them or doing anything about them. O n e can also describe what one observes (i.e., "I am noticing an urge to move"). Finally, participating means acting in the world with full eng a g e m e n t a n d awareness. The ultimate goal, of course, is to participate mindfully in life at all times. Practice in observing a n d describing can be useful steps toward mindful participation. The how skills are nonjudgrnentally, one-mindfully, and effectively. One-mindfully refers to focusing o n 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 consequences of one's own or another's behavior a n d therefore develop a plan to change it without j u d g i n g 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 o n less important goals. For example, threatening someone who has provided poor service may seem justified by the goal of proving them wrong or h u r t i n g their feelings, but if one's more

Mindfulness and Dialectical Behavior Therapy

i m p o r t a n t goal is to receive b e t t e r service f r o m this p e r s o n in the future, that b e h a v i o r is unlikely to be effective. I n m y e x p e r i e n c e , several types o f p r o b l e m s c a n arise i n t e a c h i n g m i n d f u l n e s s to patients. A few patients have o b j e c t e d to the exercises o n religious g r o u n d s . Generally, we d o n o t discuss m i n d f u l n e s s practice i n the c o n t e x t o f any p a r t i c u l a r r e l i g i o n a n d t e n d to use the word m i n d f u l ness r a t h e r t h a n m e d i t a t i o n . F u r t h e r m o r e , it may be h e l p f u l to i n f o r m p a t i e n t s that the t r a d i t i o n s o f c o n t e m plative practice do o c c u r i n m o s t religions. S o m e patients fear f o c u s i n g o n their private e x p e r i e n c e s o r allowing the m i n d to focus o n the b r e a t h b e c a u s e u p s e t t i n g t h o u g h t s a n d images c a n arise. A l t h o u g h in the l o n g r u n such exp o s u r e m a y allow h a b i t u a t i o n to occur, it is o f t e n h e l p f u l to i n s t r u c t p a t i e n t s to initially focus their a t t e n t i o n o n ext e r n a l objects o r the physical s e n s a t i o n s associated with t o u c h i n g a n o b j e c t o r e n g a g i n g in a n activity like walking. F o r p a t i e n t s with a history o f dissociation, it is h e l p f u l to p o i n t o u t that m i n d f u l n e s s is the opposite o f dissociation, that it is b e i n g fully p r e s e n t a n d aware o f o n e ' s c u r r e n t state. S o m e patients express b o r e d o m with m i n d f u l n e s s exercises a n d i m p a t i e n c e for t h e m to be over. Discuss w h e t h e r this reflects their m o r e g e n e r a l t e n d e n c y to always be active a n d w h e t h e r it w o u l d be h e l p f u l for t h e m to develop a g r e a t e r capacity for simply b e i n g a n d observing. Given the above difficulties that s o m e patients have with m i n d f u l n e s s practice, we generally keep practices in the g r o u p quite short, usually only a few m i n u t e s . Patients who find this helpful c a n t h e n be e n c o u r a g e d to practice for l o n g e r periods o n their own. We also e n c o u r a g e patients to identify activities that they d o regularly that they c o u l d practice d o i n g mindfully, such as walking back to their car after g r o u p o r washing the dishes. I n addition, specific m i n d f u l n e s s practices are suggested d u r i n g o t h e r skills t r a i n i n g m o d u l e s . For e x a m p l e , for distress tolerance, o n e m i g h t choose a n object o f focus that can serve as a distraction f r o m the source o f distress. I n a t t e m p t i n g to regulate o n e ' s negative e m o t i o n s , the exercise o f adopti n g a half smile a n d b e i n g m i n d f u l of the associated sensations may result i n a shift toward a m o r e positive e m o t i o n .

Mindfulness for the Therapist I n o r d e r to teach m i n d f u l n e s s skills to patients, a n d particularly to address their questions, it is essential that the therapist or skills t r a i n e r have e x p e r i e n c e with m i n d fulness practice. A l o n g with b e n e f i t t i n g the life o f the therapist in g e n e r a l , r e g u l a r m i n d f u l n e s s practice can also h e l p the therapist m a i n t a i n d i r e c t i o n t h r o u g h o u t the c h a l l e n g i n g course o f t r e a t m e n t that BPD patients present. O n e b e n e f i t o f m i n d f u l n e s s is a n i n c r e a s e d ability to observe a n d describe the p a t i e n t ' s b e h a v i o r in session in a n o n j u d g m e n t a l m a n n e r , which c a n b e particularly difficult w h e n o n e feels criticized o r is afraid that the p a t i e n t m a y a t t e m p t suicide. T h e ability to stay focused

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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 p a t i e n t bec o m e s t a n g e n t i a l o r o v e r w h e l m e d is essential in h e l p i n g the p a t i e n t progress. M i n d f u l n e s s practice c a n also h e l p a t h e r a p i s t regulate his o r h e r o w n e m o t i o n s d u r i n g sessions. M a i n t a i n i n g awareness of o n e ' s b r e a t h a n d o f shifts i n o n e ' s e m o t i o n a l state e n a b l e s a therapist n o t to react b u t to act in a m o r e p l a n f u l m a n n e r . A f o u r t h area i n which m i n d f u l n e s s practice m a y b e n e f i t the t h e r a p i s t is in d e a l i n g with his o r h e r j u d g m e n t s a b o u t his o r h e r own c o m p e t e n c e . T h e therapist m u s t r e m e m b e r that, j u s t like the p a t i e n t , h e o r she is d o i n g the best work they c a n in that m o m e n t : If d i f f e r e n t t h e r a p i s t b e h a v i o r o r i n t e r v e n tion is likely to b e m o r e effective, the t h e r a p i s t c a n p l a n the a p p r o p r i a t e c h a n g e w i t h o u t a n y j u d g m e n t o f the previous behavior. Finally, it is essential for the t h e r a p i s t to d e v e l o p a n a t t i t u d e o f n o n a t t a c h m e n t , striving to h e l p the p a t i e n t reach c e r t a i n goals, yet, at the same time, n o t b e i n g a t t a c h e d to those o u t c o m e s , t h e r e b y l e s s e n i n g his o r h e r d e g r e e o f suffering if they are n o t yet achieved.

References Butzlaff, R. L., & Hooley,J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry, 55, 547-552. Hanh, T. N. (1976). The miracle of mindfulness: A manual on meditation. Boston: Beacon Press. Hooley, J. M. (1998). Expressed emotion and psychiatric illness: From empirical data to clinical practice. Behavior Therapy, 29, 631-646. Hooley, J. M., & Hiller, J. B. (2000). Personality and expressed emotion. Journal of AbnormaI Psychology, 109, 40-44.

Koons, C., Robins, C.J., Tweed, J. L., Lynch, T. R., Gonzelez, A. M., Morse, J. Q., Bishop, G. K., Butterfield, M. I., & Bastian, L. A. (2001). Efficacyof dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy, 32, 371-390. Kumar, S. M. (2002). An introduction to Buddhism for the cognitivebehavioral therapist. Cognitive and Behavioral Practic~ 9, 40-43. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder.. New York: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Mlmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically suicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. Linehan, M. M., Schmidt, H. I., Dimeff, L. A., Craft,J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions, 8, 279-292. Mikulas, W. L. (1978). Four Noble Truths of Buddhism related to behavior therapy. Psychological Record, 28, 59-67. 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: Guilford Press. Teasdale,J. D., Segal, Z. V., Williams,J. M. G., Ridgeway,V. A., Soulsby, J. M., & Lau, M. A. (2000). Prevention of~relapse/recurrence in major depression by mindfulness-basedcognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623. Address correspondence to CliveJ. 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