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Identifying and Treating Dialectical Dilemmas in DBT (Part 1)

Identifying and Treating Dialectical Dilemmas in DBT - part 1

This feature by Donna Pattie, MSW, LICSW is Part 1 of 2 in a series about identifying and treating dialectical dilemmas in DBT. In this first part, Donna addresses three primary concepts of biosocial theory and steps for assessing and developing more effective solutions.

It is challenging to treat clients with severe emotion dysregulation and behavioral dyscontrol and with urges and actions to suicide, self-harm and get relief in whatever ways possible. As a DBT therapist, supervisor, and trainer I often hear from providers that their clients are not improving, they can’t treat primary targets due to other behaviors, and they are burned out. It is a daunting task helping clients move toward tolerating intolerable pain and problem-solving unwanted emotions in new ways. In delivering DBT, my experience is that the journey is long and the reward is great in seeing clients build the lives they want.

When I was asked to write this blog, I thought about topics that I and other colleagues have struggled with over the years. Immediately, dialectical dilemmas and how to effectively treat them came to mind.

To address dialectical dilemmas, it is helpful to review Marsha Linehan’s (1993) biosocial theory, which has three primary concepts:

  1. Clients have biologically based emotional vulnerability-emotional sensitivity to environmental cues, high emotional reactivity (intensity), impulsivity, and slow return to emotional baseline. “I go from zero to 100 and take forever to calm down.”
  2. Clients are subjected to an invalidating environment which may: dismiss, judge, punish or ignore the private experiences of an individual, intermittently reinforce the escalation of emotional responses, and oversimplify solving emotional problems.  “Why are you making such a big deal of this? Calm down.”
  3. It is the transaction of the biology and the invalidating environment that can cause a severe and pervasive pattern of emotion dysregulation and behavioral dyscontrol, leading to a diagnosis of borderline personality disorder.

Dialectical dilemmas are behaviors that show up as a direct result of the person’s biology, invalidating environment, and problems with emotion regulation. An individual with biological sensitivity, trying their best and no matter what they do, may experience being punished, judged, or dismissed by the environment. Dialectical dilemmas are the painful consequences of living life as a sensitive person in an invalidating environment. They were not taught the skills needed to modulate emotions, ask for help, and process trauma and loss.  The individual, without other options, finds ways to cope with unwanted emotions: suicide, self-harm, anger outbursts, substance use, etc. While these patterns may help briefly, the outcome is often poor.

Charlie Swenson, in his book DBT Principles in Action (2016, pg. 158), writes that in Marsha’s early years of developing DBT, while assessing and treating primary targets, she encountered a multitude of similar problematic behavioral patterns. Common themes presented in polar-opposite pairs on three dimensions.

Marsha identified the tendency to vacillate between underregulating and overregulating behaviors which create barriers to addressing primary targets. Charlie described the biosocial model as a perspective of “the outside scientific observer” observing someone who is suffering. Alternately, he likens dialectical dilemmas to an “inside-out perspective of one who is suffering from uncontrollable, agonizing emotional responses.”  It is this view, when shared with clients, that can be incredibly validating and offer some possible solutions for treatment.

These three themes Marsha identified (Linehan text page 67) – emotion vulnerability/self-invalidation, active passivity/apparent competence, and unrelenting crisis/inhibited grieving – provide a working framework for both therapists and clients to assess and develop more effective solutions. Keep in mind, not every client has every pattern. However, clients often swing from one pole to the other and one dimension to the next. These behaviors create barriers to progress in treating primary targets to help clients achieve the life they want.


1– Assess, with client as co-detective, as part of case formulation and when behaviors occur in/out of session. How are they managing each of these themes? What patterns are getting in the way of their life goals?  A current client shared how their emotion vulnerability and self-invalidation led them to deep despair which resulted in suicidal ideation and self-harm behaviors. They struggled to function as a parent and in their job. These are primary life goals which motivated them to work toward new skill development.

2- Name each pattern (with language they understand), how each show up, and in what contexts. These are often referred to as secondary targets. Despite the title, these are equally important to address in real-time as you are addressing primary targets. Breaking these down into classes/categories of behavior allows us to be more efficient and precise while addressing larger patterns.

3- Develop solutions based on each dilemma. Remind them of their goals. Validate why behaviors makes sense given the biosocial model. Get commitment and troubleshoot what might get in the way.  These solutions may be added to the diary card, ie. allow sadness, opposite action to shame, etc.

4- Address in real-time when they are occurring in session. Reward small steps toward progress.

Click here for part 2, in which Donna will provide a tool you can use with your clients to identify patterns on each dialectical dimension and a solution roadmap to remove obstacles to achieving their life goals.

Donna Pattie, MSW, LICSW is the DBT Trainer and Consultant for 15 DBT outpatient teams at Nystrom & Associates, Ltd across the state of MN.  Donna is a Linehan Board Certified DBT therapist and DBT Team Lead in New Brighton, MN for a Linehan Board Program Certified Team. Read her full bio here.