Making Lemonade out of Lemons: Dialectics and the end of Suffering

I recently completed a six-month-long training in Dialectical Behavior Therapy (DBT), a comprehensive mode of treatment developed by Marsha Linehan, Phd, ABPP for people whose intense emotions are overwhelming and lead them to use destructive behaviors (such as self-harm, suicide attempts, substance abuse, compulsive shopping or gambling, eating disorders) to regulate them. Dr. Linehan found that these suicidal and self-injuring patients struggled with traditional cognitive-behavioral therapy and because they felt invalidated by its focus of change. And yet, they also desperately wanted to change in order to stop suffering. Dr. Linehan incorporated mindfulness-based acceptance strategies into her treatment to balance out the focus on change – making it a dialectical approach.

“Dialectics” is a philosophy that sees the truth as the synthesis of a thesis and an antithesis, meaning that we must always try to see the “kernel of truth” in each conflicting position, thus eliminating the seeming contradictions that keep therapists and patients “stuck” in unsolvable conflicts. The concept of “Wise Mind” in DBT, for example, is the dialectical integration of reasonable mind and emotional mind. Emotional balance, then, is not achieved by denying, invalidating or exterminating emotional reactions, but rather by balancing them wisely with reason, taking in all points of view.

DBT focuses on teaching people skills to manage difficult emotions, deal with painful situations and improve relationships. The treatment components include individual therapy, skills training group, skills coaching between sessions to generalize the skills to real-life situations, and a team treatment approach that requires the treatment be applied to the therapists as well as the patients. Skills are taught in a class format in the following areas, or modules: Mindfulness, Emotion Regulation, Distress Tolerance and Interpersonal Effectiveness.

Patients are required to keep a diary card to monitor their urges, emotions, and practice of the skills. Therapists meet weekly as a team to enhance their effectiveness as DBT therapists.

A DBT therapist seeks to understand a behavior’s function, thus removing the judgment about the behavior’s “right-ness or wrong-ness”, and then coming up with solutions based on whether the behavior is caused by a skills deficit (remediated by skills enhancement), an inability to tolerate distress (solved by exposure), a cognitive distortion (helped by cognitive remediation) or reinforced conditioning (solved by contingency management strategies).

The functions of a good DBT program are to enhance the capabilities of the patients by teaching them skills, to improve their motivation to recover through the use of cognitive modifications and contingent reinforcement, to assure generalization to the patient’s environment through the use of after-hours coaching and homework assignments, to help structure the patient’s environment to help with recovery through contingency management, and to enhance therapist motivation and effectiveness through the use of treatment teams and consultation.

Making lemonade out of lemons is one of the “dialectical” DBT strategies that requires a DBT therapist to take something problematic in the client and turn it into an asset; for example, seeing problems that arise in therapy or in life as opportunities to practice skills, or interpreting the patient’s “resistance” to change as a strength that allows the person to persevere until changes are made. In her textbook, Cognitive-Behavioral Therapy ofBorderline Personality Disorder, Dr. Linehan explains that her rejoicing over someone’s expressed calamity forces the recipient to stop and take in new information about how this event will allow the person to practice skills. Looking back on all the many crises in my life, I see a jar full of lemonade, a lemonade that I now serve to others who are thirsty for acceptance and change.

The Counseling Group has a team of intensively trained DBT therapists ready to help those who are eager to find alternative ways to deal with their suffering and want to create “a life worth living.” I am proud to be a part of this intensively trained team. For more information about the DBT program, please visit The Counseling Group’s DBT page or call 305-857-0050.