An intellectual history of DBT

From Hegel to behaviorism to a Zen monk calling a student's bluff

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“Wheat Field with Cypresses” (1889) by Vincent van Gogh

Dialectical behavior therapy (DBT) is an endlessly fascinating cultural product. At this point, the life of its creator, Marsha Linehan, is the stuff of legend, but I’ll briefly recount it here. Linehan was born in 1943 in Tulsa, Oklahoma, to an oil executive and his wife. In her 2020 memoir Building a Life Worth Living, she recalls never quite fitting in. She was relentlessly criticized by her status-obsessed parents; her siblings, by contrast, appeared effortlessly “normal.”

In her senior year of high school, Linehan was admitted as an inpatient to the Institute of Living in Hartford, Connecticut, where she endured two years of electroconvulsive therapy, over-medication, cold pack therapy, and other “therapeutic” indignities of the era. Her symptoms, which began with migraines and depression, escalated into self-harm and suicidal behavior. Unbeknownst to Linehan, this was the beginning of her journey to develop an effective treatment for individuals struggling with chronic self-harm and suicidal behavior.

Perhaps no one has more fully embodied the idea that “research is me-search” than Linehan. As her memoir and other DBT texts document, almost every now-RCT-validated idea in DBT came from one of Linehan’s personal encounters with psychiatric treatment, Zen Buddhism, or dialectics.

Love DBT or hate it, no one can deny how ambitious Linehan’s project was — or how vast a terrain DBT covers. Linehan did not merely research a handful of discrete interventions. She crafted an entirely new framework for delivering psychotherapy — a thousand strands woven into a bold new tapestry.

Of course, like all scientists, Linehan also stood on the shoulders of giants. She’d be the first to admit it. Last year, in my DBT training program, I spent some time tracing back the origins of as many skills as possible (including skills taught to the therapist!), and placing them in a chronology of Linehan’s life and work. Here’s what I learned:

First, a meta-commentary

What is a “skill” in DBT?

In 2024, Lily Scherlis, a PhD candidate in the history of science, argued that DBT skills are a product of workplace management science leeching into the broader culture:

In the first part of the twentieth century, “skills” left the workshop and factory and moved into the C-suite and boardroom, where the ability to manage others’ emotions became known as “leadership skills.” In the ’90s, DBT brought skills out of the workplace and into the most high-risk regions of mental health, developing formulas that have come to define popular conceptions of wellbeing. If you are a skilled manager of your own mind, your feelings will not go on strike.

I don’t dispute Scherlis’ account, which draws heavily on the work of sociologist Eva Illouz, whose book, Saving the Modern Soul, I really enjoyed and which I wrote about positively here. However, I think there is an important element missing from Scherlis’ account: skillful means.

In Buddhism, skillful means (or upāya) refers to a teacher’s ability to adapt their message to their students. Tricycle, the Buddhist magazine, puts it this way: “The Buddha likened his teachings to a raft—once the river was crossed and the far shore of liberation reached, the raft should be abandoned. In other words, the words or forms used to reach the goal aren’t intrinsically valuable but are worthwhile to the extent that they help us attain awakening.”

This dual lineage¹, of managerial skills and skillful means, culminates in the DBT skills training — a 2.5-hour weekly course, 6 months in duration, in which clients learn every discrete skill in the manual. Individually, the skills should reduce target behaviors, like self-harm. Collectively, they should go a long way in Linehan’s ultimate goal: helping every client build a “life worth living.”

1960s

Principles of behaviorism

DBT is a behavioral therapy – meaning it uses the principles of learning and rewards and punishments to guide interventions. How did Linehan, who trained when psychoanalytic therapy was still in its heyday, become a behavioral therapist?

Linehan earned her bachelor’s and her PhD at Loyola University in Chicago. While in school, Linehan encountered two books that converted her to the cause of behavioral therapy. The first is Personality and Assessment (1968) by Walter Mischel (the guy behind the marshmallow test). The book essentially takes to task psychodynamic notions of personality. Mischel argues that while scores of cognitive capacity are fairly consistent, other supposedly enduring “traits” vary widely by context and testing apparatus. In short: we are as much situation as self. “I memorized almost everything Mischel said,” Linehan wrote in her memoir.

The second book was Principles of Behavior Modification (1969) by Albert Bandura. Bandura was the originator of social learning theory, the idea that humans can learn by observing others, even in the absence of direct reinforcement of their learning (see: Bandura’s famous Bobo doll experiments). In Principles, Bandura worked to apply research findings on operant conditioning and social learning to clinical settings. Specifically, he proposed that all behaviors were learned, and that new behavior could be elicited through reinforcement, modeling, and extinction — the primary concerns of a DBT therapist to this day.

1970s

Opposite action

In graduate school, Linehan also encountered the work of psychologist Arthur Staats (eulogized as the inventor of the “time out” upon his death in 2021). In the early 1970s, Staats was formulating his theory that we can shape our own emotional responses.² This is the underlying principle for the DBT skill of opposite action, in which clients in distress are coached to act opposite to an ineffective emotion by adopting the thoughts, physical expression, and behaviors of an opposite emotion.

Interpersonal effectiveness

One of Linehan’s first independent areas of scholarly focus was this field of “assertiveness.” In the mid-1970s, while teaching at Catholic University of America, Linehan and colleague Kelly Egan began studying assertiveness training for women.³ While Linehan was still a decade away from developing DBT as we know, these were the roots of interpersonal effectiveness, one of the four skills training modules.

DEARMAN

In 1976, husband-wife duo Sharon and Gordon Bower published a self-help book called Asserting Yourself: A Practical Guide For Positive Change. It laid out the couple’s DESC model for conflict resolution: Describe, Express, Specify, and Consequences. I think it’s fair to say that Linehan translated these principles into DEARMAN skill, a critical part of the interpersonal effectiveness module. DEAR stands for Describe, Express, Assert, and Reinforce (while MAN stands for stay Mindful, Appear confident, and Negotiate).

Cope ahead and “Check the Facts”

In addition to reading Mischel and Bandura, Linehan also cites Donald Meichenbaum as a major influence. In particular, Meichenbaum’s work on cognitive modification became the “Check the Facts” skill, which guides clients through a series of questions to check the accuracy of their emotions. Meanwhile, his research on stress inoculation forms the backbone of the DBT skill “cope ahead,” in which one imagines, in great detail, how they will handle a stressful situation they expect to occur, thereby increasing their effectiveness in the moment.

Validation

Back in 1956, Carl Rogers, a leading figure in humanistic psychology, argued that therapists must hold their clients in “unconditional positive regard.” Linehan adopted this stance in her earliest clinical work, to a degree. She would later take this idea and run with it, articulating six distinct levels of validation:

1. Staying awake

2. Accurate reflection

3. Mind-reading

4. Validating based on past history/biology

5. Validating based on present events

6. Radical genuineness

Willingness and willfulness

In the mindfulness module, DBT teaches that to be effective, we must let go of “willfulness” and move toward “willingness.” But what do these concepts mean?

In 1978, Linehan, an ardent if unconventional Catholic, visited the Shalem Institute for Spiritual Formation in Washington, D.C. There, she met Gerald “Jerry” May,⁴ a psychiatrist and theologian who was developing his framework of willingness and willfulness. In 1982, in his book Will and Spirit: A Contemplative Psychology, he’d describe the concepts like this:

“Willingness applies a surrendering of one’s self-separateness, an entering into, an immersion in the deepest processes of life itself. It is a realization that one already is a part of some ultimate cosmic process and it is a commitment to participation in that process. In contrast, willfulness is the setting of oneself apart from the fundamental essence of life in an attempt to master, direct, control, or otherwise manipulate existence. More simply, willingness is saying yes to the mystery of being alive in each moment. Willfulness is saying no, or perhaps more commonly, ‘yes, but…’

But willingness and willfulness do not apply to specific things or situations. They reflect instead the underlying attitude one has toward the wonder of life itself. Willingness notices this wonder and bows in some kind of reverence to it. Willfulness forgets it, ignores it, or at its worst, actively tries to destroy it. Thus willingness can sometimes seem very active and assertive, even aggressive. And willfulness can appear in the guise of passivity.”

1980s

Principles of Zen

Zen Buddhism, which emerged in China, is typically understood as a mixture of Mahayana Buddhism (think: the Four Noble Truths) with Daoist principles (think: wu wei, or effortless action). White westerners first embraced Zen in the early 20th century as masters like D. T. Suzuki lectured and published for audiences in the United States.⁵ Americans seemed particularly attracted to the emphasis Zen places on “direct insight” — a path to enlightenment that was seen as less concerned with scholarship and more compatible with a lay lifestyle than other forms of monastic Buddhism.

Shortly after earning tenure at the University of Washington in 1983, Linehan convinced her chair to allow her to take what became a year-long sabbatical to study Zen Buddhism. First, she drove to Shasta Abbey in California. Then, she spent several months training with the German Catholic priest and Zen Master Willigis Jager. “I’ve got to learn methods of acceptance myself in order to be able to teach acceptance more effectively to my clients,” she told her chair. “I don’t know a lot about Zen practice, but the one thing I do know is that it is about learning how to accept where you are in the world.”

Radical acceptance

Perhaps the hardest skill in the DBT manual to teach is the skill of radical acceptance. Linehan’s instructions spend a lot of time defining what radical acceptance is not (it is not approval) before even beginning to try to convince people of the benefits of what it is: accepting this moment as it is, even (and perhaps especially) when this moment is excruciatingly painful.

Linehan has attributed her development of radical acceptance to a number of forces, including Nazi concentration camp survivors, Viktor Frankl in particular. In his 1946 book Man’s Search for Meaning, Frankl, a psychiatrist interned in Dachau, wrote that suffering was guaranteed, but freedom remained: “Everything can be taken from a man but one thing: the last of the human freedoms — to choose one’s attitude in any given set of circumstances.”

Zen Buddhism also influenced Linehan’s conception of radical acceptance.⁶ Somewhere along the way, a Zen instructor told her “the dandelion story,” adapted from The Song of the Bird, a 1984 book by Indian Jesuit priest and psychotherapist Anthony de Mello. Linehan’s version goes like this:

Mindfulness

In her memoir, Linehan described many lessons of Zen practice learned on her sabbatical. Though not specifically named by Linehan, the practice of shikantaza — commonly if imperfectly translated as “just sitting” — was clearly influential in her life and work. Where other meditation may be focused on a mantra or even the breath, Linehan cultivated this “choiceless awareness.” Notably, DBT trainings also emphasize eyes-open meditation, a hallmark of Zen practice.

In addition to her personal meditation experiences, Linehan described the teachings of Thich Nhat Hanh, the Vietnamese Zen Buddhist monk, as a “revelation.” She writes: “His words were simple, direct, and kind. He taught that when you wash the dishes, just wash the dishes. That mindfulness was not some esoteric practice — it was a way of living in every moment.”

However, Linehan was determined to develop DBT as a secular and scientific enterprise.⁷ The work of psychologist Ellen Langer helped Linehan to bridge her spiritual practice with her clinical practice. In the 1980s, Langer and her team at Harvard were developing novel ways to assess the benefits of flexibility, mindful observation, and related concepts.

Today, DBT treats mindfulness as the core skillset.⁸ Each class returns to the module four times in a 6-month course, for a total of eight weeks of mindfulness training.

Extending

One stylistic strategy DBT therapists learn is the art of “extending” — a term Linehan borrowed from aikido. Instead of resisting another’s movement, the goal is to join it, and take it one step further.

Linehan learned this lesson not in a martial arts class, but during her Zen sabbatical. Here’s how the story⁹ is recounted in a 2002 profile of Linehan in Tricycle:

“After three months, she went to a priest and dramatically told him she was on the edge of a spiritual breakthrough and wanted to sit nonstop for three days. The monk took her hyperbole seriously, saying he was sure she knew what she needed. But since Shasta Abbey didn’t do things that way, why didn’t she go to the nearby Holiday Inn, meditate for as long as she liked and then come back? Out on a limb not of her choosing, Linehan backtracked and returned to the schedule.”

Contemplative prayer

After her initial period of Zen studies, Linehan decided to explore her Catholic roots from a new vantage point. She trained in “centering prayer,” a method developed by Father Thomas Keating, an American Trappist monk. Keating, whose work was in close conversation with Zen Buddhism, encouraged practitioners to sit twice a day for 20 minutes, with the following guidelines:

1. Choose a sacred word

2. Sit comfortably, eyes closed, settle, and silently introduce the sacred word

3. When thoughts emerge, return to the sacred word

The DBT mindfulness module includes a section on more explicit spiritual practices, including contemplative prayer.

Dialectics

DBT is a balance of the two major forces in Linehan’s own life — acceptance (from Zen) and change (from behaviorism). Linehan reportedly planned on called her therapy “Zen Behavior Therapy,” or ZBT. That changed in the late 1980s as the result of a conversation with her assistant Elizabeth Trias, whose husband was a Marxist philosopher at the University of Washington. “Marsha, your treatment is dialectical!” Trias told Linehan.

While Marx indeed described a dialectic of materialism, Linehan’s dialectics are rooted in a more traditional Hegelian philosophy. The DBT individual and skills manuals hold firm to the idea that multiple conflicting things can be true at once — and that we can “synthesize” these tensions, including with something as simple as an “and” statements.

DBT as we know it was born.

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Credits: Original art by Seattle-based illustrator Mara Parks Potter. Follow her on Instagram @maraparkspotter.

1. In her memoir, Linehan describes herself as lacking emotion regulation “skills” long before she began practicing Zen Buddhism — a potential point in favor of Scherlis’ history!

2. These ideas are fully articulated in Staats’ 1975 book Social Behaviorism.

3. In 1983, Linehan and Egan wrote their own book, also called Asserting Yourself. The dust cover calls it "an excellent aid to social self-analysis”!

4. Will is a fixation in the May family! Gerald May’s older half-brother (by 30 years), Rollo May, was a pioneer of existential psychology. Rollo’s best-known 1969 book was called Love and Will.

5. For a history of Buddhism in “the west,” check out How the Swans Came to the Lake by Rick Fields, which I wrote about here, in a post of Buddhist psychology.

6. The phrase “radical acceptance” has been further popularized by psychologist Tara Brach, whose 2004 book Radical Acceptance is, in my experience, many people’s first introduction to the concept!

7. Case in point: Eyes-open meditation comes from Linehan’s Zen practice, but is usually promoted as a means of “generalizing” mindfulness practice to everyday life — a core behavioral principle. “We live our lives with our eyes open” is a common refrain.

8. Within the mindfulness module there are actually six discrete skills: the “what” (observe, describe, participate) and the “how” (non-judgmentally, one-mindfully, and effectively) of mindfulness.

9. Linehan offers her own, first-person account of this story on p. 245 of her memoir. There, she uses it as an example of “illusion of freedom in the absence of alternatives” and as a personal encounter with radical acceptance.