By Gregory Holich, MS, LPC, Continuing Education Presenter

Young adult with glasses and hair in bun looks to side window and smiles thoughtfullyEditor’s note: Gregory Holich, MS, LPC is the dialectical behavior therapy program coordinator for Timberline Knolls Residential Treatment Center in Lemont, Illinois. His continuing education presentation for GoodTherapy, titled “A Comprehensive Approach to Treating Co-Occurring Disorders,” took place on June 22, 2018. The recorded event is available as a homestudy course at no additional cost to Premium and Pro GoodTherapy members ($14.95 for Basic Members and mental health professionals without membership) and is good for two CE credits. View or see more details.

Dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) can be extremely beneficial therapeutic strategies. Combining the principles and skills of DBT and ACT can enhance therapeutic interventions with people struggling with eating disorders, substance use issues, and other co-occurring conditions.

This approach can prove valuable in navigating dialectical dilemmas. At their core, dialectical dilemmas are the extreme states a person may present in treatment. The goal of DBT skills training is to find a synthesis between these polarized states.

Dialectical dilemmas are based on the bio/social model. The biological component refers to a person who is out of emotional control (under-regulated). Conversely, the social component refers to a person who attempts to over-control emotions (over-regulated).

While the dialectical dilemmas can inform the clinician where a person is at in the present moment, the ACT model of psychological flexibility can serve as a compass to guide both the clinician and person in treatment where to go in therapy. When used in tandem, both dialectical dilemmas in DBT and the psychological flexibility model in ACT can enhance therapeutic assessment and decision-making.

Dialectical dilemmas and their corresponding ACT model of psychological flexibility include:

Active Passivity

In this situation, a person’s problems remain unsolved due to their perception they do not have the capacity or external help required to rectify them. Essentially, they intentionally do nothing to help themselves and may rely on others to solve problems for them. This leads to high stress and a condition referred to as learned helplessness.

Therapeutic approach: Approaching active passivity through the lens of the ACT psychological flexibility model, the clinician may assist the person in therapy in clarifying values and taking action based on those values. This intervention is referred to in ACT as committed action. While it is necessary to help a person identify and clarify their values, committed action stresses the importance of behavioral change that is guided by those values and may include problem-solving, assertiveness, and skills training.

Apparent Competence

In some cases, it serves the person’s desires and goals to appear competent. This is avoidant behavior. Often these avoidance techniques are verbal in nature and designed to mask the person’s true emotional state. Their emotional experience is often misread by those around them, which in turn leads to the unintentional invalidation of their experience by others.

Therapeutic approach: Defusion techniques can help a person become unstuck from unrealistic expectations or standards, while the inclusion of values can help guide behavior. Additionally, the ACT process, referred to as self-as-context, assists people in increasing awareness of their thoughts, emotions, urges, and memories. Ultimately, the therapist assists people in becoming observers of their thoughts instead of reacting impulsively.

Emotional Vulnerability

In this dilemma, the emotional experience is profoundly heightened, far past what would be considered reasonable. There are no small or minor feelings; everything is exaggerated to a nearly traumatic degree. People are inordinately sensitive to all emotions, not just those that are painful. This can inadvertently lead to avoidance of people, places, things, and experiences that may elicit what is perceived as an undesirable emotional response.

Therapeutic approach: Through the ACT process of acceptance, people are encouraged to begin to make room for uncomfortable feelings and emotional experiences.


In this situation, the person is defined by “should” and “should nots” regarding emotion: “I should not feel fear,” “I should be happy.” Often, self-invalidation is a learned behavior, typically due to ongoing invalidating environments.

Therapeutic approach: Acceptance of thoughts and emotions that a person is experiencing becomes the first step toward making changes in the moment, including self-validation. People benefit from learning why their thoughts, emotions, and urges make sense, then choose a committed action guided by values. In turn, mood-dependent behavior becomes values-directed behavior, regardless of mood.

Inhibited Grieving

Sorrow, grief, loss, and pain are valid human emotions. In this situation, the person refuses to feel them. Across the board, they negate or avoid feeling emotional states. Even happiness, if perceived as painful, will be avoided. But the truth is emotions do not go away simply because they are ignored.

Therapeutic approach: Using the ACT model of psychological flexibility, people learn ways of getting in contact more with the present moment. In addition, the process of accepting emotions, past events, and future limitations can help in moving people toward more meaningful lives.

Unrelenting Crisis

In this situation, crisis is ongoing; one leads to the next, which leads to the next, and so on. If a true crisis is not readily available, the person creates one. Whereas most people find chaotic, catastrophic, or calamitous states to be unpleasant, for this person, a crisis is a comfort zone.

Therapeutic approach: Effective ACT interventions may include both committed action and values work. It is imperative to work with people in making commitments and following through with those commitments in ways that will not contribute to ongoing crises.

Correctly identifying a person’s dialectical dilemmas, then utilizing the best possible therapeutic approach, can help facilitate meaningful change and lead to the person living a meaningful life.