Dialectical Behavior Therapy A Contemporary Guide for Practitioners

A definitive new text for understanding and applying Dialectical Behavior Therapy (DBT).

• Offers evidence-based yet flexible approaches to integrating DBT into practice

• Goes beyond adherence to standard DBT and diagnosis-based treatment of individuals

• Emphasizes positivity and the importance of the client’s own voice in assessing change
• Discusses methods of monitoring outcomes in practice and making them clinically relevant

• Lane Pederson is a leader in the drive to integrate DBT with other therapeutic approaches

Lane D. Pederson is the owner of Mental Health Systems, one of the largest DBT-specialized practices in the USA, and is the founder of the Dialectical Behavior Therapy National Certification and Accreditation Association. As a DBT speaker, Dr. Pederson has trained over 7,000 therapists across the United States, Canada, and Australia. He is an outspoken advocate of flexible and evidence-based applications of DBT, and his books include DBT Skills Training for Integrated Dual Disorder Treatment Settings (2013) and The Expanded Dialectical Behavior Therapy Skills Training Manual (2012). Dr. Pederson can be contacted for DBT Training and other inquiries at www.drlanepederson.com.

Acknowledgments ix

To the Reader xi

Definitions xiii

1 Why Learn DBT? 1

2 Introduction to DBT: Brief Background and Current Controversies 4

3 The Contextual Model and DBT 9

Comparisons of DBT with Other Therapies 10

Therapeutic Factors that Most Affect Outcomes 13

Adopting versus Adapting Standard DBT: The Question of Treatment Fidelity 15

The Answer to Fidelity: EBP 21

4 DBT: An Eclectic yet Distinctive Approach 23

5 Is It DBT? A Guide for DBT-Identified Therapists and Programs 27

6 Dialectical Philosophy 31

Dialectics in Practice 32

Validation versus Change 32

Acceptance of Experience versus Distraction from or Changing Experience 33

Doing One’s Best versus Needing to Do Better 34

Noting the Adaptive in What Seems Maladaptive 34

Nurturance versus Accountability 35

Freedom versus Structure 36

Active Client versus Active Therapist 37

Consultation to the Client versus Doing for the Client 37

Dialectics and Evidence-Based Practice 38

When Not to Be Dialectic: Dialectical Abstinence 38

Dialectics with Clients 39

7 The Biosocial Theory: Emotional Vulnerability, Invalidating Environments, and Skills Deficits 41

The Role of Invalidation 44

How the Biosocial Theory Guides Practice 45

Being Flexible to the Client’s Theory of Change 47

8 Client, Therapist, and Treatment Assumptions 49

Client Assumptions 49

Therapist Assumptions 51

Treatment Assumptions 53

9 The Five Functions of Comprehensive DBT 55

Motivate Clients 55

Teach Skills 56

Generalize the Skills with Specificity 56

Motivate Therapists and Maximize Effective Therapist Responses 57

Structure the Environment 57

10 Treatment Structure 58

How Much Structure? Level-of-Care Considerations 59

Program Treatment Models 61

Individual Therapy Treatment Structure 70

Group Skills-Training Session Structure 72

Additional Treatments and Services 73

Expectations, Rules, and Agreements 73

11 DBT Treatment Stages and Hierarchies 79

Pretreatment Preparation 80

Pretreatment and the “Butterfly” Client 81

Stage One: Stability and Behavioral Control 82

Stage Two: Treating PTSD, Significant Stress Reactions, and Experiencing Emotions More Fully 85

Stage Three: Solving Routine Problems of Living 85

Stage Four: Finding Freedom, Joy, and Spirituality 85

12 The DBT Therapeutic Factors Hierarchy 87

1. Develop and Maintain the Therapy Alliance 87

2. Develop Mutual Goals and Collaboration on Methods 88

3. Identify and Engage Client Strengths and Resources to Maximize Helpful Extratherapeutic Factors 89

4. Establish and Maintain the Treatment Structure 89

13 Self-Monitoring with the Diary Card 90

14 Validation: The Cornerstone of the Alliance 96

Levels of Validation 97

Validation versus Normalization 99

15 Commitment Strategies 101

16 Educating, Socializing, and Orienting 107

17 Communication Styles 110

Reciprocal Communication 110

Irreverent Communication 114

18 Mindfulness 118

19 Skills Training 125

20 Changing Behaviors 133

Behavioral Contingencies 139

Behaviorism and the Therapist 142

The Most Effective Methods of Changing Behaviors 143

21 Behavioral Analysis 150

Behavioral Analysis Example 152

22 Dialectical Strategies 160

23 Cognitive Interventions 168

24 Telephone Coaching 177

25 Dealing with Safety Issues 180

Essential Practices 180

Suicide Risk Factors 183

Protective Factors 183

Suicide Assessment 184

Self-Injury Assessment 187

Creating the Safety Plan 190

Safety or No-Harm Contracts 193

From a Safety Plan to a Safety Commitment 194

26 Use of the Hospital 197

27 Consultation 200

28 Evaluation of Clinical Outcomes 209

Appendix A Mindfulness Exercises 216

Appendix B Plans for Safety and Skills Implementation 218

Appendix C Professional Growth in DBT 227

References 229

Index 241

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