Dialectical Behavior Therapy: A Contemporary Guide for Practitioners

Dr. Pederson s clinical expertise shines as he takes DBT out of the hands of researchers and translates it into a practical, flexible, and powerful approach to human problems. This is your all–in–one source for understanding and practicing DBT and, beyond that, for doing good clinical work in tough client situations.

Barry L. Duncan, Psy.D., author of On Becoming a Better Therapist: Evidence–Based Practice One Client at a Time

Bridging research and practice, with this straightforward, accessible guide, Pederson delivers on his promise to place DBT philosophies and techniques all–squarely into the hands of real–world clinicians working with real–world clients who so desperately need it!

Linda Curran, clinician, trainer, and author of Trauma Competency: A Clinician s Guide and 101 Trauma–Informed Interventions

New to DBT? Been using it for a while? Either way, this text will deepen your knowledge and strengthen your clinical skills. Dr. Pederson is an expert DBT clinician and trainer. He has created a comprehensive overview of DBT that has sufficient breadth and depth to empower readers to begin using DBT or improve their current practice. This text will be your go–to resource for all things DBT.

Cathy Moonshine, author of Acquiring Competency and Achieving Proficiency with Dialectical Behavior Therapy, Volumes I and II

This book promises to be the most influential DBT publication to date, not only in its superb description of the approach but also in the way it builds a bridge between research and practice with a focus on what is most effective for clients. The future of our field rests on outcome–based modifications and customizations to evidence–based treatments, and Dr. Pederson provides an in–depth analysis of research that empowers DBT therapists to embrace the future now. This is a must read for all DBT therapists.

Dr. Mark Carlson, DBT trainer for PESI Healthcare and author of CBT for Chronic Pain and Psychological Well–Being

This is a clear, succinct, and readable guide for those who want to understand DBT. Dr. Pederson describes the components and techniques necessary to deliver the comprehensive treatment as well as some intriguing adaptations to standard DBT. Readers will find practical information that allows them to provide effective, evidence–based treatment with a sharp focus on the therapeutic relationship and, ultimately, outcomes. Anyone looking to improve his or her clinical skill and be a more effective clinician will find this book to be a useful resource.

Britt H. Rathbone, co–author of Dialectical Behavior Therapy for At–Risk Adolescents

This is the first book to show in detail how dialectical behavior therapy skills and approaches can be
adapted and integrated into the broader evidence–based practice of psychotherapy. DBT was first developed in the late 1980s by Marsha Linehan as a response to the failure of standard cognitive and behavioral models to effectively treat chronically suicidal clients, and was built on a dialectical balance of acceptance and change. The standard form of DBT remains highly structured, as was appropriate to its original treatment group. However, today s therapists are increasingly encouraged to combine and integrate empirically supported treatments in a broader form of evidence–based practice that recognizes the importance of therapist expertise and judgment balanced with client needs and preferences. In short, most therapists want to incorporate DBT into their skills portfolio rather than become a specialist. This groundbreaking book makes a compelling case that today s best research evidence supports the adaptation of DBT, and presents the approach as a robust theoretical orientation that can be applied to a wide range of clinical presentations.

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

Lane Pederson is the owner of Mental Health Systems (MHS), one of the largest DBT–specialized practices in the USA, and is the founder of the Dialectical Behavior Therapy National Certification and Accreditation Association (DBTNCAA). As a DBT speaker, Dr. Pederson has trained over 7,000 therapists across the US, Canada, and Australia. An outspoken advocate of flexible and evidence–based applications of DBT, his books include The Expanded Dialectical Behavior Therapy Skills Training Manual and Dialectical Behavior Therapy in Integrated Dual Disorder Treatment Settings.