Table of Contents
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
Appendices
- Appendix A Mindfulness Exercises 216
- Appendix B Plans for Safety and Skills Implementation 218
- Appendix C Professional Growth in DBT 227
References 229
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