Dialectical Behavior Therapy

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 ixTo the Reader xiDefinitions xiii1 Why Learn DBT? 12 Introduction to DBT: Brief Background and Current Controversies 43 The Contextual Model and DBT 9Comparisons of DBT with Other Therapies 10Therapeutic Factors that Most Affect Outcomes 13Adopting versus Adapting Standard DBT: The Question of Treatment Fidelity 15The Answer to Fidelity: EBP 214 DBT: An Eclectic yet Distinctive Approach 235 Is It DBT? A Guide for DBT-Identified Therapists and Programs 276 Dialectical Philosophy 31Dialectics in Practice 32Validation versus Change 32Acceptance of Experience versus Distraction from or Changing Experience 33Doing One’s Best versus Needing to Do Better 34Noting the Adaptive in What Seems Maladaptive 34Nurturance versus Accountability 35Freedom versus Structure 36Active Client versus Active Therapist 37Consultation to the Client versus Doing for the Client 37Dialectics and Evidence-Based Practice 38When Not to Be Dialectic: Dialectical Abstinence 38Dialectics with Clients 397 The Biosocial Theory: Emotional Vulnerability, Invalidating Environments, and Skills Deficits 41The Role of Invalidation 44How the Biosocial Theory Guides Practice 45Being Flexible to the Client’s Theory of Change 478 Client, Therapist, and Treatment Assumptions 49Client Assumptions 49Therapist Assumptions 51Treatment Assumptions 539 The Five Functions of Comprehensive DBT 55Motivate Clients 55Teach Skills 56Generalize the Skills with Specificity 56Motivate Therapists and Maximize Effective Therapist Responses 57Structure the Environment 5710 Treatment Structure 58How Much Structure? Level-of-Care Considerations 59Program Treatment Models 61Individual Therapy Treatment Structure 70Group Skills-Training Session Structure 72Additional Treatments and Services 73Expectations, Rules, and Agreements 7311 DBT Treatment Stages and Hierarchies 79Pretreatment Preparation 80Pretreatment and the “Butterfly” Client 81Stage One: Stability and Behavioral Control 82Stage Two: Treating PTSD, Significant Stress Reactions, and Experiencing Emotions More Fully 85Stage Three: Solving Routine Problems of Living 85Stage Four: Finding Freedom, Joy, and Spirituality 8512 The DBT Therapeutic Factors Hierarchy 871. Develop and Maintain the Therapy Alliance 872. Develop Mutual Goals and Collaboration on Methods 883. Identify and Engage Client Strengths and Resources to Maximize Helpful Extratherapeutic Factors 894. Establish and Maintain the Treatment Structure 8913 Self-Monitoring with the Diary Card 9014 Validation: The Cornerstone of the Alliance 96Levels of Validation 97Validation versus Normalization 9915 Commitment Strategies 10116 Educating, Socializing, and Orienting 10717 Communication Styles 110Reciprocal Communication 110Irreverent Communication 11418 Mindfulness 11819 Skills Training 12520 Changing Behaviors 133Behavioral Contingencies 139Behaviorism and the Therapist 142The Most Effective Methods of Changing Behaviors 14321 Behavioral Analysis 150Behavioral Analysis Example 15222 Dialectical Strategies 16023 Cognitive Interventions 16824 Telephone Coaching 17725 Dealing with Safety Issues 180Essential Practices 180Suicide Risk Factors 183Protective Factors 183Suicide Assessment 184Self-Injury Assessment 187Creating the Safety Plan 190Safety or No-Harm Contracts 193From a Safety Plan to a Safety Commitment 19426 Use of the Hospital 19727 Consultation 20028 Evaluation of Clinical Outcomes 209Appendix A Mindfulness Exercises 216Appendix B Plans for Safety and Skills Implementation 218Appendix C Professional Growth in DBT 227References 229Index 241