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 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.