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
