The Dialectical Behavior Therapy Primer E-Book

Beth S. Brodsky

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 575

Veröffentlichungsjahr: 2013

Beschreibung

Dialectical Behavior Therapy (DBT) has quickly become a treatment of choice for individuals with borderline personality disorder and other complicated psychiatric conditions. Becoming proficient in standard DBT requires intensive training and extensive supervised experience. However, there are many DBT principles and procedures that can be readily adapted for therapists conducting supportive, psychodynamic, and even other forms of cognitive behavioral treatments.Despite this, there is a dearth of easily accessible reading material for the busy clinician or novice.

This new book provides a clinically oriented, user-friendly guide to understanding and utilizing the principles and techniques of DBT for non-DBT-trained mental health practitioners and is an ideal guide to DBT for clinicians at all levels of experience.

Written by internationally recognized experts in suicide, self injury and borderline personality disorder, it features clinical vignettes, following patients through a series of chapters, clearly illustrating both the therapeutic principles and interventions.

Leseprobe

Contents

About the Authors

Foreword

Acknowledgments

Chapter 1 Introduction

For whom is this book intended?

The challenge of treating Borderline Personality Disorder and disorders of emotion dysregulation

What is DBT?

“Top 10 questions” therapists ask about working with individuals who have BPD

How does DBT help the clinician?

Overview of the book

References

Part I Theoretical, research, and clinical foundations

Chapter 2 When DBT is indicated: The patients, the clinicians, and the evidence

DBT is an evidence-based treatment

When is DBT indicated?

Why should a clinician learn DBT?

Which clinicians are not suited to doing DBT

Summary

References

Chapter 3 BPD: Treatable or untreatable?

The myth of BPD untreatability

Modifying “psychotherapy as usual”

Evidence-base for the treatability of BPD

Summary

References

Chapter 4 BPD: Diagnosis, stigma, and phenomenology

The BPD diagnosis

The stigma of BPD

The biosocial theory of the etiology of BPD

“Being borderline”

Summary

References

Chapter 5 Understanding and treating self-harm behaviors in BPD

The problem

Nonsuicidal self-injurious behavior: Reasons and functions

Suicide attempts: Reasons and functions

Treatment implications

Summary

References

Chapter 6 The ABC’s of DBT – the theoretical perspective

Overview of DBT theory

What aspects of Laura’s experience can be validated, and how?

Change: Theory and techniques

Summary

References

Chapter 7 The ABC’s of DBT – overview of the treatment

Stages of treatment

How is DBT different from CBT?

Summary

References

Part II Using DBT in clinical practice

Chapter 8 Commitment and goal setting

Hierarchy of goals: The three S’s – staying alive, staying in treatment, and stability

Prioritizing the goal of reducing self-harm behaviors

Active clinician stance

Commitment to treatment

Commitment strategies

Validation strategies in the commitment phase

Door in the face

Orientation to treatment

Summary

References

Chapter 9 The DBT tool kit: The essential DBT strategies and what happens in the individual session

Establishing session structure

Chain analysis

Illustration of an individual therapy session

Clinical strategies for getting “unstuck”

Summary

References

Chapter 10 Skills training: The rationale and structure

The skills deficit model

Rationale for skills training

Principles of skills training

Skills training in DBT

Reinforcement of skills training in individual therapy

Summary

References

Chapter 11 Skills training: The four skill modules

The four skills modules and order of modules

Finding the middle ground

Mindfulness readings

Summary

References

Chapter 12 Between-session contact and observing limits

In vivo skills coaching

The value and importance of being available between sessions

Reporting good news

Relationship repair

Modes of skills training

Twenty-four-hour rule

Addressing therapy-interfering behavior

Arbitrary versus natural limits

Balancing dependency and autonomy

Summary

References

Chapter 13 Management of suicidal behavior

Filling the gap

Comprehensive history taking

Safety planning

Obtaining commitment

Immediate crisis management

Summary

References

Chapter 14 The Safety Planning Intervention

The Safety Planning Intervention

The steps of safety planning

Implementation of the safety plan

Safety Plan Intervention: An illustrative case example

Summary

References

Chapter 15 The three C’s of consultation

The three C’s – consult with DBT colleagues, consult to patient, consult with other clinicians

Consulting with colleagues: The DBT consultation team

Non-DBT collaboration and coordination of treatment

Coordination of care – DBT model

Summary

References

Chapter 16 DBT case formulation

DBT versus psychodynamic formulation

DBT case formulation

Dialectical dilemmas in a DBT formulation

Summary

References

Chapter 17 Beyond Target 1 – Therapy and “quality of life” interfering behaviors

Therapy-interfering behaviors

Quality of life goal setting – Target 3

Summary

References

Chapter 18 The end of treatment

Why BPD patients drop out prematurely

Clinician initiated “vacation” from treatment

When treatment goals have been achieved

Serious suicide attempts and suicide

Final thoughts about doing DBT with suicidal individuals

References

Index

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Library of Congress Cataloging-in-Publication Data

Brodsky, Beth S.The dialectical behavior therapy primer : how DBT can inform clinical practice / Beth S. Brodsky, Barbara Stanley. p. ; cm.Includes bibliographical references and index.

ISBN 978-1-118-55624-5 (ePDF) – ISBN 978-1-118-55659-7 (emobi) – ISBN 978-1-118-55660-3 – ISBN 978-1-118-55661-0 (epub) – ISBN 978-1-119-96893-1 (softback : alk. paper) I. Stanley, Barbara, 1949– II. Title. [DNLM: 1. Borderline Personality Disorder–therapy. 2. Cognitive Therapy–methods. WM 190.5.B5]RC569.5.B67616.85′852–dc23

2013002841

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image © GettyImageCover design by Cyan Design

“Start where you are. Use what you have. Do what you can.”                                                                             Arthur Ashe

This quote embodies the kind of encouragement that DBT provides for patients and, in true dialectic form, helps them move beyond where they are, develop more than what they have, and do more than what they can.

About the Authors

The authors of this book are, in a sense, unlikely candidates to write a volume on Dialectical Behavior Therapy (DBT), a form of cognitive behavioral therapy (CBT). Both authors were originally trained in psychodynamic models of psychotherapy. However, also conduct clinical research on suicidal behavior and nonsuicidal self-injury. In an effort to provide effective treatment for the suicidal and self-injuring individuals that they were studying, they found psychodynamic treatment approaches wanting. This led them to a DBT-intensive training conducted by Marsha Linehan at the University of Washington and the development of a research program investigating the efficacy of DBT and other CBT approaches to chronically suicidal and self-injuring individuals. The DBT model not only seemed to be effective and helpful to patients, but it also suited the personal style of the authors, allowing room for them to be their “genuine and natural selves” while maintaining professionalism. They introduced DBT at their home institution, Columbia University, where the basic therapy training model for ­psychiatric residents and psychology trainees is psychodynamic in nature, and where graduates with psychotherapy practices primarily adopt a psychodynamic approach. As such, the authors have spent a lot of time bridging psychodynamic and cognitive behavioral concepts and techniques. In doing so, they have considered how many aspects of DBT – the model, the way of thinking about patients and their problems, as well as the techniques – can be used by clinicians who practice other models of therapy or who ­primarily do psychopharmacology. This volume is the result of their years of practicing and teaching DBT.

Clinical psychologists, Barbara Stanley, PhD, and Beth Brodsky, PhD, are ­internationally recognized experts in suicide, self-injury, and borderline personality disorder (BPD). They are both on the faculty of the Columbia University College of Physicians and Surgeons, in the Department of Psychiatry. They have received an NIMH grant to develop a curriculum on teaching DBT to psychiatry residents in training. The only other DBT grant given under this program was to the treatment developer, Dr. Linehan.

Dr. Stanley is Professor of Clinical Psychology and the Principal Investigator of an NIMH-funded grant comparing the efficacy and studying the mechanisms of action of DBT and antidepressants in the reduction of suicidal behavior and self-injury in BPD. She is the author of numerous professional articles and chapters, is a frequently invited speaker on BPD, suicidal behavior, and DBT and has participated in several NIMH work groups and review groups. She serves as editor-in-chief of the Archives of Suicide Research. With her colleague, Dr. Gregory Brown, she developed the Safety Planning Intervention that is used throughout the Veterans Health Administration, state mental health systems, and on crisis hotlines across the United States. She was awarded the American Foundation for Suicide Prevention Research Award and the New York State Suicide Prevention Center Research Award. She is a DBT trainer for Behavioral Tech, LLC.

Dr. Brodsky is Associate Clinical Professor and the lead DBT therapist in Dr. Stanley’s treatment study. She serves as a supervisor of interns and psychiatry residents learning DBT. She, too, is the author of many articles and chapters on BPD, DBT, suicide, and ­self-injury and is a frequently invited speaker on BPD, suicidal behavior, and DBT. She serves on the editorial board of the Archives of Suicide Research. She is also a member of the Virginia Apgar Academy of Medical Educators at Columbia University.

Drs. Stanley and Brodsky have been active collaborators for several years. They also have DBT-based private practices in New York City and are frequently called upon to ­provide consultation on “difficult” patients with BPD for mental health professionals who are not trained in DBT. They have found that mental health professionals from a wide spectrum of clinical training can be helped to improve their work by applying DBT ­principles. In this book, they draw on their extensive experience and summarize their understanding of the phenomenology of BPD, and of the theoretical principles and ­treatment techniques of DBT.

Foreword

Borderline Personality Disorder (BPD) is a serious and underrecognized public health problem. It is relatively common – almost 2% of the general population and more than 20% of psychiatric outpatients have this diagnosis. These are people who suffer a great deal themselves and are often a cause of great suffering for their loved ones. BPD can be expensive to treat but even more expensive not to treat. And it can be deadly – the suicide rate in BPD is 10%.

The bad news is that currently available medications help just a little bit, or not at all. The good news is Dialectical Behavior Therapy (DBT). This is a very effective psychotherapy that helps therapists help their patients to find the way out from the maze of their previously self-destructive behavior. Marsha Linehan first developed DBT three decades ago, and it has since provided much needed guidance for clinicians and welcome hope for patients and their families. DBT is a wonderful, evidence-based treatment widely used around the world.

But DBT has one serious problem – it requires a lot of training for the therapist and a lot of commitment, time, and effort for the patient. The complete DBT package is simply not practical for many clinical situations. It always seemed to me that there was a place for a simpler, less demanding application of DBT techniques to everyday clinical practice. This book fills that niche. It will help clinicians incorporate aspects of DBT into their work with patients whenever the whole DBT treatment is impractical.

Marsha Linehan is a friend of mine. But I could never convince her of the value of this kind of “DBT light.” Another friend, Barbara Stanley along with her long time ­colleague, Beth Brodsky, now fill the gap. Their book provides a comprehensive introduction to DBT and a very accessible approach toward integrating DBT with other psycho­therapy ­techniques. This approach will be useful to everyone who works with borderline patients – those experienced in DBT will find many pearls; those with no prior DBT training will find a complete toolkit.

The authors received DBT-intensive training with Dr. Linehan and were inspired by her to conduct extensive research on its effects. The ideas in this book are a ­product of their years of experience in conducting the full DBT model in clinical and research settings, as well as in training and teaching DBT to psychologists, psychiatry ­residents, and other mental health providers. Their rich clinical experience comes through in the many vivid case examples. The authors present a practical DBT-informed interventions and ­hands-on, step-by-step guidance to help clinicians become more effective in the management of suicidal and self-harm behaviors and in making decisions about hospitalization of their patients.

Although the book is targeted mainly to clinicians, it will also be a very useful read for patients, family members, and loved ones. It provides hope for a happier and more stable future and concrete guidance on how to get there.

Allen Frances, MD

Acknowledgments

There are many individuals to thank for their help and support in the writing of this book – our families, our colleagues and editors, and especially our patients, from whom we have learned so much. But we particularly want to acknowledge Dr. Marsha Linehan, the developer of Dialectical Behavior Therapy. Her ideas about treatment and under­standing borderline personality disorder are nothing short of genius. Her approach ­transformed the way we treat patients. Marsha is one of the very few individuals who has moved our field forward by a quantum leap. Her original text, Cognitive Behavior Therapy for Borderline Personality Disorder, is an amazingly dense work with gems of clinical insight packed into every page, and we base our work on this original text. The inside of Barbara’s textbook jacket is filled with several columns of notations and associated pages of paragraphs that she found to be deeply insightful and helpful. Beth’s copy of Linehan’s text is filled with bookmarked pages and highlighted passages. In our team meetings, we have included readings of these paragraphs, and they always served as the basis for thought-provoking and interesting team discussions. We have often thought that many of these paragraphs could easily have been expanded into chapters because there is clearly so much behind each of these ideas. We express our deepest gratitude to Marsha and hope that this ­volume, meant to be a readily accessible guide to clinicians and patients, expresses our desire to remain true to the spirit of the DBT model.

Beth would also especially like to thank her husband, Amir Shaviv, and son, Natan, for their loving support, enthusiastic encouragement, and their patience and understanding during the writing process, and Barbara would like to express her appreciation to her children, Melissa and Thomas, who always provide balance, support, and great joy, and to her late husband, Michael, who continues to be a source of inspiration.

Chapter 1

Introduction

For whom is this book intended?

In this volume, we hope to provide (a) an accessible, easy-to-understand primer for ­clinicians wanting to adopt Dialectical Behavior Therapy (DBT) as their treatment approach; (b) guidance, tools, and, more importantly, a way of thinking about treating borderline personality disorder (BPD) for clinicians who want to incorporate aspects of DBT principles and techniques into their practice but do not wish to adopt the entire model and (c) an introduction to DBT for the patients and their families and friends who want to learn the basics of this treatment approach. While becoming proficient in DBT requires intensive training, supervision, and feedback on therapeutic performance, there are many DBT principles, strategies, and techniques that can be understood and utilized by clinicians using other therapeutic modalities and models. For example, psychopharmacologists who have knowledge of DBT may better understand and manage their BPD patients’ medication requests and suicidal behavior. Furthermore, their clinical approach to patients with BPD may be enhanced by a better understanding of the importance of validation (a central DBT concept) with this population. While we recommend utilizing DBT as developed since that is what has the empirical support behind it, we recognize that not all clinicians will choose to do so. And we believe that, whatever the treatment approach, clinicians can benefit from incorporating aspects of DBT into their practice. Thus, the primary purpose of this book is to provide a clinically oriented, user-friendly guide to understanding and utilizing the ­principles and techniques of DBT.

The challenge of treating Borderline Personality Disorder and disorders of emotion dysregulation

Individuals with BPD and disorders in which there is pervasive emotion dysregulation generally present many challenges in psychotherapeutic treatment for even the most trained and dedicated clinicians. The BPD diagnosis is one of the most stigmatized of the mental illnesses, notorious for treatment resistance [1], high treatment utilization [2], high dropout rates , high comorbidity with other diagnoses [3], and recurrent suicidal and non-suicidal self-injurious (NSSI) behaviors [1]. Therapist burnout with this population is common. The severity and chronicity of BPD symptoms cause individuals with the disorder and those involved with them a great deal of anguish and frustration. The clinicians treating those with the disorder are not immune to this sense of frustration and, consequently, act in ways that they find uncharacteristic and, ultimately, not helpful, despite initial and ­perhaps long-sustained intentions to help. Why?