Rent 9780898621839 | Cognitive-Behavioral Treatment of Borderline Personality Disorder | Marsha M. Linehan, PhD, ABPP @knetbooks.com

Summary Table of Contents Author Biography

The two volumes in Dr. Linehan''s program cover the full range of borderline conditions. In her far-reaching new text, COGNITIVE-BEHAVIORAL TREATMENT OF BORDERLINE PERSONALITY DISORDER, Linehan describes in persuasive clinical detail the development and implementation of DBT. Because the behavioral skills training element of her program is so critical for working with borderline individuals, the companion SKILLS TRAINING MANUAL presents session-by-session guidelines for imparting and integrating into the patient''s repertoire four key psychosoc... MOREial skills notably absent in borderlines. A previous version of this manual has been successfully used in psychiatric hospitals, community health centers, and other settings. Together, the two pieces add up to new promise for respectful, sustained, effective work with this growing patient group. COGNITIVE-BEHAVIORAL TREATMENT OF BORDERLINE PERSONALITY DISORDER Marsha M. Linehan For the average clinician, clinic, or inpatient facility, individuals with borderline personality disorder often represent the most difficult and insoluble cases. Now, set against the backdrop of intense patient pain, and intense frustration (and often anger) on the part of therapists enlisted to help, comes unexpected new hope in the form of Marsha Linehan''s integrative, biosocial approach to borderlines, which she calls Dialectical Behavior Therapy. At once firmly rooted in cognitive-behavioral strategies for change and specifically targeted at the cluster of behavioral problems of most immediate concern (the suicidal and other therapy-interfering behaviors), this is the only approach to date which has been empirically verified in controlled clinical studies. And it is the only approach which simultaneously addresses the BPD''s profound skills deficits, characteristic dichotomous thought and behavior patterns, and extreme relationship needs. A clinical innovator, Linehan begins by positing a biosocial framework which brilliantly links what is well known about the borderline''s difficulties regulating emotions to the environmental milieu in which such emotional sensitivity and inability to modulate emotional responses would be both a likely outcome and, unfortunately, a "poor fit." What she arrives at is the construct of "invalidating environments" (the limiting case of which is the home in which sexual abuse is normalized and the child learns to not feel what she feels). "An invalidating environment," Linehan writes, "is one in which communication of private experiences is met by erratic, inappropriate, and extreme responses....The experience of painful emotions, as well as the factors that to the emotional person seem causally related to the emotional distress, are disregarded." Building on her cogent analysis, Linehan has fashioned a flexible, compassionate, and comprehensive approach to treatment of BPDs rooted in nonjudgmental acceptance of where patients are at the moment, within a context of trying to teach them to change. Touching on everything from how to decrease post-traumatic stress-related behaviors to how to handle the between-session phone call, from how to begin and end sessions to how to avert a suicide, Linehan''s outstanding new text provides genuine hope for a population that has until now challenged clinicians of every orientation. A Companion Manual Includes Client Handouts That May Be Readily Photocopied! SKILLS TRAINING MANUAL FOR TREATING BORDERLINE PERSONALITY DISORDER Marsha M. Linehan This hands-on companion presents in session-by-session replicable detail the clinical strategies designed to remediate four specific skills areas arrested in the BPD patient: "mindfulnesss" (balancing emotion and rationality to achieve wisdom), interpersonal effectiveness, emotion, regulation, and distress tolerance. A vital component in Dr. Linehan''s comprehensive treatment program, the manual also features practical pointers on when to use the other treatment strategies described in COGNITIVE-BEHAVIORAL TREATMENT OF BORDERLINE PERSONALITY DISORDER. Currently employed in a variety of inpatient and outpatient settings, this user-friendly manual provides everything a clinician needs. It includes ''lecture notes,'''' discussion questions, exercises, and practical advice on what problems are likely to arise and how best to deal with them. Published in a large 8 1/2" x 11" format, it also features an array of client handouts that may be readily photocopied. Originally written for skills training groups, the manual can also be used with individual patients. Note About Photocopy Rights: The publisher grants book purchasers permission to reproduce handouts and forms in this book for professional use with their clients.

This volume is the authoritative presentation of Dialectical Behavior Therapy (DBT), Linehan's comprehensive, integrated approach to treating individuals with borderline personality disorder. DBT--which has since been adapted for other difficult-to-treat disorders involving emotion dysregulation--combines cognitive and behavioral strategies with elements of psychodynamic, strategic, and other modalities. Delineated are specific strategies for contingency management, exposure, cognitive modification, and skills training. In-depth descriptions of skills training procedures are provided in the companion manual. Core emotion regulation skills are also taught directly to clients in Linehan's skills training videos.

... MORE

PART I. THEORY AND CONCEPTS

Borderline Personality Disorder: Concepts, Controversies, and Definitions

(25)

The Concept of Borderline Personality Disorder

(8)

The Concept of Parasuicidal Behaviors

(2)

The Overlap Between Borderline Personality Disorder and Parasuicidal Behavior

(4)

Therapy for Borderline Personality Disorder: A Preview

(6)

Concluding Comments

(1)

Notes

(2)

Dialectical and Biosocial Underpinnings of Treatment

(38)

Dialectics

(7)

Borderline Personality Disorder as Dialectical Failure

(2)

Case Conceptualization: A Dialectical Cognitive--Behavioral Approach

(5)

Biosocial Theory: A Dialectical Theory of Borderline Personality Disorder Development

(20)

Implications of the Biosocial Theory for Therapy with Borderline Patients

(2)

Concluding Comments

(1)

Notes

(1)

Behavioral Patterns: Dialectical Dilemmas in the Treatment of Borderline Patients

(31)

Emotional Vulnerability versus Self-Invalidation

(11)

Active Passivity versus Apparent Competence

(7)

Unrelenting Crises versus Inhibited Grieving

(8)

Concluding Comments

(1)

Notes

(3)

PART II. TREATMENT OVERVIEW AND GOALS

Overview of Treatment: Targets, Strategies, and Assumptions in a Nutshell

(23)

Crucial Steps in Treatment

(4)

Setting the Stage: Getting the Patient's Attention

(1)

Staying Dialectical

(1)

Applying Core Strategies: Validation and Problem Solving

(1)

Balancing Interpersonal Communication Styles

100

(1)

Combining Consultation-to-the-Patient Strategies with Interventions in the Environment

101

(1)

Treating the Therapist

101

(1)

Modes of Treatment

101

(5)

Individual Outpatient Psychotherapy

102

(1)

Skills Training

103

(1)

Supportive Process Group Therapy

103

(1)

Telephone Consultation

104

(1)

Case Consultation Meetings for Therapists

104

(1)

Ancillary Treatments

105

(1)

Assumptions About Borderline Patients and Therapy

106

(2)

Patients Are Doing the Best They Can

106

(1)

Patients Want to Improve

106

(1)

Patients Need to Do Better, Try Harder, and Be More Motivated to Change

106

(1)

Patients May Not Have Caused All of Their Own Problems, but They Have to Solve Them Anyway

107

(1)

The Lives of Suicidal, Borderline Individuals Are Unbearable as They Are Currently Being Lived

107

(1)

Patients Must Learn New Behaviors in All Relevant Contexts

107

(1)

Patients Cannot Fail in Therapy

108

(1)

Therapists Treating Borderline Patients Need Support

108

(1)

Therapist Characteristics and Skills

108

(4)

Stance of Acceptance versus Change

109

(1)

Stance of Unwavering Centeredness versus Compassionate Flexibility

110

(1)

Stance of Nurturing versus Benevolent Demanding

111

(1)

Agreements of Patients and Therapists

112

(5)

Patient Agreements

112

(3)

Therapist Agreements

115

(2)

Therapist Consultation Agreements

117

(2)

Dialectical Agreement

117

(1)

Consultation-to-the-Patient Agreement

117

(1)

Consistency Agreement

117

(1)

Observing-Limits Agreement

118

(1)

Phenomenological Empathy Agreement

118

(1)

Fallibility Agreement

118

(1)

Concluding Comments

119

(1)

Note

119

(1)

Behavioral Targets in Treatment: Behaviors to Increase and Decrease

120

(45)

The Overall Goal: Increasing Dialectical Behavior Patterns

120

(4)

Dialectical Thinking

120

(3)

Dialectical Thinking and Cognitive Therapy

123

(1)

Dialectical Behavior Patterns: Balanced Lifestyle

124

(1)

Primary Behavioral Targets

124

(36)

Decreasing Suicidal Behaviors

124

(5)

Decreasing Therapy-Interfering Behaviors

129

(12)

Decreasing Behaviors That Interfere with Quality of Life

141

(2)

Increasing Behavioral Skills

143

(12)

Decreasing Behaviors Related to Posttraumatic Stress

155

(5)

Increasing Respect for Self

160

(1)

Secondary Behavioral Targets

160

(4)

Increasing Emotion Modulation; Decreasing Emotional Reactivity

161

(1)

Increasing Self-Validation; Decreasing Self-Invalidation

161

(1)

Increasing Realistic Decision Making and Judgment; Decreasing Crisis-Generating Behaviors

162

(1)

Increasing Emotional Experiencing; Decreasing Inhibited Grieving

162

(1)

Increasing Active Problem Solving; Decreasing Active-Passivity Behaviors

162

(1)

Increasing Accurate Communication of Emotions and Competencies; Decreasing Mood Dependency of Behavior

163

(1)

Concluding Comments

164

(1)

Note

164

(1)

Structuring Treatment Around Target Behaviors: Who Treats What and When

165

(34)

The General Theme: Targeting Dialectical Behaviors

166

(1)

The Hierarchy of Primary Targets

166

(2)

Treatment Targets and Session Agenda

167

(1)

Treatment Targets and Modes of Therapy

167

(1)

The Primary Therapist and Responsibility for Meeting Targets

168

(1)

Progress Toward Targets Over Time

168

(5)

Pretreatment Stage: Orientation and Commitment

169

(1)

Stage 1: Attaining Basic Capacities

169

(1)

Stage 2: Reducing Posttraumatic Stress

170

(2)

Stage 3: Increasing Self-Respect and Achieving Individual Goals

172

(1)

Setting Priorities within Target Classes in Outpatient Individual Therapy

173

(13)

Decreasing Suicidal Behaviors

174

(1)

Decreasing Therapy-Interfering Behaviors

175

(2)

Decreasing Quality-of-Life-Interfering Behaviors

177

(1)

Increasing Behavioral Skills

178

(1)

Reducing Posttraumatic Stress

179

(1)

Increasing Self-Respect and Achieving Individual Goals

179

(1)

Using Target Priorities to Organize Sessions

180

(1)

Patient and Therapist Resistance to Discussing Target Behaviors

181

(3)

Individual Therapy Targets and Diary Cards

184

(2)

Skills Training: Hierarchy of Targets

186

(1)

Supportive Process Groups: Hierarchy of Targets

187

(1)

Telephone Calls: Hierarchy of Targets

188

(2)

Calls to the Primary Therapist

188

(2)

Calls to Skills Trainers and Other Therapists

190

(1)

Target Behaviors and Session Focus: Who Is in Control?

190

(1)

Modification of Target Hierarchies in Other Settings

191

(3)

Responsibility for Decreasing Suicidal Behaviors

192

(1)

Responsibility for Other Targets

193

(1)

Specifying Targets for Other Modes of Treatment

193

(1)

Turf Conflicts with Respect to Target Responsibilities

194

(1)

Concluding Comments

195

(4)

PART III. BASIC TREATMENT STRATEGIES

Dialectical Treatment Strategies

199

(22)

Defining Dialectical Strategies

201

(1)

Balancing Treatment Strategies: Dialectics of the Therapeutic Relationship

202

(2)

Teaching Dialectical Behavior Patterns

204

(1)

Specific Dialectical Strategies

205

(14)

Entering the Paradox

205

(4)

The Use of Metaphor

209

(3)

The Devil's Advocate Technique

212

(1)

Extending

213

(1)

Activating ``Wise Mind''

214

(2)

Making Lemonade Out of Lemons

216

(1)

Allowing Natural Change

217

(1)

Dialectical Assessment

218

(1)

Concluding Comments

219

(1)

Notes

220

(1)

Core Strategies: Part I. Validation

221

(29)

Defining Validation

222

(3)

Why Validate?

225

(1)

Emotional Validation Strategies

226

(9)

Providing Opportunities for Emotional Expression

228

(2)

Teaching Emotion Observation and Labeling Skills

230

(1)

Reading Emotions

231

(3)

Communicating the Validity of Emotions

234

(1)

Behavioral Validation Strategies

235

(4)

Teaching Behavior Observation and Labeling Skills

235

(2)

Identifying the ``Should''

237

(1)

Countering the ``Should''

237

(1)

Accepting the ``Should''

238

(1)

Moving to Disappointment

239

(1)

Cognitive Validation Strategies

239

(3)

Eliciting and Reflecting Thoughts and Assumptions

240

(1)

Discriminating Facts from Interpretations

240

(1)

Finding the ``Kernel of Truth''

241

(1)

Acknowledging ``Wise Mind''

242

(1)

Respecting Differing Values

242

(1)

Cheerleading Strategies

242

(7)

Assuming the Best

244

(1)

Providing Encouragement

245

(1)

Focusing on the Patient's Capabilities

246

(1)

Contradicting/Modulating External Criticism

247

(1)

Providing Praise and Reassurance

247

(1)

Being Realistic, but Dealing Directly with Fears of Insincerity

248

(1)

Staying Near

249

(1)

Concluding Comments

249

(1)

Core Strategies: Part II. Problem Solving

250

(42)

Levels of Problem Solving

250

(1)

First Level

250

(1)

Second Level

250

(1)

Third Level

251

(1)

Mood and Problem Solving

251

(2)

Overview of Problem-Solving Strategies

253

(1)

Behavioral Analysis Strategies

254

(11)

Defining the Problem Behavior

255

(3)

Conducting a Chain Analysis

258

(6)

Generating Hypotheses About Factors Controlling Behavior

264

(1)

Insight (Interpretation) Strategies

265

(7)

What and How to Interpret: Guidelines for Insight

266

(4)

Highlighting

270

(1)

Observing and Describing Recurrent Patterns

271

(1)

Commenting on Implications of Behavior

271

(1)

Assessing Difficulties in Accepting or Rejecting Hypotheses

271

(1)

Didactic Strategies

272

(3)

Providing Information

273

(1)

Giving Reading Materials

274

(1)

Giving Information to Family Members

274

(1)

Solution Analysis Strategies

275

(6)

Identifying Goals, Needs, and Desires

276

(2)

Generating Solutions

278

(1)

Evaluating Solutions

279

(2)

Choosing a Solution to Implement

281

(1)

Troubleshooting the Solution

281

(1)

Orienting Strategies

281

(3)

Providing Role Induction

282

(1)

Rehearsing New Expectations

283

(1)

Commitment Strategies

284

(7)

Levels of Commitment

284

(1)

Commitment and Recommitment

285

(1)

The Need for Flexibility

286

(1)

Selling Commitment: Evaluating the Pros and Cons

286

(1)

Playing the Devil's Advocate

286

(2)

``Foot-in-the-Door'' and ``Door-in-the-Face'' Techniques

288

(1)

Connecting Present Commitments to Prior Commitments

289

(1)

Highlighting Freedom to Choose and Absence of Alternatives

289

(1)

Using Principles of Shaping

290

(1)

Generating Hope: Cheerleading

290

(1)

Agreeing on Homework

291

(1)

Concluding Comments

291

(1)

Change Procedures: Part I. Contingency Procedures (Managing Contingencies and Observing Limits)

292

(37)

The Rationale for Contingency Procedures

294

(3)

The Distinction Between Managing Contingencies and Observing Limits

295

(1)

The Therapeutic Relationship as Contingency

296

(1)

Contingency Management Procedures

297

(22)

Orienting to Contingency Management: Task Overview

297

(4)

Reinforcing Target-Relevant Adaptive Behaviors

301

(1)

Extinguishing Target-Relevant Maladaptive Behaviors

302

(4)

Using Aversive Consequences ... with Care

306

(8)

Determining the Potency of Consequences

314

(3)

Using natural Over Arbitrary Consequences

317

(1)

Principles of Shaping

318

(1)

Observing-Limits Procedures

319

(8)

Rationale for Observing Limits

320

(1)

Natural versus Arbitrary Limits

321

(1)

Monitoring Limits

322

(1)

Being Honest About Limits

323

(2)

Temporarily Extending Limits when Needed

325

(1)

Being Consistently Firm

325

(1)

Combining Soothing, Validating, and Problem Solving with Observing Limits

326

(1)

Difficult Areas for Observing Limits with Borderline Patients

326

(1)

Concluding Comments

327

(2)

Change Procedures: Part II. Skills Training, Exposure, Cognitive Modification

329

(42)

Skills Training Procedures

329

(14)

Orienting and Committing to Skills Training: Task Overview

330

(1)

Skill Acquisition Procedures

331

(3)

Skill Strengthening Procedures

334

(3)

Skill Generalization Procedures

337

(6)

Exposure-Based Procedures

343

(15)

Orienting and Commitment to Exposure: Task Overview

345

(2)

Providing Nonreinforced Exposure

347

(7)

Blocking Action Tendencies Associated with Problem Emotions

354

(2)

Blocking Expressive Tendencies Associated with Problem Emotions

356

(1)

Enhancing Control Over Aversive Events

357

(1)

Structured Exposure Procedures

358

(1)

Cognitive Modification Procedures

358

(12)

Orienting to Cognitive Modification Procedures

360

(1)

Contingency Clarification Procedures

361

(3)

Cognitive Restructuring Procedures

364

(6)

Concluding Comments

370

(1)

Notes

370

(1)

Stylistic Strategies: Balancing Communication

371

(28)

Reciprocal Communication Strategies

372

(21)

Power and Psychotherapy: Who Makes the Rules?

372

(1)

Responsiveness

373

(3)

Self-Disclosure

376

(7)

Warm Engagement

383

(5)

Genuineness

388

(2)

The Need for Therapist Invulnerability

390

(3)

Irreverent Communication Strategies

393

(4)

Dialectical Strategies and Irreverence

393

(1)

Reframing in an Unorthodox Manner

394

(1)

Plunging in Where Angels Fear to Tread

395

(1)

Using a Confrontational Tone

396

(1)

Calling the Patient's Bluff

396

(1)

Oscillating Intensity and Using Silence

396

(1)

Expressing Omnipotence and Impotence

397

(1)

Concluding Comments

397

(1)

Note

398

(1)

Case Management Strategies: Interacting with the Community

399

(38)

Environmental Intervention Strategies

401

(5)

Case Management and Observing Limits

401

(1)

Conditions Mandating Environmental Intervention

402

(2)

Providing Information Independently of the Patient

404

(1)

Patient Advocacy

404

(1)

Entering the Patient's Environment to Give Her Assistance

405

(1)

Consultation-to-the-Patient Strategies

406

(17)

Rationale and Spirit of Consultation to the Patient

407

(1)

The ``Treatment Team'' versus ``Everyone Else''

408

(1)

Orienting the Patient and the Network to the Approach

409

(2)

Consultation to the Patient About How to Manage Other Professionals

411

(8)

Consultation to the Patient About How to Handle Family and Friends

419

(2)

Arguments Against the Consultation Approach

421

(2)

Therapist Supervision/Consultation Strategies

423

(11)

The Need for Supervision/Consultation

424

(2)

Meeting to Confer on Treatment

426

(2)

Keeping Supervision/Consultation Agreements

428

(1)

Cheerleading

429

(1)

Providing Dialectical Balance

430

(1)

Working Out Problems of ``Staff Splitting''

431

(2)

Dealing with Unethical or Destructive Therapist Behavior

433

(1)

Keeping Information Confidential

434

(1)

Concluding Comments

434

(3)

PART IV. STRATEGIES FOR SPECIFIC TASKS

Structural Strategies

437

(25)

Contracting Strategies: Starting Treatment

438

(10)

Conducting a Diagnostic Assessment

438

(2)

Presenting the Biosocial Theory of Borderline Behavior

440

(2)

Orienting the Patient to Treatment

442

(1)

Orienting the Network to Treatment

443

(1)

Reviewing Treatment Agreements and Limits

444

(1)

Committing to Therapy

444

(2)

Conducting Analyses of Major Target Behaviors

446

(1)

Beginning to Develop the Therapeutic Relationship

446

(1)

Caveats in the Real World

447

(1)

Session-Beginning Strategies

448

(2)

Greeting the Patient

449

(1)

Recognizing the Patient's Current Emotional State

449

(1)

Repairing the Relationship

450

(1)

Targeting Strategies

450

(4)

Reviewing Target Behaviors Since the Last Session

452

(1)

Using Target Priorities to Organize Sessions

453

(1)

Attending to Stages of Therapy

453

(1)

Checking Progress in Other Modes of Therapy

453

(1)

Session-Ending Strategies

454

(3)

Providing Sufficient Time for Closure

454

(1)

Agreeing on Homework for the Coming Week

454

(1)

Summarizing the Session

455

(1)

Giving the Patient a Tape of the Session

455

(1)

Cheerleading

456

(1)

Soothing and Reassuring the Patient

456

(1)

Troubleshooting

457

(1)

Developing Ending Rituals

457

(1)

Terminating Strategies

457

(4)

Beginning Discussion of Terminating: Tapering off Sessions

457

(1)

Generalizing Interpersonal Reliance to the Social Network

458

(1)

Actively Planning for Termination

459

(1)

Making Appropriate Referrals

460

(1)

Concluding Comments

461

(1)

Special Treatment Strategies

462

(62)

Crisis Strategies

462

(6)

Paying Attention to Affect Rather Than Content

463

(1)

Exploring the Problem Now

463

(2)

Focusing on Problem Solving

465

(2)

Focusing on Affect Tolerance

467

(1)

Obtaining Commitment to a Plan of Action

468

(1)

Assessing Suicide Potential

468

(1)

Anticipating a Recurrence of the Crisis Response

468

(1)

Suicidal Behavior Strategies

468

(27)

The Therapeutic Task

469

(1)

Previous Suicidal Behaviors: Protocol for the Primary Therapist

469

(7)

Threats of Imminent Suicide or Parasuicide: Protocol for the Primary Therapist

476

(14)

Ongoing Parasuicidal Act: Protocol for the Primary Therapist

490

(2)

Suicidal Behaviors: Protocol for Collateral Therapists

492

(1)

Principles of Risk Management with Suicidal Patients

493

(2)

Therapy-Interfering Behavior Strategies

495

(2)

Defining the Interfering Behavior

495

(1)

Conducting a Chain Analysis of the Behavior

495

(1)

Adopting a Problem-Solving Plan

496

(1)

Responding to the Patient Who Refuses to Modify Interfering Behavior

497

(1)

Telephone Strategies

497

(7)

Accepting Patient-Initiated Phone Calls Under Certain Conditions

498

(4)

Scheduling Patient-Initiated Phone Calls

502

(1)

Initiating Therapist Phone Contacts

502

(1)

Giving Feedback About Phone Call Behavior During Sessions

502

(1)

Therapist Availability and Management of Suicidal Risk

503

(1)

Ancillary Treatment Strategies

504

(10)

Recommending Ancillary Treatment When Needed

504

(1)

Recommending Outside Consultation for the Patient

505

(2)

Medication Protocol

507

(3)

Hospital Protocol

510

(4)

Relationship Strategies

514

(5)

Relationship Acceptance

515

(2)

Relationship Problem Solving

517

(2)

Relationship Generalization

519

(1)

Concluding Comments

519

(1)

Scale Points for Lethality Assessment

519

(4)

Note

523

(1)

Appendix: Suggested Reading

524

(3)

References

527

(20)

Index

547

Marsha M. Linehan, PhD, is a professor of psychology and an adjunct professor of psychiatry and behavioral sciences at the University of Washington. She is also Principal Investigator and Director of the Suicidal Behaviors Research Clinic, a federally financed research program for evaluating treatments of suicidal behaviors. She has an on-going clinical practice and is active in clinical consultation, supervision, and training of mental health professionals in the United States and Europe.

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