C2<Jc :z_ 1.

;,,f,-:

i Tools for Tough . Circumstances

fj
1
.,
If you've picked .up this book, it's likely that the grim statistics on treat-
ment failure come as no surprise to you. As -U:terapists, we can ali recall
cases in which, despite our best efforts, our usual ways of working failed
our clients. When clients come to us prone to emotion dysregulation, with
multiple, serious, chronic problems, and with a history of failed therapy
relationships, we know the oddsare against us. . .

"It doesn't matter what {do~ nthin'g changes_;,

Marie is i~ her mid-20s. She comes to her third session of individual
therapy agitated and tells her therapist that she has "completely lost it" .
at work. She's going to be fired, and that means she will be evicted when
she can't pay .the rent. When the therapist asks what happened, Marie
angrily jerks her body, kicking the coffee table ir; the process. It's not
clear if she meant to l<ick the table or if it was an accident, but she flushes
red from head to toe, becomes mute, and curls up in the chair. She begins
to bang her head against the armrest. This derails any help the therapist
might have offered regarding the .crisis at work, and the way she acts
in: therapy creates a new situation about which Marie w~ll feel shame.
As the therapist gets fytarie to stop banging her head, Marie says qui-
etly, '1 just nee d to end this." Given Marie's history of near-lethal suicide
attempts, the therapist now must manage to assess imminent suicide risk
with a mostly ~ute, overwhelmed, and soon-to-be-homeless client.

If you met Mrk at a party, you'd assllll1e he worked in a funky, su~cess-

ful high-tech firm. You'd never guess he barely scr~pes by on temp work
as a software prograrnmer. His life has become more and more restricted

--
 .t. DOING DIALECTICAL BEHAVIOR THERAPY Tools for Tough Circumstances
t,
by anxiet.y and brief manic episodes that are followed by crashes into . . al reactions. This book presents ~ow DB'~ is can-
as their own emohon t' f the individual therapist, illustratmg why,
self~loat~g. For _mo~ths, he stays trashed with marijuana, alcoh~l, and
ant1-anx1ety med1Cat1on. He sleeps 18 hours a day, leaving his house only ducted from ~et~:::~;~ ~ols to achieve therapeuti~ p rogress. .
1
to get food. After 15 years of.working wth many therapists, he's not sure when, and ho that protocols and procedur es m an em_ergency
whether to blame them or hunself th at his life remains miserable. . In the same _way d t omprehensive DBT is essential far clients
11 w coordmate ac 10n, e
room a .. . ik M . In cases like Mark's, you may not need the
!r clien ts l~e Mari~ and Mark, exquisite vulnerability to emotions
th suic1dal cnses I e ane.
; 1model yet DBT's basic theories,_hierarchy of prioriti~s, adndh_tr~at7nt
1
and intense em_o~10nal pam defeat a quality life. Unrelenting misery makes . l t For this reason I have orgamze t 15 oo to
thought~ of suicide or nonsuicidal self-injury among the few things that
t ateg1es remam re evan .
s rl 1 . . s n both sets of circum stan ces. You can adopt on y t ose
, 1 h :1
offer rehef. Repeated treatment failures make therapy itself evoke intense he p c 1n1c1an 1 1 t hil
t likely to be helpful to you and your e 1en s .w e
hopelessness. elements of DBT m Os . k f DBT 1
al so comrng to understand the full therapeutlc fram.ewor . o d as a
T~eatment decisions we make in such circumstances are extremely package so that you ~an structure the treatment environment an your
com_phcated. When we focus on how the client needs to change, the client clinical decision making when needed. . . 1
p_anics because s uch efforts have often failed in the past. It also triggers This book recognizes that the science on wh1ch DBT draws is con-
e1ther anger or shame at the implication that' change .is possible: you, the stantly evolving: new data from research on the dev:lopmen~ a.nd evalu- 1

therapist, don't have a clue about h ow impossible change actually is, or else
' ..
1 you believe, as others have, that the problem is the client's poor motivation
or personality flaws. When, in response, we drop a change orientation and
1 , :
instead focus on acceptin g v ulnerabUity and limitations, this too sets off
panic in the client, especially despair that things will never change. Out
of desperation, your client may reject the help thaJ you offer and demand
help that you cannot give. Suicide attempts, threats of s uicide, and the
'.
anger directed at us are stressful. Our own emotions, confusion, or skills
deficits complicate m atters further, leading us to ex;pect change beyond
the client's capability and to fail to offer sufficient.warmth, flexibility, or
resourcefulness when needed. The non-s top effort of .striking the right
balance-accepting the client's true y ulnerability while also insisting on
change-wears us down. It might as easily have been us, as therapists, say-
ing, "I can't take this. It doe~n} :11~tt~r ~ttat I d ?~not!'i!:~ changes."
Dialectical behavior therapy; or DBT (Linehan, 1993a), evolved.:to _h elp
therapists and clients irt exactly. thes'e.circumst,ces, and a grq~g ntpri-
ber of randomized clinical trials ~upport its 'efficcy\ see review by Lynch,
Trost, Salsman, & Linehan, 2006). When clients have complicat~d, severe,
chronic problems and multiple treatment providers, when rrsei-y makes
suicide seem the client's only option, _DBT helps therapists find order amid
. ';.} "
ation of DBT as well as the psychopathology and disorders_ it 1s used to
treat must be continually integrated in a rder to offer our pahents the best
possible clinical:care. Linehan (1993a) developed DBT first as a tr~atment
far chronic suicida! behavior, and then subsequently for border line per-
sonality disorder (BPD). H owever, the very diagnosis of BPD has under-
1
gone extensive revision and will likely continue to do so. As new data
emerge, we can expect the components of DBT to change as well ~s the ~
kinds of clients for whom it is indicated. To date, far example, published
randomized controlled trials conducted by different research teams sup- ~
port the efficacy of QBT across a wide variety of behavioral problems,
including suicide attempts and self-injurious behaviors (Koons et al., 2001;
Li.nehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Heard, &
Armstrong, 1993; Linehan, Comtois, Murray, et al., 2006; van den Bosch,
Kqeter, Stijnen, Verheul, & van den Brink, 2005; Verheul et al, 2003), sub-
stance abuse (Linehan et al., 1999, 2002), bulimia (Safer, Telch, & Agras,
2001), binge eating (Telch, Agras, & Linehan, 2001), and depression in the
elderly (Lynch, Morse, Mendelson, & Robins, 2003; Lynch et al, 2007). This
makes it important to realize that DBT is not only indicated for chroni-
cally suicidal behav ior and BPD. PBT's '.set Qf,p~ gpls ad prtocols CaJ:l
be applied
-
more
broadly
~ ,.
foa:angfcpgni_tiye.:behavioral
...., ..., .... ,. a. - _..,..., - ~-4and.other, theo-
W' -

:: chaos. As a comprehensive outpatient t:re_at__i;nent package;':DBTsfiucfrs
the.tre_a tment environment,4i,to. weekly_individual thefapy,:we'eklfgiup
sk$ training, telephone .coaching, and a peer' consulttiii.'.tamof.Q~'F
therapists. Within that environment, Off[, consists of a hierarchy of treat-
ment priorities and core strategies for addressing those priorities. These
features offer systematic guidelines for clinical decision making that help
therapists treat life-threatening and therapy-interfering behaviors as well
r~tically.compatj.ble' strategies,to tieat disorders characterized by perva-:
"t. '":...
~ . -. . . ti
siveemotion dysregulation. An rmportant aim of this book, therefore, lS
to make it easy for you to flexibly use DBT's comprehensive package r its
components to keep up to date with the latest research findings. .
A first step in helping you use DBT flexibly is understanding the core
problem of clients like Marie and Mark: pervasive emotion dysregula-
tion. Llnehan's biosocial theory, described next in this chapter, expl ains

1 :

i '
 4

DOING DIALECTICAL BEHAVIOR THERAPY Tools for Tough Circumscances 5

how th
is core problem can l -
problems. DBTs treatment ead to such diverse and difficult secondar because these behaviors function to regulate emotions or are a conse-
of pervasive emotion dysregc~:Pt_onents f~llo_w from an understandingy quence of failed emotion regulation.
are dese b d ion and Its 1m t Th
n e m the second half of th . pac . ese components
way that client problems are ranke is ch~pter. Key among them is the Biosocial T he ory: T he lm pact of Vulnerable Biology
a reasonable quality of li'e Th h. d accordmg to the threat they pose to and lnvalidat ing Social Environment
1
gu t.d es case formulation (cave
' 1s 1erarch f tr
d. . y o eatment goals and targets
cal decision making The th re_ m deta1l Chapter 2) and in-session c11n1- Vuln erable Bio/ogy and lt s Conseque nces
. erap1st uses t t
. pnonty over the _less important Thre J o g1ve the most important tasks Linehan hypothesized that three bicilogically based character~sti~~ !'.:~n-~
a re then used to move the .
c 1ent toward the
e sets of core treatment strategies
. tribute to an individual's vulnerability. First, p~p~f :pr,~e "'.!o e~otimt
egy sets-behavioral chan e st t . . ra~eutic goals. The core strat- a.y'i?egu1atlori. react im~lii:ftly: a:no.:a~:~ow';'t lireshtilds(highsensitiv:ityf
cal strategies-are first intg d ra ~g_1es, ~al1dahon strategies, and dialecti- Second, they e.xperieni:"1' f.;cl. .xpre~iS<emo tio&!_teajfelyJ!!igh feadivity),
detail in Ch pters 3 4 a dr5o uce ti:1 th1s chapter and then described in f1.djhis h;gh_arousal dysregulates;.f:Ognitive.:pr9ces~e~ :t~>.<?! Third, they
' , n , respechvely Ch t 6 b .
o f strategies together i"llust t h . ap er nngs the three sets expriez:c_~. ~,!011g:!~ting. ~rousal :.(slq~..r~~~ _tqJ :.~t_lipe).. In fact, the \
' ra mg ow the d .
case formulation and h . h y are use m the context of the data do suggest that those who meet the criteria for BPD experience more
ierarc y of treatrne t ta .
emphasizes the crucia l im t n rgets. Fmally, Chapter 7 frequent, more intense, and longer-lasting aversive states (Stiglmayr et al.,
s ultation team-a requirerJ::\a7e and worki.ngs of the DBT peer con- . 2005) and that biological vulnerability m.y contribute to difficulties regu-
team is a community of thera n_ ~ tmprehensive DBT. The consultation
a lso applying DBT to themsef1s s ;:atmg a community of p atients while
... I '
. lating emotion (e.g., Juengling et al., 2003; Ebner-Priemer et al., 2005).
Ccinsider' th-imp~ct of sach"!bic5logic.Lv.uilieraqilify.:Dilii.c.iilty:reg,-t .
1

and provides emotiona1 supp;~s~eedee~e~m strengthens therapists' skills 1 i:-fa'.fmg e'incitiiC:{e ns:cf.ficiilt:t reglating"' in:osf fe),s:Qf. ope:~Jf most
when clients face tremendous s ff . o meet t_h e challenges that arise ' of what we do and w ho we are depends on mood stability and adequate
ing DBT starts with unders tanc.~ ge~tg and emot1onal pain. Understand- emotion regulation. The same action r.ay feel easy or hard depending on
dysregulation. n is core problem-pervasive emotion our,mood. Take' the common experience of sch moozing with strangers
at a cocktail party. In . great mood 1 you breeze right up to chat w ith the
most i.nteresti.ng person in the room; in a vulnerable, insecure mood, you
cli.ng to the wall, barely making eye contact. You put off a dreadedtask
THE CORE PROBLEM for months. La ter, in the righ t mood- voila-you tackle it in an af.temoon.
OF PERVASIVE EMOTION DYSREGULATION Those of us who can regulate emotion without much effort take this abil-
Linehan exp1a ed th 1 :. - -- ity for gran ted. We occasionally have bouts of m ood-dependent behavior,
. m e eho ogy and mamtenanceof BPD 1:n ii'~~ .t but for the most part we m udd le through.
~eory of emotion ~ysregul_a,.ticiti. DBT has since be~n ~d;pt:(for: s::s~:~:; Imagine, however, that due t biologi<::al vulnerability your emotions
d1sorders and patient populations (~.g. substa b b . . instead vary wildly. You can't predict what mood you'll be in. If your
. a1 . , nce a use ulurua and
anttsoc1 and other personality disorders) but th b" ' . 1 th ' behavior varies wildly at social gatherings based on your mood, are you
d ( , e 10soc1a eory has
re~ame c~tra1. see Crowell, Beauchaine, & Linehan, 2009 f . a shy person or an outgoing person? If you can manage responsibili.ties
rev1ew) It pro s . th t . . ...... -- . - .. . ' or a recent
. po es. a pervas1ve emoticiri d;y:sreg:lati&~- - . ~-I "- ili\) when you're "together enough" em otionally, <loes that make you irrespon-
b. ti
E t d
f lri b b" , :.o--. _ -
gu1 . . h .. . ... . . . .
-
_com. ma on o vu era Je 10Iogy nd.myalidatingsOcliiF""""'..,. ~-=-.:::::-: ~
. .. --~ -
mo 10n ysre . ~tion 1s t e.m ab1hty, despit!! one~sJi~sfHfoifs!.r a:;::-:~:'
. .. ar1ses, rom e
.env1_qnments, .
"
,
sible and lazy 'h~n you can't manage? Are you cut out for school ora cer-
tain type ofwork? How can you tell when your ability to perform seems
lor regulate emo~10nal cues; ex:perieces; ctions,,verbal'.r__:.;..~ ;;:,.;~ ge
b l
.or n onver .a express10ns
. .
. . .
. t.incl!;!r normativecondition

-- ,;.~...,!<!.,,,.~~sp.onses,.antl/
-
{ d ysreg ula tion is "when this inability to 'reg :. 'a-t--e"cem . -51,ti;;>,;;;,e
.:.r.~. a~s-.... . -- aon
1ve-emo
largely beyond your control and d ependent on your em otional state? Toe
impact of this unpredictable variability affects all cj.reas of lile. Like liv-
_ _ : .w .
_ e1
"

~--o

t i'
o '=""
ns ..~cy;,,~
. .occurs, acrQs.s1
:'.: ~ ing in a nightmare, your efforts h ave no effect or go terribly wrong ..This
a w1de ran ge of.emotions, proolems, anct -situatia rl!'c' o
'" h"'
t
;.e""
. ___,..._,_.,.,___ .. s. 1ne an
~
x
t' (L" h . biological'vulnerability is e)(<\cerbated, and in sorne cases even created,
Bohus, & Lynch, 2007). Such d ifficulties with dysregu1ation 1e d t 1~ by transactions between the emotionally vulnerable person and a social
b h ( . . a orna
a d apt1ve e aviors. e.g., smcrdal behavior, purging, abusing substances), environment that is pervasively invalidating.

6
DOING DIALECTICAL BEHAVIOR THERAPY
lnvalidating Social Environment and lt s Consequences
Think first abo1:1t emotional developII_lent in an optimally validatin envi-
. ronment. Emohon evolves as a rapid wh0 1 b d g . .
. . , e- o Y response: our physiol-
; og_y, P:rcephon, act1?1:s, and cognitive processes coherently. fire to ether
\ onentmg a nd orgamzmg adaptation toco f 1 h . g.
. t d . b . n mua e anges m the envuon-
men .an . m our_ o~1es. We hear an unexpected noise, and immediatel
/ em o t1on fires, ?nenhng us so we're prepared. In healthy emotion~l deve-
. opment, car~g1vers respond to a child in ways that strengthen the links
betw~en envuon~ental c~es, primary einotions, and socially appro riate
( emot1onal express1on wh1le weakening the links f 11 p
ate expression. Our c~regivers' responses v.i.dat' ?hr. ~t~c-~affy _mt
.. rP:J:>n-
. d . _. . e w a 1s e . ec IVe,'appro-
!mate, ~n 1:11akes sen~e about our responses a:na invalida.t thaFwhich is
j.
meffective, mappropnate, and <loes not II\ake _sense.1 For example, bas~d
!
on thes e ?rocesses of acculturation, we learn to interpret certain noises as
cues for mteres t or fear, and learn to modulate how we express~ hat we
feel. ~thers' validating responses teach us to use emotion to understa.nd
w hat 1s happening within and outside our skin as a moment-to-rnoment
readout o~ our own s tate and our needs with respect to the environment.
In an . optima! environmnt, caregivers provide contingent, appropriate
so~thmg for strong emotions. They strengthen and help the_individual
r efme the naturally adaptive, organizing, and comrnunicative functions
of emotions.
None of uf .g et th perf~ctly optimal envirnrnent, of \::rie. 'Ev.en
~ the bes t p arents are tired; they're stresseq. They are thernselves habi:~-
ally _an xious, .r:1g~y, or d:pressed. From these compromised states, they
pun1sh or mm1m1ze vahd expression of primary emotions. We conse-
q uently learn more or less dysfu1:ctio_na~ ways_'?f expressing nd making
sense of our emotions. Bigger'problems aiis, howivei, whi:tcaregivrs
consistently and persistently fail to respond as needed to';p~~y' emq-
tion and its expression. Pervasive invalidation occurs when, more often
tha n not, car.e givers treat our valid primary responses as incorrect, inac~
curate, inappropriate, pathological, or not to be taken seriously. Primary
r esponses of interes t are persistently squelched or mocked; normal needs
for soo thing are regularly neglected or shamed; honest motives consis-
tently doubted and misintetpreted. J:he person theref.o re learns to avoid,
interrupt, and control his or her own natural inclinations and primary
.!
''
emo tonal responses. Like a creature in a chamber with an electrified grid
'
1. for the floor, he or she leams to avoid any step that results in pain and .
invalidation.
For example, say that in contrast to my well-regulated siblings, I
express more need for affection or express emotons longer !nd more
intensely than fits my caregiver'~ _tolerance. This r~peatedly provokes
1
rools for Tough Circumstances 71
and scorn (invalidation). Eventually I attempt to inhibit my 1
patience h t ~
irn . haps by learning to inhibit both overt behav10rs t a expre~l!I
behav1or, per f d,
need for affection and maybe ev~n my prvate expen~c~. o nee~
~~ it In pervasively.invalidating envuonments, f.e~ ~~.11d!tio~g_!ak_.
' ~1ce~:._ We not.only .av:~td the elE:ctri~ grid'. O~ ll}Vali~ti_on,.b~t alsq_ ~yo 1
f :eX: erience .of the prvate events (thoughts, sens~tions, or e;notio~)'v
~ _.nr!~:h;:P_ ht l : d anyw
.whic nug ea
hre near the grid; We become extremely sens1-
. 1ct . W
" d to all cues that might bring on the painful zap of mva 1 ation. e
tize f
hobc of our own valid, natural responses. Histon_e s o pervas1ve
b ecome P ,. lidf
invalidation leave people not on.ly hypersensitive to others ~va _a ion,
but sensitive to any response of their own, valid or not, that m1ght p~ompt
thers to invalidate them. Responding naturally is often as evocative as
~ropping ,a sp~der ~ _t_he _lap 9f so~eone_:"'.-~ ~ ~~ide~ P~?~ . .
I:i.inehan's theory, different co~~l!l~~W ~f_b~?]?gic~vuln~~i.t-
nt)i:apd, i:q~ial-_i_r1v~dll.tion can resultin fair~Y'similar expenenc;e~. _P~o-
iP$..~JlY..,so .tr!1.Y~ ci#.~r~t dev:elo~men~al r~utes,-yet...en9--~p. w1th the
same dif#cultie1?/ For those with a h1gh b10Iog1cal vulnerab1hty to em~-
'ti~~ dysregulation, even a "norma_l" leve! of ~validati~n may_~e suffi-
cient to create serious problems. Like those w~th attenhon defi.ats, they
face enormous b,ut often hard-to-perceive difficulties. For example, if o~e
child with normal attntional processes and one with attention-deficit/
hyperactivity disorder (ADHD) are playing a board game and getti~g
too rowdy, a stem "Settle down in there!" from an-adult in the kitchen 1s
enough for the kid with normal attention capabilities to comply. But the
kid with ADHD may ned the adult to come in and provide step-by7step
coaching: "No. It's not your tum. Give the dice to Joey. Sweetie, look at me.
Set the dice down. Thanks. OK, now watch. It's Joey's turn. No, put your
hands in your lap. That's it. Let's see, he gota five ..." (and so forth). Over
time and with practice, such coach ing turns into self-regulation. The same
acve coaching approach is also needed to help those trying to manage
pervasive emotion dysregulaton. As with attention dysregulation, addi-
tional guidance and structure are require.d to develop self-regulation of
emotion. Few parents know how to provide such help; most parents cap
qeovrwhel~e~ ~Y: tp.e p.ee9-s .o~.a higr-!Y v~~~~\e clul~-:~qnseq_u~tly,'
'stjl. ,emotionally ::vlnerp.):>le children. seldomlearn effectiv.e strategies to
~nage their ove~'o/h~lqi.4'g !?IDQtional experience, DBT targets these def-
icitsand explicitly teaches the skills required to regulate emotion. ,
O_ther, people \;1e~ _lije :with_very~Uh.le biqlogicaJ.. vulnerabi!ity, bu
~p~rierce Sch_eXq{?Ille \1 p,t!rSistenti.,v;alidtiol. over time ~_f th~
deyelop probfems.regulitirig _e1,otion. ~hiJ.dlw2.4eXl!al abus~is a proto-
'typical invalidating environment related to BPD (Wagner & Llnehan, 997;
2006). However, not all individuis who meet BPD crit~a report histories
of sexua,l abuse, and not all vitims of childhood sexual abuse develop
 8
DOING DIALECTICAL BEHAVIO R THERA PY fools for Tough Circumstance s 9

BPD. It remains unclear how to acc . . .

s ee Rosenthal, Cheavens Leuez & ount for md1v1dual differences (e.g., d egulation. Through clnica! observation, Linehan characterized three
beginning to piece together {he ' ~y~ch, 2005, for one line of research Y:erns in which clients flipped from underregulated states in which the
toms and childhood sex 1 b m ed1ational fac tors between BPD symp- ~J:ent 5 overwhelmed by emotional exp erience to ovei;regulated states
tha t it is the-experience oufa a us_e). ~nehan (1993a) has therefore argued with rapid avoidance of emotional experien ce.
pervas1ve mvalid r h
any o ne specific type of t S . a ion t at is causal rather than
rauma uch hist . l
s ensitized to invalidation. . ones eave people extremely
fmotion Vulnerability and Self- lnvalidation
The difficultes I've described
. of em otion dysregulation. When th:o fa~ follow from the _core p roblem Bibogicl ivtj..lnrability and a-history .. of pervasive, inv~lid.atioi}'. crea te
whether due to biological vulnerabilit env1_ronm~nt ~oorlr fit_s our needs, xquisite sehsit~~tyi Toe slightest c~e can ~~t ~-f f e~ot1~7:1-~l__ p arn~- the.
a range of problema tic e t y o_r pervas1ve mvalidation, we Jearn equivalent of touching third~de~ ~e.p.~m~. ~e:1:1:~.t1._ie ~d1~~u alcq.nI1ot,
. mo ion regulahon st t . Wh contro l th,e.,cmset and offset of events that trtgger _emqh ~~ALresp on s~s,
tive exp erience and express1on of em f
ra egies.
.
en our norma-
then withdraw and t . o ion e ic1ts d 1scomfort in others who the. persol} cah oecome .. desperate for nything tlJ,at _':_ill'.l!la~e:the .pa1n
en 1c1ze rather tha h d
w h o we are and how we k _n e pan support us, we leam that en_d! For many, it's as if their.physical body ~a~not w1t~stand the for~es
are evo es mterpe s . .
learn to avoid o u r valid . r ona reection. We thereby raging through it. Even dysreg':,lation of po~1hve emotions creates_pam .
of blun ting m asking anpdr/ 1omad~ytres~onses and instead develop patterns For example, a client rep orted, I got so excited when I saw my fr1:nds,
'
em o tions Avoidan ' b r 1s ortrng our expenence and express10n . of . J couldn't stand it. I laughed too loud, talked too much-everythmg I
a slig ht ~attention ~~ m ouYr fr~ sudbtle: w e protect ourselves when we sense did was too big for them." :,-motion vulrierabilit:t .'-refe~ ~~t:gJy_t<f t.he
. 1en as we sp eak by ch h 'xqi,tisite .sensitivty buf fu;rther fo the .d msequeiices.ofliy~g _a,$."-~:p ~'fsbn
g omg to say to a Iess risky self-disclo . . angmg w at we were
escape a v ulnerable first flash of sad~::: ;;:1t~::::ar~nets w~ r~pidly wn is exquisitely _s e~sitive, Unavoidable day-to:-day exp enences. tngger
Avo1dan ce may be obvious full- . . Y ee mg irntated . intense emotional pain to the point where having ernotions can b_e come
sive that we e "th . l ' . out escape. our emotional state is so aver- traumatic: p eople in this situation cannot tell when they will be undone
1 er mvo untan ly escape it by dssociatin ~r find d by emotions. Pe;formapce befoin~sJqt~l}Y. ':1?P~e'.d i~tah~i .b~i:us~ it:is~~f9,;
a te m e tho~s such as intentiona l self-injury to end emoti~nal ain esp ~r-
.to..ernotional $ttes ilie pers.h'isunable:tocontroL T~ tJ.I!pred1ctal;>.ility
s_u ch learn_rng p rocesses affect us ali, those prone to emotionpd s~:V:~~ Joils personal and intetpersornil expectations leac;ling.th clien,t UJd 9th:.
tion expen en ce ~ore pervasive social invalidation and come to:lte;nate ersto feel frustrated and disillt'.tsion!:!d. Toe p erson desp airs because.she
betwee~ strateg1es that over_regulate and underregulate emotion and its experiences her emotio~l sensitiv.ity as biological, as part of her tempera-
~xpress10~. These problemahc beh avioral patterns wreak havoc in clients' ment, and therefore as something that will never change. The client finds
D 1 1~~~ _t~erapy and are discussed next. herself trapped in a nightmare of dyscontrol. Life is a continua! fight to
endure a typical day's events. Suicide may seem the only way to prevent
Dia lectica l Dile mma s : Seconda ry Be havioral Patterns future excruciating suffering. Suicide can also be a final communication
. '
tounsympathetic others.
M an aging em otion vulnerability and ongoing invalidation oft t d For exquisitelY, sensitive p eople, nearly any therap eutic movem ent
h l . d l b en s ran s
t _ e c 1ent m ~ 1 emn:i-a ..~et~~~ ?verregulatmgand tiri4tr_eg_~tatiog.emo.- evokes emotional pain, much as debridement does in the treatment of
tlona~ expene~ce -and ~ press10~:'- ~in~an~called the~~_p att~ _j'.dialecti~ serious bums. Snsitivity' to' criticism makes it painful to r~~eive neede<!_
cal _d ?emmas . be_c_ause an_~~s-~~~t!~:.u::l.e a: of '.''dialecticsl'.:is; that;any. one feeqback! As we saw in the case of Marie at the beginning of this chapter,
?J~OI} _con~am s lts .?.~ . ~~~7~!S~ -~: ~2PP.g~!?:e-~.f.o n. Toe client's in-session emotion dysregulation (dissociation, panic, intense anger) inter-
mev1table failures -to regulate .em ohon,Ieacl-... to~increased~invalidatio rupts therapeutic tasks. The generalization of changes and plans m ade
(" W hy are you s~
}~~itive?.~'.'Y'r e ..rzy.!~m i~ 'Gtf"d ;e;.-'it!1 );!>whi;. in session goes awry due to emotion dysregulation in daily lile. Therapy
in tu~n le~c;is _to r edoubled. .effotts..J:o se!.f:.~E:W -te~ rJ o !YPict.::fur.- itself may be traumatic because the client cannot regulate the emotion
ther m vahdahon . At t~e_g~er .f ~~~gie,:~c).j.~n!~tP'l Y.:i_e_s~fl.lt.ezexpression evoked in therapy. Clients often feel humiliated by their helplessness in _
as they t ry to comm~~cate..,"'Y~~ ti}~1r_resp_q_rise_s_;gre..!.Y.!.liQ:.(a'IDJnQ~azy! the face of overwhelming emotion. Understan,d ing emotion vulnerability
1
You don t understand! ~). Over h ~ e, common behavioral pattems develop means the therapist must understand and reckon with the intense pain
as clients a ttempt to resolve the dilemmas inherent in pervasive emotion involved in living without "emotional skin."

_______ ... _
 JU .t
DOINd D IALECTICAL BEHAVIOR THERAPY
11
-( 1s for Tough Circumstances
00

People learn to respond to th . .

r dysregulation by invalidating th e1rlong~mg vulnerability to emotion

. lid .
uwa ~han takes at least two forms
. emse ves Just
'
th
th
. as o ers have done. Self-
regulation harshly .(.'.'.Lshou!4:4.1; .In e,_t~rst, the person judges dy~-
.
alienates helpers; and it makes suicide one of the few means of communi-
cating that more help is needed. .
Apparent comp etence is deadly. At one moment:H~e clienLappec-s
.

to control and avoid natural p r i m ~ ) - Here, the p erson attempts able.to cope and then (unexpectedly to _the ~bs~yer)_3.t otjler times it's.as_~
~o_n turns against the self with self-Ja;:ponses. When this fails, the per- the.cop:lpetency did ~ot exist. Clients ~~ve learn . ed ~o ."app~~r compet~t" J
mury may be used to punish oneself f /~d self-hatred. Intentional self- thiit is, to :1de emotlon and vulnerabihty so tpat.095-eryers see very little

way ), block emotional ex .

tl
may,,deny and ignore the v ulnerabili;r ;re. In the__second, the p erson
y o ysregulahori ( ~ s
_expi:essed emotion. Often clien~s may verbali~e i:iegative emoti~ns b~tnon-
verbally convey little, if any, d1stress. Yet therr mtemal expenence lS that
fectionistic expectations. ;~n~nce, nd hold unrealistically-high oi.pe;~ they have just screamed their distress-they have become so sensitized to
of solving life problems a nd fo1;11lg so, the person minimizes the difficulty their own expression that simply saying anything at aH feels nake~ and
1 s to recognize more h elp is. needed. This
p~ttern often defeats attempts to chan raw. When verbal and nonverbal expressions of emotion are incongruous,
tnal-and-error learning needed to g_e as the person won't tolerate the we ali default to believing that the nonverbal is the more accurate expres-:
. acquire self-management strategies. sion. Therapists (and others in the client's life) are likely in these instances
to m isread. If a client says to you, "That really bothered me" in a matter-
Active Passivity and Apparent C of-fact voice, it is easy to think that he or she is basically OK and miss the
ompetence
( actual experience of extreme but unexpressed distress. A second misread-
Over time, people leam -to res ond . . {
problems that are beyond th . p b ' ~ass1vely when they. are left :w1th ing 'c an come from the typical assumption that behaviors generalize (i.e.,
eir capa ihty hil h . . . .. if I am friendly and outgoing at one party, I will be frieRdly and outgoing
them are minimized At t1mes, remauung
. . . w e t e difficulties
. fsolving ,.
.
a vulnerable-looking woman s tann . . pass1ve achvates others\ at the next party). However, as described above, mood influences how dif-
. Seeing ficult or easy it is to perform many behaviors. ~er:_i the core prqblem is
: the road in abad neighborhood mi gh~elplessly at--a flat tire on the side of
'i emotion dysregulation, clients have little control of fu~-emotiona~t
) help
.
doesn't arrive she . ht
'
g prompt someone to stop to help If
m1g express mo d 1st
mg her watch and beg re ress-frantically check- ~nd therefore little cqn_trol over tll.eir behavio!'.'a l -~pabiJiJi~: This will pro-
mnmg to cry. Acf . . .. ..
resp~nd.to problems passively in the i'ace1ve pass1~1ty _IS the ten~ericyto
. duce variable and conditional competence across settings and over time.
\ murucatmg distress in ways that ctivate o~~;;:tiffic1ent help while com-
, Far example, Mark, who we rnet at th
scrapes by as a software ro
. . .
e start ?f th1s chapter, barely
crastination, and moodinepss ghrarnrnledr because h1s perfectionisrn, pro-
ave e to rnany d d .
Yet observers (and the client herself) will expect continuity and be repeat-
edly surprised when a competency fails to generalize as it might with IJ.lOre
emotionally regulated people. Because othe.rs misread, they inadvertently
create an invalidating environment, failing to help because they cannot
see the distress. In the:worst cases, other~interpret_the abs~ce ~f _e xpecte_d
l
many that his latest employer did not h . . m1sse eadlines-so
ashamed, he hides out refus1n t renew is contract. Devastated and competence as manipulation and.become less willing to help.
, g o answer calls and p tf h . . .
a drawer unopened When h is 1 dl d ' . u mg 1s mall mto
of
mov~ out. Instead searching ; ; a;e: pp~:~:n~oelie_n ds,Mhe kasks Mark to . Unrelenting Crisis and lnhibited Grieving ~
day m b d d 1'l ve, ar spends the
Unrelenting cris~s refers to a se~-per,etuating pattern in which a person 1
to encou:ag:~c:Jv: ;:b~~~~l:~~::ri!~~!te a~! efforthis_by the therapist both creates and 1s controlled by mcessant aversive events. An emotionalfy 1
to do wh t 0 penences mself as unable
a is n_ecessary and he actually is unable to at without mor vulneraple person may impulsively act to decrease distress: this c:an.inad-
h~lp. If he had ust broken a leg, help might be forthcomin e vertently increase problems that quickly snowball i.nto w~rse probl~
w1thout observable deficits, others view him as lazy. When f H:wev~, For example, Marie "lost it" at work, and is going to be fired which in tum
ers _far help he is ineffective-others experience hirn as dem. e da~ s ot d- can lead to eviction_from ~er apartment. Another client yells in anger at
whmey M k' - an mg an
ar s expenence, however, is that the situation is hopeless a case worker and 1mpuls1vely en_ds.. an inte.rview. This means that the
mat~er what ~~ does. From the therapist's perspective, the situation wo:~ needed housing applicatio~ is not completed. When another appointment
ens mto a cns1s that could easily be solved if Mark would co e a r cannot be scheduled, the chent ends up in a homeless shelter. Residing in
(e.g.,_ c~ec~ Crai?slist ~o _find another place). When this patte!n ofca~::: a homeless shelter then exposes the cliettt to a host of cues that remind
pas51vity 1s habitual, lt mcreases life stress as problems go unsolved; it her of a past rape, setting off daily flashbacks and panic attacks. Such

---~-:::.~ .:. --- -

-~.-
 12
DOING DIALECTICAL BEHAVIOR THERAPY f ools fo r Tough Circumstances 13
1

~relenting crises can dominat h

- ficult to make progress.

lnhibited grieving is an .
e t erapy to such an extent that it is dif-
. -
rnotion d ysregula tion with the following: a combination of c.ore}r~a.~en t
: trategies-c)l;mge, acceptance, and dialectical strategiJs, summanzed

Q tional. responding The tra d -

-
ave been shattering_ The m
1
~ e.motional experiences, an =b;tary, automatic avoidance of pain-
h ion of the natural unfolding of em o-
ge 1es t at sorne 0 f
- . . .
li
our c ents have endured
r;; Table 1.1 and a framework of guidelines that structur~s the !reatment
environment and prioritizes treatment goals and targets accordmg to the
eXtent of the client's disorder.
trauma or revicti.....,;~~t y ay mhtb1t gnef associated with childhood
h " U L < l ion as an adult o . f k
t atare the consequence of matad ., r gr~e evo_ ed by current losses
To stop the emotional pain th apti_ve copmg or mordinately bad luck. Co re Tre atment Strat e gie s
increases sensitization to e' ti~y avo1d and escape which inadvertently Change Strategies
mo on cues and reactio S cl .
s t antly experience loss sta t th . ns. orne ients con-
th e process by avoiding' o d. r e mourn1ng
. process ' au omatica lly mh1bit
t . . . DBT's fust set ofrore.stra t e g i e ~ ~~~~~g--~~h~ ~~h ~v-
cess, and cycle through r t1strac~ng from relevant cues, reenter the pro- iqral pri,nciples arid protcols Irom cogrutiye-~_ehav10r~l a1i !. ~t.~ ~ :~~p-
Th e individual never fullcone act w1th the cue and reticlly compatible strateg~es to) :rea.~ pervas1ve emo_t10!1 gysr~gulation.
. . escape, over and again.
painful events. y xpenences, mtegrates, or resolves reactions to Behavioral chain 'nlysis-a form of functional analysis-is used to iden.-
tify th~ ,:_;ariables~tha~c~nt~?-~..5P~~~fic.~s~an~es of ta.rgete~ ~roble~s s u~h
as self-injury.l OBT case.formulation_1s !:~sea .on. the:fu~ftiq~l,p_!ttem.s
The three behaviora l patt d .b that emerge from these 0 chain ~alyse~-: Treatment plans address wh at
fallout from the toxic comb' e:~s e;~~ ed ~hove are the developmental
invalidation Wrul II f ma ion o iolog1cal vulnerability and social e~ds to go differently in the behavioral chain so that th client does not
engage in the problem behav ior. Sorne clients~like Mark introdu~_ed ear-
reactions to .our o:n\m~ti~;a~epva~~pthhe:beituthal, somewhat problematic
D 1 rf d . ' ree pattems wreak havoc lier in this chapter, lack basic capabilities n eeded to regulate emotion and,
c1~It'sl e an b ~era_p y m particul,ar offer a gauntlet of evocative cues: th~ therefore, part of DBT's solution is to teach skills to remedy these deficits.
own e av1ors or others behaviors may prompt d sre ulaf Skills train ing is d iscussed later in this chapter.
hese secondary responses _to dysregulation, in wh ich the cfent !scill:~;; But leaming new skills is not always enough . F?r example, the capa-
rom under- to overregulahng emotion, create further serious roblems bilit'ies Mark dos have are often disrupted by conditioned emotional
Consequently, the behavioral patterns themselves become t tmp responses, problematic contingencies .and dysfunctional cognitive p ro-
gets in DBT. rea ent tar-
cesses. Therefore, DBT's change:s_tr/iteg!es _i.pdua.e:!lof orily .~!ls t~~g
In su~ary, then, the first key component of DBT is the biosocial b, t also three other gr~ups of cognitiye-behavioral proce<:!,ures:~xp,~~U!,~
theo~y of d1Sorder. It propases t~at (1) problema tic or disordered behavior, therapy, contingen cy.managemetjt;.nd cognitive modificatin. However,
parhcularly
. extremely
. dysfunctional behaviors, may be a consequence o f beca1,1.s e.j:>ervasive dysregulatjonJeads to mood-dependentJ;,eh!1..Y!.<?~-:t:td
emot10n dy~regul_ation oran effort to re-regulate emotion; (2) invalidation rises, the DBT therapist must pften,modify these,1>tcU1dai:.dognitive-
plays a role m mamtenance of current difficulties regulating emotion; and .b ehaviorherapy (CBT) intervenho.n sto b~ ~~~~~ssful. T~~se modifica-
(3) common . pattems subsequently
. . . develop
. as a person s truggIe s to regu- tions are described fully in Chapter 3. Change.,strategies also'incld~Je~ -
la te emot1on and <leal w1th mva11daho~; these pattems become p~oblems niques-for,increasing client motlvation and commi.tment to change. J'.he1>e
that themselves must be treated. DBT s overarchina treatment rtional ~ommitment strategies include.prns and cons, devil'.-s.dyocate,:~haping,
th erefore is to teach and s upport e motion reg ulatio~ and to reinsta te th: and others listed in Table 1.1. Behavioral expertise is required in DBT. A
natural organizing a nd communicative functions of emotion. lack ofbehavioral expertise is a genuine barrier to the therapistwho wish es
to work from a DBT framework.

HOW.DBT TREATS
PERV ASIVE EMOT ION DYSREGULATION
DBT trea ts p ervasive emotion dysregulation and t}:le subsequent com-
mon p atterns tha t develop as the individual copes with pervasive
7 Validation Strategies
DBT's second coreset of strategies, validation, ~mphasizes acceptanc~. Fo
example, Mark's history has left him exquisitely sensitive to invalidatio
This sensitivity ted to him losing his job: his boss's rquests for chang
 IS

.,. 1 for Tough Circumstances

14 DOING DIALECTICAL BEHAVIOR THERAPY ,oo s }m change
. , attempts to help ,
im and his prior therap1st s evaluations felt excru-
verw h e1med h performance
TA~L~ Li. DBT Core Strategies ata Glance o . . res onse to the poor . effective and need e d
Behavioral change strategies (change-oriented)
app~opnathe~y mMufh of Mark's responding_ was m tions feel intolerable.
.atmg to im. k han ge i.nterven h
Cl h ge but for clients like Mar , e . 1 Validation comes from t e,


Behavioral chain analysis
Task analyses
to e an , f becorne cruc1a .
Nalidation strategies there ?reh 1997b see also the excellent ~o . m .
b kE pa-J
Solution analyses ent-centered tradition (Lme an b , 1997). DBT defines vahdati~n ~s


Skills training (see Table 1.2)
Self-monitoring: the DBT diary card
cli B h t & Green erg,
thy Reconsidered, by o ar . tion that the client's perspective::fr
val1d in
th 1



Exposure
Contingency management
Cognitive modification
Oidactic strategies (psychoeducation)
J-:ern athy plus the com.muruca
(L so!e way. With _e~pa~y,
clie nt's .perspective, w1th
:::d:c::.: atel understand the worl
yo1 also actively communicat~ that
om e

al< s sense" . cond .ihons "

Orienting the client's perspective. ro elump vahdation .
WL
'th "facilitative
d. .
Commitment strategies lt might be temptmg to t t "the sugar that helps the me icme
o Pros and cons or "common factors," orto relegate 1 o . the "real thing," of change-
o Foot-in-the-door
o Door-in-the-face cro down," as if to coax the client lt?dent_gange1nU:tself, can produce powerfuH
o Freedom to choose; absence of altematives oriented strateg1es.. H ~wever. ' va 1 a io ' '
. 1 d and precise. U sed genuine Y an.
. l d
o Linking prior commitments to current commitments change when it is achve,_ dis~p me ~sal that is a normal effect of invah-
o Devil's advocate
o Shaping with skill, it reduces phys1olog1cal _aro hons to fue! Skill in the use of
. more adaptive emo ll
dation ~nd it can_cue what and what not) to validate as we as
Validation strategies (acceptance-oriented) validat1onstrateg1~s centers on r t(d sx le~els of validation as shown
Empathy + commwcating client's perspective is va lid in sorne way how to validate. Lmehan (1997b) ~ e t i !'date at the highest possible
o Level 1: Listen with CO.II!pJe_~i\"Y!!,I'~ness; _b e awakJ . Table 11 and she advised therap1sts o va l 4
1n d d th Chapter
o Level 2: Accurately reflect the dient's cni.municatioh level. Validation strategies are covere in ep m .
o Level.3: Articula te wwerbalized emo.tions, thoug~g;, .';!Cb!:_h,!!.~io~ patterns
o Level 4: CornplUnicate how_beh~ior makes sense in terrns of past:
circumstances'
/\ Dialectical Strategies .
./ The tension between. the need to accept clients' true vlnera~ilities and ~
o Level 5: Communicate how behavior makes sense in current circumstances
o Level 6: Be radically genuin ~
e necessary change is a constant dilemroa for V
Dialectical strategies yet encourage them to rnak h '
the therapi.st and often the root of therapeutic impasse. To_ nav1~ate, t. er~-
Oialectical assumptions and dialectical stance
Oialectical balancing
pists take a dialectical stance and use dialectical strateg1es. D1ale_:hcs ~
o Change and validation strategies both a view abmlt the nature of reality an~. a metho~ o~ persuas101:' lri
o Stylistic strategies: Reciproca! and irreverent b th an essential idea is that any one pos1t1on contams 1tsafiEes1s or
o Case management strategies: Consultation to the client and environmental o;p~site position. Progress_ comes from the resolution of the t:" J:>POS-
intervention
Specific dialectical strategies ing positions into a synthes1s. In other words, the way fo~~d 1~ to s1mul-
o Dialectical assessment taneously accept the client and push for change. Polanzation 15 natural
o Entering the paradox and expected. Therapeutic movement happens by keeping both ends of a
o Metaphor
o Devil's advocate
polarity in play. In DBT, therapeutic impasse signals the need to explore
o Extending both poles of the dialectical tension.
o Activating wise mind Dialectical strategies provide the practical means for both the therapist
o Making lemonade and the client to retain flexibility arnid conflicting and even contradictory
o Allowing natural change
"truths." For example, in Mark's past therapies, when the therapist pushed
too hard for change, Mark woltld no show for the next session. When the
therapist dropped a change focus, accepting Mark's vulnerabilities, he

---- "" -
 lb

DOING DIALECTICAL BEHAVIOR THERAPY Toois for Tough Circumscances

1:
became despairing and hi hl
then also failed to h l .. . ' .
Y cn~ical of the therap1st s meffectiveness-
tance of vulnerab1st owd or appomtments. This tension between accep- IJl
inirnally trained, overworked staff i:n her residential placement. ThE
l way the client was able to get staff attention and help was througli
1 1 Y an need for cha 00
y ;,..,g extreme emotion and out-o-control behavior. In her case, pro
clients like Marie Ma . .d h nge lS even more pronounced with expre55..,, ' uld d
. . ne an er thera . t d . d ng crisis management as a stopgap to reduce acute problems co en
s1on that started this h B p is ma e 1t through the tough ses- 1
plan to help Ma . c apter.. ? the session's end, they'd generated a crisis " ~ominating therapy to such an extent that efficient, effective ~eatment
ne avert a su1c1de atte t Al h h ~~comes unlikely. Perhaps training the staff to better respond rrught ~e a
in better shape the th . f mp t oug Marie left the office
client. La ter th;t aft erap1stMea~ed more crisis behavior on the part of his better Iong-term solution. However, because s~af~ tumover was sky h1g~,
. emoon ane saw he h h . h ever was trained would likely be gone w1thm the month. Instead, it
mg to be dishonest M . d' . r p armacot erap1st. Not want-
' ane escnbed to hirn h h . w ; be more efficient to train the client until her skills are so robust-t~at
were dead. she ex l d h . ow mtense1y s e w1shed she
she could ,follow ~h/;~ : at she hk~~ her new therapist but was not sure : : could regulate emotion even i,n the face of staff inv~lidation. Bu_t that
about her ability to con~ ii the _c~1s1s plan they created; she's terrified
decided fhat Marie needro er su1c1d~l b~havior. The pharmacotherapist
ould take time and, in 'tru th, it would be an incred1ble challenge for
w one to regulate emotion in such a chaotic living situation. It's clear that
any 'd 1 11 b
nearest eme ed to be hosp1taltzed. He sent h er directly to the without significant ch anges, leaving he_r ~ the re~1 ~ntl~ sethng w1 _ e
d hrgez:cy room for evaluation. The next moming instead of the a recipe for continued crises and ps~ch1atnc hosp1taliz~tioz:is, yet _makmg
expecte e eck-m ca!l from Marie, the individual therapist arrived to a the needed changes within the settmg appears dauntmg 1f not improb-

toe~:
:ess~ge_from the ch~r~e nurse at the local state hospital: between leaving
a;1macotherap1st s office an~ reaching the emergency room, Marie
_overdose and then was mvoluntarily committed for 72 hou rs'
able.
Perhaps a better option would be to encourage _h ~r to mov~ out _of
the residential setting. Yet witho1,1t the-structured achvity of a res1dential
o b servation.
placement, she will go downhill into inactfvity ~nd ru:111in.a tion. H~r p~-
. Ta~ing dialectical perspective means one unders tands that suicidal ents w ill p anic at the thought that they w1ll have to p1ck up the p1eces if
chents hke Marie often simultaneously want to live and want to d S she is nt living in a structured environment an ~ it's not elear the~ ~ould
aloud to her therapist, "I want to die" rather tha~ killing he lf _1e. aymg financially supp.ort such a m o:ve (or the therap1st ~ h o propases 7t.). For
h . rse m secrecy
con t ams w1t. m lt .the
.opposite
,, position of "I want to 1ve
1 ." Th 1s
" d oesn,t successful social activity outs1de a structured env.1rorunent, she d 1:e:d
mean wantmg to hve 1s more true" than wanting to die: she genuinel friendships, which would require better social skills than she ha~. Th1s m
<loes not want to live her life. Nor does the Iow Iethality of her suicid~ tum would actually require that she could tolerate yo~r corrective feed-
attempt mean th at she really did not want to die. It's.not even. that she back of her social skills and get through a group skills training session
.alternates
. . .between
. the two-she
. . simultaneously
. . . holds both O pposmg without becoming so dysregulat~d that she storms out of the room w~en
pos1tions. Toe client ~eessmc1de .as the _o nly option out of.an unberable invalidated. . . . ~-:,;.
life. R~ther than.~eco~~.po!arized, in.a ?,ialectica.1:appro~ch.'the theiapi~i: Where to begin? Horst Rittel's term '~wicked ..p roblems" (Rittel "";?
agrees that the clients.life lS ~bearable!and that the .client needS:-. a ;w,ay Webber, 1973) cap tures the way that complex interdependen~es.among
out, an~ o_ffers ano~er route, u~mg ~erapy to build a life_thatis geriiri~ly {prgble~;lI.\.ak~_it <;lifficult:e.ve.n to concepfualize how to solve oneaspec,t
. wo: th h':'.m g. As w1ll be descnbe~ m more de_~ail in Chapter ?,.aq~P,tng qf.-the.-prol:)l~!ll.Y"ith.o ~t creating another proplem: With wicked p roblems,
a d1alechcal stance means embraong a worldv1ew inwhich.you:can;lild ~e~et are ,~Q;_irt~Y. complic:ated -relationships. and depeng.~ncie~ among
the positiori,of co~pletely accepting the clent:anctrri.om~nt_as:: they'. are pr_oblems.that beginning .t9 work on one ~ften leads to work pnse.ver!
w hile siipultaneously moving urgently for change'. This third and final set 0tli:ers. 1

~
of core strategies involves the ability to resist ov~implificatign and move
beyond trade-offs to find genuinely workable blends of problem solvirlg
and validation, reason and emotion, and accep tance and change.
Clients who have experienced repeated s uicida! crises and psychiat-
ric hospitalizations often face a complicated web of interconnected prob-
lems. In these complicated, high-risk circumstances, more is needed than
the biosocial- theory and core strategies described so far. For example, one
client's hospitalizations were prompted by invalidating interactions with
,_, tD.BT's answer.tp '.'ic1:<ed problems is .to a~d structure. DBT structures
the treatment environment according to the client's level of disorder. J'h.~
..
~
~o_~J !!~Q.r<;l.~r~aJ he-client's behavior,__th_e more.s~ryices are;n eededa:r.-9,
!h.efi:nqret cQmprehensive the . tre.<ltme11t. Furthermore, with clien ts wh o
have repeated suicida! crises like Marie, DBT adopts a framework ofpro-
tocols and procedures that structure the ther~pist's clinical decision mak-
ing and work in mch the same-way protocols and procedures in an emer-
gency room allow coordinated action amid urgency and uncertainty.

xc{ eA. w...oL' ~0o tl..dJ..la.Li_0 htmh~'h <1./J r~rth.~

 19

f Tough Circumstances
DOING D IALECTICAL BEHAVIO R THERAPY Tools or . DBT
18 Modes of Cornprehens1ve
'J Functions and Treatment
r,l.\.6lE ,_. Modes
Structuring the Treatment Environment
fUJl.ctions Skills trainin~ (individual or gro~p),
Standard comprehensive DBT as it h as been m anualized and research ed 1 es. Helping
-r:--fog clients' capab!1t1 apy psychoeducat10n
. pharmacother '
is structured to provide ali the treatrnent that a highly disorderecl client (Enhatl.- . responses for effechve
clients acqu tre
needs in arder to achieve an acceptable quality of life. Comprehensive performance
treatment for h ighly disordered clients, from this viewpoint, requires that Individual psychother!I-PY, milieu
-~ - . . a motivation: Strengthening treatment
treatment accomplish five functions \that follow from the impact of perva- Iznp::r_o_yino . .- .. d helping reduce factors
. l progress an
sive emotional dysregulation d escribed earlier. These are: clin1~a . . d/or interfere with progress
t(hat i;::::ti~:, cognitions, ov_ert behavior,
e.g., f )
l. Enhance ~lient cap.abilitie~. People with pervasive emotion dys- environmental actors ,
regulation usually lack capabilities for effectiv~ly.regultirig emo- Skills coaching,.rnilieu tre~tm~nt,
~ - ifaeneralization: Transferring therapeutic communities, m ~rvo
'tion; they n eed to learn new skills and sometimes receive pharma- s~i:~1response r~pertoire from therap}'. interventions, review of sess1on
cotherapy to enhance their capabilities. to clients' natural environmei:t ~d helpmg tapes, involvement of family/frieotls
2. Improve client motivation _to chJ}ge As discussed earlier, cliel}.!_~~ integrate skillful responses w1thm the .
often feel hopeless apput'. change 'nd,_have.learri~_q.Jp~:be;p_asiv;~ changing natural environment
in the faci:i of problem's; they need help in becoming motivated to ~,,h. . . therapists' skills'~d motivations: i Supervision,\J:herapist cons~ltation
En ancmg the meeting, cntinuing educahon,
leam and then use new responses. Acquiring, integrating, and genera iz1_ng treatment manuals, adherence and
3. En sure that new client cap.abilities generilize to the naturl_.e nvi- 11ve
cogn1 , emotional' and overt behav1oral
ff . competency monitoring, and staff
d verbal repertoires necessary for e ective
ronment. Because emotion dysregulation keeps_n ~wly learned :;plication of treatment-i~cluding the incentives
resp onses from readily generalizing, generalization to different strengthening of therapeutic re~poi:s~s and
settings and circum~t<l:nces__must be directly addressed. the reduction of responses that mh1b1t and/
4. Eriha nce . therapist capabilities and motivatiox. , to::treaL clienl$ or interfere-with effective application of
effectively. Client emotion dysregulation, unrelenting crises, ~d treatment
su icida! b ehaviors wear down therapists' motivation and often str~tring the envirorunent throug~ Clinic director orvia.administrativ
s tretch their skills to the limit. Therefore, th~rapists need suppor~, ~ ontingenc5i! manage~~nt wit~- ll;e _... interactions, ca~e m.aagement,.~rn;l. .
~i;;;~ _e ;t pr.Qg!~~ a~ a ~~!~-~s we": as_ : .family ad_~~>Uples nterven!ions;
motivation, and ,ways to increase their own skills. .
,through contingency management withirn
S. Structure the enviroi:nent in .the way$ essential to supprf di: Jh~ client's community,, '
ent 'and therapist capabilities (Linehan, 1996, 1997a; Linehan et
al., 1999). Particularly when emotional intensity and crises are
an expected part of the work, everyone must know their role and
what to do and what not to do to provide a clear, coherent, and to play needed roles on the tearn. All teain members are asked to share
well-organized approach. When treatment fails, it is often because DBT's basic philosophy. Therapy tasks are clearly delegated to different
it has failed to function in one or more of these ways; as a result, members of the treatment team with the individual therapist and client
client and/or therapist needs were not met. responsible for seeing that all treatment targets are adequately addressed
by someone in the system.
In standard comprehesive DBT, the above functions are spread
among various modes of service delivery. Table 1.2 summarizes the above The Role of Skills Training
treatment functions along with examples of service modes. For example,
clients in comprehensive treatment may receive weekly individual psy- Individual '.herapy ~ess~on~ ~re typical.ly crowded with high-priority
chotherapy, weekly group skills training, telephone coaching of skills, tasks and cnses makmg_ 1t d1f~c~lt t~ sustain a step-by-step skills training
and therapists participate in weekly or biweekly meetings of a DBT peer f~:.'.:s.:.~~~nsequently, s_kil~s trammg _is taught.in a group format as a class.
consultation tearn. The client and the individual therapist form the cor~ of _l.:men~n (1993b) has.t.a k~n var_ious evidence-ba,sed,pro.tocols and distilled .
the treatment team, and they then engage other providers and loved ones herrqnto four. categones of skills that cliE~nts ,ca,n leam -~nd pr_actice: ;
.LU

DOING DIALECTICL BEHAVIOR THERAPY

,.. ; DBT Skills
-rt..SLt.: . .:,. . Change-oriented skills
mind~ulness: emotion regulation, distress tolerance, and interpersonal .. tance-oriented sk11ls
effe~hveness-. Table 1.3 offers a complete list of skills by category. The dia- ~ Emotion regulation
core aun dfulness
~ectic of acc_e ptance_and change_disc~ssed earlier runs through the skills Changing emotional responses
~ u r m ind .
a~ght to chents. ~1~dful~ess.and d1stresstolerance skills ai:e accep_t~~.c~ Check the facts . )
Qnented:. Br practicmg mmel.fulness skills, cVents become increasingly,
TaJo.ng ble mind (logical analys_1s)
Reas~na . d (emotional expenence) Opposite acti~n (to the emollon
Problem solvmg
?le ~o w~lingly and nonjudgmentally engagew ith'their immediate e~pe- ~ouoi:i ~Ul(adding_ intuitive knowledge to
WJSe mm . )
hence. Mmdfulness skills also help clients refrain from impulsive ation reaSon and emotion '. !'- ABC PLEASE
Red uce vu lnerab 111
Accumu late pos1t1ves
and when they do act, to act from "wise mind," the intuitive blend of "What" skills Build ma.stery
emotion and reasc,m that radically accepts and responds to the moment Observe ~ope a head of time
justas it is. The distress tolerance skills include crisis survival skills which Describe , Treat fhysicaL illness
Parbc1pte,
. . . a llowing expenence
are stopgap measures used to tolera te distress without impulsively doing Bala nced :5ating
"How" skills t.void mood-altering drugs (unless
things that make the situation worse. They also include reality acceptance Nonjudgmentally p rescribed by your doctor)
skills that are psychological and behavioral versions of meditation prac- Qne-mindfully Balanced Sleep
tices intended to develop a_lifestyle of participating with awareness and Effectively fxercise
wisdom.
Interpersonal effectiveness
Emotion regulation and interpersonal effectiveness, on the other Oistress to1erance and acceptance
Objective effectiveness: DEARMAN
hand, are change-oriented skills. Clients leam the natural and adaptive Crisis survival . Qescribe
11P your body chem1stry
functions of the majar emotions and leam practica! techniques far pre- o Iemperature (i~e) of your face
Express
venting emotion dysregulation, far changing or reducing negative emo- 55ert
0 Jntensely exerc1Se el
Beinforce
tions, and far increasing positive emotions. They leam how to manage o frogressively relax your mus es
M ind fu lly
interpersonal conflict, asking far what they want ~md sayin~ no,~ ways Distract with wise mind: ACCEPTS .'lppear confident
that can obtain their objectives while maintaining good relationsh1ps and 0 Activities tfegotiate
0 Contributing
keeping self-respect. . . 0 !:omparisons . ) Relationship efectiveness: GIVE
Wheriever.ipossil:!le,. itj .session and dun~g coachmg ~alls, the thera~ " otions
o J:if.m (use opposite emottons C,entle
t encourages the client to pra"ctice replacmg dysfunchonal responses1 0 fushing away
Lnterested
0 Ihoughts
Yalidate
~~th appropriate DBT skills. The individual_ t~er~pist i1: DBT_ leams the 0 ~ensations
,Easy manner
skls frorn the inside out, so that from pract1cmg _extens1vely m her own Self-respect efectiveness: FASf
Self-soothe with five senses
life she can explain how to use the skill in tough cucumstances. o Taste fair
o Smell Avoid apologies
o See Stick 10 values
. .d ua I Therapist and the Consu/tation Team
The I n d ,v, o Hear Iruthful
o Touch
! omprehens1ve DBT, each individual therapist participates . inh a peer-
IMPROVE the moment
.n c . arn. Toe team's role.is. to help the-the~ap1~t:~ave.,.~ tl'!loti,-
co~sultat:n:~l needed to conducf effective therapy.' The team ~~-lp~ .~~
o lmagery
o Meaning
vation an s I s t alize difficulties in the ther~py: and'remecly o frayer
t learly concep u ~ bl o F,elaxation
therapis , eh the t erap1st's
h skills deficits' orls
. . .or,.h er~
. . .own pr9 em-.
e 0 Qne thing at a time
these. be t ey . . . eontingencies that mterfer.e w1tl) conduc~mg
. s eognxtions, 0 r fD T o Yacation
abe emotion
, This 'proeess of Peer eonsultation is a reqmred component o B o 'Encouragement
therapy. . in de th in Chapter 7. . Pros and cons
and is desenbed thp
. ct ctual erap1 st and other members of
.. a DBT consultation
. d o Accepting reality
The m tivi f 'fe assumptions about chents, o Willingness .
O a set o spec1 . . therap1sts, ants o Tuming your mmd
team agree . - 1 4 These are assumptwns, that 1s, not statemen
. t e d m Tab1e d-upon default settmgs
therapy l 1s f or h ow we'11 operate, o Radical acceptance
o Mindfulness of current thought:s
of fact. They are our agree
ll
 DOING DIALECTI,.. 23
'-'""- BEHAVIOR THER.APY jaols.for Tough Circurnstances
TA3LC 1.4. OBT Assum tioru .bout Cllen.,. Th
....., era , Vld Ther.a ists d s back to examine factors that interfere with needed behaviors. We
AMumptioru about cllcnia
Jea ume
u that new behav1ors . must be leamed in all relevant contexts: . what.
Cl,mis Ar~ dorng 1~ ~ 1i.-..,
e,
- tfflt.6 """"' to improvt'
-, , .lln. -~ bl session in the context of a supportive therapy ~elahonship '
Cltc.-nts cannot fati 1n OBT 15 poss1 e J.Ilf th t h h 1s possible w hen alone in .the rruddle. of the 1
is dilfere.nt rom a w 1c
To.. 11\,e, of suic1d.1l ind1viduala re unbt,.11 ght Few o f us wou ld Change p laces w ith our most d1stressed . chents-
CllfflL, must lcam - betuv,.or, ,n ali
C l1<"ms m.ay not luvt' uu~ .. 11 ol t ht-,
,ie.:V~ _.
Utqt ~ rurriently be:Jng ln.-ecf_
""1 cont.ats.
ru . . l
the1r llves are ru Y un
.
bearable without change. Yet wh1le cl1ents want to
. ffi H
th"'m anywAy r own FOblcms. but they ha~ 10 resolve prove an d are d omg the best they can ' often that 1s not su c1ent. e
C lic:-n11 nt'cd 10 do ~l~r, try h.ardtt. and/or ~ : 'she in fact must try harder and be more motivated. In essence t~e boy
more motw~ 10 ch.ngie on the diving board is exactly where he should be: all factors reqmred.to
~umplloru bot..i, th~"PY "nd thcrapists create the current circumstance, to have him freeze, trapp~d between d1v- 1
~ m os1 c-anng 1h1ng t~niputa cn d

Cl,,ruy, p1t:cu.1on. "nd comp<ll.lton
DBT
r to hl-lp darn11 cha~
-.re o th,e ul most mporuncie '"1~ conduct of
ing or re t reat ;..,g
... down the stairs' have occurred.
.
alon thc way, must go differently far him to d1ve.
. Something, somewhere
. .
Tht r l.1111on\h1p brlwN-n IJ\cra ~d so we assume it is .with our clients:~erapy-1~:m ::;t..u;ientify:w~at..
l"q1alA p ..,, nd cliffll.l ia real rtlatlOn.lhlp ~lwttn needs to change in a rder to have needed behav1or occur Th: assumption
ThtrpiAll can f.t 1J ro
rllt-t11vt:ly, IJI.JT nn IIpplyll<'h~=~~::r:.i:~:~ly.
10
rh 1
ThtrDpiAt who 11 r1111nd1v1du1la w I'th
Evm w~n appll~
come.
is that even though the client m ay not have cause.d all of h1s _or her own
problcmS,
he or she must solve them anyway. Here the therap1st assumes
' b d th b
1 bt-h1v1()u nt-c-d upporc pc-rvu,vc iemotton dys~ulation ond Stage that the client can't fail but inste.ad views itas the therap1st s JO . an e ~o
f Lherapy to motivate and enable change. The analogy here 1~ much like
oh otherapy: when the patient dies, we don!t .blame the pahent. Rather
e em f il d t
cs.p,cially wh n lhc chips ar down TI..-- .
the assumption is that "treatment fails" because the p~achh?n:r a e o
'd, . ' le5C USU.mphons function like a follow the protocol or it could be that the treatment 1tself 1s m~dequate
gu , ropt> ,n dnr~ tw,, ly'"t:~verrt I oding the therapist back lo em ath and must be improved. By explicitly agreeing to these as_sumpho~s ~nd
for wh111 ,1 l !I truly likc lo lav m our cents' ski Th . p .y
w1th llw idea lhat dienls, nii with ali p ople o~at acnyass~mptt '. onsdbe~m eturning to them the lherapist and team avoid unproduchve polanzahon
t~ b h "' g1ven rme omg :nd more rapidly resume a useful stance of phenomenological em~athy.
1t c:st I e can and, fur1h ~r, th t clien ls wnnt to improve v 1., d
b ck , d . ,e ami set- A dialectical stance informs conversations between the therap1st and
11 ~ <1n cxcruc1ntmgly slow pro"ress it can s...._ "asy 'o th
1 . . o '-"= '" , r us as erapISts cotultation team. This means that polarization is an expected phenom-
o co_mmun1co1e fru s lrallon, nn d 10 acl as if the problem is the client's lack en n, something to be explored rather than avoided. At each point in time,
of w1llpowcr-h or .she s imply does nol wan1 to change badly enough . th assumption is that any understanding ~s partial and likely to le~ve out
. Hu i 1magme a k1d who has prncticed indoors ali spring lo do his first something important. For example, a therapist asks for consultat1on on
dave o{( lhe 10-meter platform. Then on lhe first beauliful summer da h his work with a client. The team immediately remembers her-she'.s the
compe les. His famiJy nll sit in the audience as he dimbs the diving :lat~ one who habitually expresses distress with her husband and her hea!th
Cor~. He walk.s out lo lhe edge, and looks down. A huge wave of fear and in an overly dramatic, h elpless style that has bumt out ali her supportive
verhgo s wecp through him. He retreats lo the stairs to climb down. He people. Toe therapist hasn't talked about this client in weeks. What the
makes ~ye contact with his dad; the power of his dad's e.ncouraging smile teain hadn't realized is that, for the last 6 weeks, the client has only spo-
turns h1m around and moves him back to the edge of the platform. At the radically attended individual therapy sessions. The therapist is ~eeking
edge, he freezes. This-is n~t at_aU .ke spring practice: no buddies joking help now because the client left a message that moming casually mf~rm-
.r ound on the platform w1th h1m and no coach talking him through. Just ing the therapist that she attempted suicide. The client took a mmor
SJknce as he feel~ fearful an~ humiliated. He steps away from the edge. overdose of Advil, went to the emergency department, and somehow
Now, does that k1d want to d1ve? Yes! More than a nything. But fear is in finagled placement to the city's most plush, supportive day treatm~nt pro-
the way. The needed behavior has not been practiced in ali rele.vant con- gram. The individual therapist flips out in exasperation. WhilehlS tearo-
-...... texts.
mates commiserate and help plan the therapist's next move, somebody
lt 's like this with our clients. The OBT assumptions, that our clients on a dialectically informed team will wonder aloud:. Has the individual
,\ want to improve and at any given moment are doing the best lhey can, therapist inadvertently shap:d the client to communic1e distress in fhis
 . nd Secondary Targets, by Stage
24 ,.. , e- Herarchy of Prrmary a
DOING DIALECTICAL BEHAVIOR THERAPY -r.ASLi.: . :> .
. "dual Psychotherapy
of In d ,v,
~ behavioral targets
dysfunctional manner because he was not responding to lower-level com- pr1tll y tment
munications? Has he too bumt out as others have? Someone else on the ~ t m e~nt: Agreement and comm1
~ - als and methods
team will wonder if perhaps the team has played a role by shaping the Agree~:~;tg~mplete agreedupon plan
o conun1
therapist: Did the tearn's impatien ce with slow progress make the therapis t
.. ~oral control
hesitate to ask for h elp w ith the client's spora dic attendance and his own ..,._,._ l,di.avioral d~con.tro -+
Sttlgt 1:~~! ~ : . . .
sense of burnout? On a dialectically informed team, such dialogues are , .-- e.lif-threatening behav1ors ~
valued, not viewed as splitting and part of the client's pathology. l. ~ ~ a l or homicida} crisis beha':'1ors
The role of the individual therapist-the focus of this book-is to pro-
vide psychotherapy a nd work with the client to make progress toward ali
uic1 . 'dal self-inurious behav1ors
Nonsu1a
Suicida! ideation and com_mum~a
Suicide-related expectanc1es an
:t
t' s
ie
fs
treatment goals. While others h ave input, the individual therapist does Suicide-related affect . . .
the lion's share of treatment planning and crisis management. Next, I out- -~'ase
2. ~
thernpy-inre.rfering ~av10~ .
..:, - a1 ",!mterfenngbehaVtors
line the framework of treatment priorities that structures the conduct of J . Beae~e qu 1~-0 -ur~ ,
individual therapy. In DBT, the individual therapis t structures therapy 4_ ~~ }:>el:ta~lO~ skil\s
Core mindfu\ness
based on the extent of client disorder. With highly disordered clients, the Distre55 toleranc:e
therapy environment is highly structured. Interpersonal ef~ectiveness
Emotion regu latton
SelJ-management
Hierarchy of Treatment Goals and Targets
~~-: , ; _ . _ . . , ~ miotr ,1,:;rpuii,~
for Individual Therapy Sta 2=~"~ ,=-r-..;,;;.;;:- - - - -
ge ~- , 'ti ed based on individwil case formul,1t1on
No a priori hierarchy; instt?ad, pnor1 ,:
Toe key tool that individual therapis ts use to structure and prioritize their
many therapy tasks is the stage-based hiera rchy o treatment goals and [)ecre~ : toms (e. PTSO intrusiv symptoms) .
targets. Tr.eatment goals,are the overar_ching.desired erid pointfora stage of 1n1r:wve symp . g...(11 nd ~haviors that function ns 11vo1d11nce)
,a,vo,dance ol e.mohons .
.
(Le voidance 1hat includes wlut 1s Stt1l
Avoidance of situations and ~n~:~ted ~ 11voida.~ o tnuna-rela~ c ~es)
1
1.w rk~Target?)I!.DBTuarelbeaviors iclentified as needing change: whe.ther
to be increased or dec.reas~d. DBT s tages treatment using a commonsense in PTSD but that Is ~t (bpih h . yhtened ond inhbited emotion.al expenencmg,
Emotion dysregulahon ot e1g / . )
notion: 'Prioritize problems.according to the.threat they pose to a reasoi;i- specically related to anxlety/fear, angec, sadness, oc ishAme gu1 1t
able quality of life~The rapy tasks a re organized hiera.rchically so tha t the Se1f..inva1idatlon
mos t important tasks take priority over the less important. Line.han (1996)
has described DBT as a treatme.nt with five s tages. Table 1.5 shows the 5eaJrlda,ry behavioraltargel.1,(relevant llCTO$S ali stagn)
hierarchy of primary targets for prelTeatrnent, Stage 1, and Stage 2 in indi-
rn,crus,e emoton modulati.on
vidua l therapy. In addition, there are secondary treatment targets. These Decrole emotional reactivity
a ddress the behavior patte.ms, the dialectical dile.mmas, described earlier.
Little has been written and less researched about Stage 3 and Stage 4 of Lncre~ seU-validat ion
OBT. Linehan says that in;Stage 3, the.therapjst helps the client synthesii1( Dtt:reue Kt-1.nvaJidation
what was learned in earlie.r s tages, increase his or h er self-respect and the tncnue reallstic decision making and judgment
se.ns of abiding connection, and,work toward r~olving pioble.m.! i i-liv4 Decruse crisi.s-generating behavion
ing. In Stage 4, the therapist foc~ses .on the sens~ _oi ~~~ple te!'~ _thaf
lncrease emotional expmrndng
many individuals experience, e~.en ,~ter probl~s-m living _a re essentially
DK:reue inhibited gnevl.ng
esolved.' The task is to give up ego and parhapate fully m the moment
:Vith the goal oi becoming free oi the need for reality to be ~f~ent from ~ active problml aolving
it is at the moment. ~ lthoughthe-sti.ges,f thi!~PY are-ptesented.lii}e~) Oecrnse acti~ pusivity
erogress. is!often not J.in!:!l!:~~-.f!t...the.stag1:_s .9'(e.rlae, When problems arise Increee aa:wate commurucation
o emotons and competmcies
-;-is not uncommon t return to discussions like those of pretreatment to Oecruse mood dependmcy of behavior
~gain conunitment to the treatment goals or methods. At termination or
25
 26
27
DOING D IA LECTICAL BEHAVIO R THERAPY T h Circumstances
Tools fo r oug 11 eed base~d'
before b~eaks, especiallr_if no t well prepared, the client may resume Stage . t h ow therapy w 1 p~oc.
1 behaviors. The trans1tion from Stage 1 to 2 is also difficult for many, . . . ex ectat10ns a bou . d socia liza tion abou
therapy w ith imph c1!rie~ces. Explicit orientation :ctations can head o .
because ex:p osure work can lead to_inten se painful emotions and conse- on past therapy e_xp roles responsibilities and .~xpf r well-irormed con-
quent beh aviora l dyscontrol. Only p re treatment, Stage 1, and Stage 2 h ave client and therap1st d d, . poin tment a llowmg o
been acticulated to date and the,cefo,e l only cov,c these thcee stages dings a n isap \
in th1swell
book. misunders tan innino- therapy. . - nderstandably ambivalent
sent before beg .. o . the pretreatment stage u . . their. past treat-. \
Clients often enter therapy can off{}_r g1ven h.! dis.!
.~ .,_ .. . us .about what help . h, . .sf need to thoroug y
Pretreatment St age: O rientation and Commitment
lndtsusp1c10 - th client and t erap1 , . t that gen-
failures ..Therefore, e ' . . . - na theiap.ulic;_agr~emen - - : I '
DBT clients begin in pretreatmen tt Th e individual therapis ~and client men
C . ervations tq reac . . his 1ob to active y
A ]! i.Iss concen}_s an~ r~~ . - . .J T-h e therapist v1ews it as t n. t and
use this s_tructured pr~treatment phase to for1!1.._u l~te the problems the cli- .L. f b th parties. . retrea me
ent ~x:penences and taller a treatmen t plan . The goals re to learn eough. ~ ely wo;~n~:nc: the client's m otivatiohi~ s_:a ~~:~:;h~ most import~t
assess an needed-t s 1 . sed in
about each Other to determine Wh ether they can work together Weil as.~ throughout therapy whenev;r ific commitment strateg1es are u . A
team, agree to the essential goa ls and m e thods of treatmeC and theii""tor ts of DBT. A number o spec . h th change-oriented s trateg1es. .
mutually com.mit to complete the agreed-upn plan of therapyt targe d . T ble 11 w it o er . . lly com rrut-
DBT. These are liste _m a 1if h e or she is at least m1mma k d
Beca use DBT requires voluntary rather than coerced consent, both the . . ready to begm Stage . 11 et what they can ta e, an
client and the therapis t must have the ch oice of committing to DBT over ::1~:':ceatment~OBT thecap;,is t'.;'!~:~ y!dually shaping gceatec com-
an o ther non-DBT option. For example, in a forens ic unit or when a client is take what they can ge~. They wot t the t;eatment p rocess as I illustrate
t nt and motivatlon throug ou
legally m a nd ated to treatment, h e or she is not considered to have entered m1 m e h b ok
repeatedly throughout t e o . -
DBT until a con sidered verbal commitment is obtained. While it is not
important to have a written contract, it is important to have a mutual ver-
bal commitment to treatment agreements. Sp ecific ag reements may vary 5 . .
/ Attammg 8 as,e Capacities
by settin g and the client's problems. Por example, th.clientmght-agree tage . . Dyscontrol)
to work on identified treatme nt-targe ts for a specified length of time and (Reducing Behav1ora 1- el of disorder, whose
.th the most severe ev . i.fi
to attend al! sch edule9- sessions, pay fees andJhe ~ e. The:therapist mightJ St e'T 'clients are those w1 . so ervasive that they s1gn -
agree to provide the best_.treat:ri1ent pq_ssibJ~ (including increasing their pcot~ms and dyscontc;: ;: '.:,'!:,:;;;;
:7.h u/emp>, ai,d pse a th,eat.10
own skills as needed), to abide bf ethicaJ principles, and to participat c~Jly imp_'.'lir quaht)'." o I ' t re uire comprehensive DBT. The. pnmary
,!ife: These are the clients tha q h I the client a ttain the bas1c capaa-
a~~
in consultation. In the same m anner, therapists on the consultation team
undergo a pre treatment process as they consi_d er and agree tq consulta- . tr~~tment goals for Stage 1 to : ~ngaged in treatment, followed by
tion team agreements prior to joining the cons ultation team (described ties he or she needs to s tay a i~e a~ 1t of life llie individual thera.
. the cl1ents qua I Y .- .
in Chapter 7). All such agreements are in place before beginning formal
t:reatment. those !leeded to unpr~ve . e in sessions according.to the foUow~g pn-
pisJ. allocates treatmen~ tim h . . (2) therapy-interfering behav1ors of
. (1) lif threaterung be av1ors, . . th client.'.s
As in any CBT package, orieting strategies (change-oriented) are orities: e- . .ors that seriously compronuse e
used to vividly link treatment, methds to -the clie1:1t's ultima!~ goals so the therapist or client; (3) bfie~a~1 b ha~ioral capabilities needed ! mak~
quality of life; and (4) de ats m e . .
that the clien t under stands .w hat isprposeci, why..,it i_s_;p.rop.osed, and,
h ow to do it. Orienting is p artic tflai-!y e~p~astt~d.ti o~T; fiot ,Pnly, a.t life changes. . . life-threatening behaviors, pn-
the beginning of treatment but throughout,_'bec~use-emot1on dys~egula- -- Within the highest pr~ondty catedg?ry,order of priority) to: suicide or
h ned (m escen mg . "dal
tion m ay disrupt collaboration \ vith"therapy tasks: ~ven well~cons1.dere~, ority. is.d furt . er
s asstg . . nonsu1c1
behav1ors, . "dal self-inurious behavior; su10
b liefs
gen tly offered th erap ist interventions can be exp ~nenced as h1!5hly mvali- hom1c1 . e cnsi . . . s1.uc1
. 'd e _related exnectancies andTI.. . e yJ,
~ ~a~
. d commun1cahons, r
dating. Conseguently, you must fregu ently explam why a particular tre~t-
~
ideation d ff t These are also listed in Table 1.5. ,..,... /
ment task is necessar y to reach th e dient's goaJs and further, you w!H and suiCide-relat~ ec . behavior of either the..client or the therap.s.t
need to instruct the client specifically h ow to do the therapy t~sk desp1te .. f fering behav1or 1s. ariy_ - .- . - th t' prorruses
m er . ei ffects the therapeutic Ielationship 9r a _i:om :- . -
or in the face of emotion dysregulation . Additionally, n;tany chents enter that_effctiveness
.tb~ negat~v y a of. treatment. .- For c1ien ts this may include nussmg
 29
28
DOING DIALECTICAL BEHAVIO R T HERAPY Tools for Tough Circumscances

' sessions excess h ldber 2007 Fruzzetti, Santisteban, & Hoff-

! in th ' ive ps:yc iamc hospitalization, inability or refusal to work DuBose, Dexter-Mazza, & Cho . gt'does ~hat is needed to help the client
erapy, and excess1ve demand th h - 2007 Porr 2010). The t erap1s . .
indude for . . son e t erap1st. For therapists this may
~:::~fer ;hat i; learned in therapy to the client's daily hf.e.
phone callsge~t~g ~ppomn:nents or bein g late to them, failing to retum

~m;:;::~~m~;:;b::i:::;y~".:'!:;-;;i~~:~~:~:;f
sub e. ~roblems such as mood or anxiety ...discfrders;
e 2 . Nontraumatizing Emotional Experience
Stag . . B hav,ors Related to Posttraumatic Stress)
15 (Decreasing e .
1 -
e na~c:i~b:~~r : a :~ .d order~;1:s~cho~c and dissciativphei.9- . . 1 t 1 d become more f unchonal,
. . . p o ems such as an mability to inaitain 'stable hous..:. As clients stabilize, gain _b ehav1ora con ro ' an& L. h 2006) iln stagel
~ ll)g, m attention to m ed ica! problems, 1o~es.tic yioleri~e~ag sii":o'ii - - ' a enter Stage 2 of treatment (Wagner m~ _a_n,. .. _. -4
cm
,t ~:;nci;nr ;,~rl:s . -pQ~ttrat:!Il}atjc S~;SS_ disorder (P-'f~~)_r:~'?ns~J
' Th~ Diary Card ~, -d...t-: - attz
an raum
- m -g- e-m
otional experiences. tiere the_targets__may. mclude
'> . . ) d r,
:d _...,. . m trusive.syrriptoms (e.g., PTSD-intrus1ve symptoms; avo~ :-.
ecreasmg . . -. d ) d a:void-"'
The individual therapist manito tli d -- - -. f 0 ti:o0 s (nd-behaviors that functon as avo~ anee an .
the ,client's dail . _. ::-- ~ -~~ an,._Q!l'ter_J<:ey_behaviors through ,anc;e ,. ~ o
:._ f .em
,. -t - t ns -
a n
=- exp
er1
ences (1
.. .
e,~avo1dance that
1nc u d es. w hat 15
st t f Y _comp1etion _()f...a _diary_,ru:_d. Review of the card at the ,-nce o s1 ua 10 ~ : - - - - - -
a r ~ ev~ry session helps the therapist determine what tar ets ma need - -. .P..Ts-o but that s not specifically .li.mi.t~.d .to avoidance-of-trauma-
seen ,m - ,. . - d d hib 't d o
a ttention m that session. 1Lti:i:0iet failst5'-.Cilltou(ii.e'~d!'- ..~Y... , ,.
to the se - . - - ,car ,or.:1,.mng tJ
'rel~t;~"G"i~[~~~!~!l !'.!Ysre~\ation (both heigh_tene an m 1 e em -
ss10n, 1t IS treated =as.thrapy~inferfei:ig oehaviod 1be th t ' n~f'experiencing, specifically related to anx1ety/fear, anger, sadness, "
then w orks on ta_rgets in arder of priority by we~~gt~gether the::~e shame/guilt); ~~-:E~~~jQ-.t!.fl_ In contra~t to Stage 1 t~rg~t_s,_.S~age 2t_
treatment strategies (change, validation, and dialectics). The priority of a t . etsare not-thqught:of,hierarch1cally.but mstead the pr~o,r._iti_zatiQn .~t
target need_n?t a_l'w~ys equate with the amount of session time spent on it. t:~~ts_i~;".det~~~d,-~y.Jb.~ ~E:vel of.severy ~1:d life disn:ptior:1 caused by.
The therap1s
. t s a1m
. 1s to. get the most progress in each c11rucal.m terac t10n, the~prob~:rris;tl,.e .clints' goals,.and_the.funchonal re~ationshir be~een
b a 1ancmg
1 what 1s most unportant with the client's capability and th t
av a.i1a ble. Th lS
IS
. d escnb ed in detail in Chapter 6. e ime
,1:arM~i f For example, if intrusive images_provoke~ an mcreas~ m s~1c1~al
ideation, they might be prioritized. If, mstead, ~ten~~ sel~-mv~hdatton
and self-loathing were most related to in creases m suic1dal 1deat10n, that
1
Priorities for Phone Consultation would be prioritized. . .
- ' Because of the lifetime prevalence of PTSD among treatment-seekmg
The .individual: therapi~~-.0.- al~?.~!.~~ ~~~ o~ ~~p9~si~!?-f~~,.seeing,
that new b~hav10rs are gen~ra,1.izecLto ali relevantenvrronmen'ts1:r.IW tnet-
. ,
individuals with BPD (36-58%; Linehan, Comtois, Murray, et a l., 2006;
Zanarini et al., 1998; Zanarini, Frankenburg, Hennen, & Silk, 2004; Zim-
apist notonly uses the.,_~er1pe~,e_atic;:~lup~s,ii~l;ey.(place 1!'.>r~g.iets, rnerman & Mattia, 1999) and the high incidence of reported new experi-
,to learn and app_ly ne~ resp2,~~~~l~~~H:~ ~ .~~~lt;1.:1..q_*-e~;!h~r~j:>y,~ ences of adult abuse (Zanarini, Frankenburg, Reich, Hennen, & Silk, 2005;
to ensure ~~at IS lea~ed g~I}er1.i.~~s:!o...all,'neededL~ ntex ts. To do this, Golier et al., 2003), exposure-based CBT protocols such as prolonged exp o-
the ~herapist ~es ph~ne _consultation and i~ vi~o therapy (i.e., therapy sure should be considered (e.g., Foa et al., 2005; Foa, Rothbaum, Riggs-,
outs1de the office), which m standard DBT w1th h1ghly suicida! and emo- & Murdock, 1991). However, b ehaviors common to people.with emotiOI} \
tionally dysregulated clients, is considered essential. There are different idysr~tion ar~ ~ssociated-unfortunately .~ ith, poore!'_outcome in pro-~
priorities for p_h?ne ~~~ :~.!!...!~: in~~=:;.l t~:rapy sessions. In phone lon~d .exposjgi (e.g., avoidance, severe depression, overwhelming anxi-
calls, fue theraplSt. p~:.1~ ; ; ~i)1aecreasmg-t.l!i.ci.9.e~~~-Mnaf.ib'rr~ ety, gu:, shame, anger, excessive physical tension, numbing, and diss o-

~
{2) increasing ge~~riiliz - . ~ ~~~~::rns~~~!.~ecreasingitlf~s_eru;][pfJ:oh_;;
fct, alienation, ano clisfanceUrorli'lte1.t}je..rap~ :i!Jh'esgI<:QXc;:bfug,:calls are
brief typically 5-10 i:itjn}it~.:..ij[dgfiiJjog. fi.lrdru!iplfrppn~~g
. the'therapist~igh~~e f~~~~~~g an9;_~tmerlfs'JfUL~p_e_ajj~
f'.f>p;l.lllunities, m.vu:_o mteJ._:'~ tippsj(~as~ g ~ ~ ~eWRfJ~~~\&n
t,epes, and systems mterve~pn - Tl:is f~ct;~n of generalization can also
include family and others m the client s socral network (Miller, Rathus,
ciation; Foa & Kozak, 1986; Foa, Riggs, Massie, & Yarczower, 1995; Jaycox
& Foa, 1996; Meadows & Foa, 1998; Feeny, Zoellner, & Foa, 2002; Hembree,
Cahill, & Foa, 2004; McDonagh et al., 2005; Zayfert et'al., 2005) .
}1gca~~ ~Lt!'eJr..~Ji,~~lty regul~ting ~E tq_~er~tingJntE:r!>~ ~II)otiqhs,
:~om~JJ:i:~r~J:may .be a increased...r.is~ of. impulsiv_e ancL~~lj-;des~c.t"!v~ 0
_behv.iqr~;.g.~_g ea>.2~~e-pased tnerapy:,Therefore, . in DBT, the client
and ~herapist are encouraged to carefully assess readiness to engage in
 30
DOING DIALECTICAL BEHAVIOR THERAPY
Tools for Tough Circumstances 31
~xposure-based. ~herapy (Stage 2). Tentatively, indicators of readiness
mclud_ec the ability to control suicida! and noosuicidal self-inju.n . 1 Any given momentis like
behav1or (e.g., abstmence from these behaviors for 2-4 mo th ) finn. 045 {rom several sets of p~inciples simuit~n~ous ~g holding all the threads,
.
comnutment not to engage in these behaviors in the futu e n ds,a d hand-weaving an intr~cate ta~e~try. tliat:rn bef~re you yet moving with
. . to '."'e sk,lls
strated a~ility r, an u,emon-
. to elfecHvely manage urges to engage these' orking the tiny sechon_thats imme h \nehan .rst began to teach
w . . mmd In fact, w en 1 . h " ' .
behav,_'" The chent and therap;st m;ght test whether the client is readf . the overall p1cture m li . ical demonstrations often said to er, you re
to be_g m Stage 2 work by choosing an ;tem from the exposure hier.u:chy
that IS of _Jow d 1stress and see how he or she manages it. Exposure may
DBT others who saw he_r c n
r
. l effective personal style and
a gifted therapi.?t. You ha~e an ;mazmg else could pull that off." And
understanding of thes~ patie_nts, : : o :~d ractice, have indeed "pulied
be contra,_n d,cMed whe~ the chent cannot be exposed to the trauma cues 15t th
et hundreds of therap s, wi tr ) g I:> his analysis of outstand-
w ithout d1ssoc1ating or is currently experiencing crises or Jogistical ssues
that would block participaton in treatrnent. i off." As Makolm Gladwe~l {2~08 1rgtu_ess.:portant it's not talent that
h"l' sorne mnate ta en 1 i ' . A d
Many treatment development ellorts are under way to adapt expo- ing performers, w 1 e . es and good outcomes. It's practice. n
s_ure-based ~r~cedu res f~r ind1v1duals with pervasive emoton dysregula- explains performance ~ff~re;c to conceptualize the client's problems
h?n a nd su1c1dal behav1o~s, ncluding technques designed to improve the first thing to pract1ce is oCwh t 2 I'll describe how case formula-
. . 1 of DBT In ap er ' . . ki
d1stress tolerance, lurther lltrate anxiety and other emotfons during expo- using. the prmc1p
d DBT es to structure
. the therapist's clinical dec1s1on rna ng
h full
sure, and rnanage suicidality. For those with less severe disorder (e.g., tion is use m 1 for an 1n . d.1v1"d u al c11ent Whether you use t e .
those without s uicidal and nonsuicidal self-injurious behavior) an abbre- and treatrnent p annmg_ . t d use its philosophy and strateg1es
del of DBT or ms ea , fir t
viated course o{ DBT s kills tra ining prior to exposure (e.g., Cloitre et al., comprehens1ve
to inform your t~erapy, case forrnu1a fion is the individual therap1st s , s
rno
2002), a DBT-nformed exposu re treatment (e.g., Becker & Zayfert, 2001; step.
Zayfert et al., 2005), ora standard expos ure trea tment w ithout any prim-
ing intervention might work. Harned and Linehan's (2008) preliminary
data suggest that clients quite ea rly in Stage 1 DBT can in fact success-
fully participa te in prolonged exposure for PTSD if they are well oriented,
behav.ior is stabilized, and sufficient emotion regulation skiUs have been
acquired. It's to be expected tha t cents may continue to experience low to
moderate urges to self-injure or attenpt suicide while undergoing expo-
sure treatment. If these urges become too intense, exposure therapy may
need to be temporarily postponed while the primary therapis t helps the
client regain or strengthen behavioral control_. Far this reason it may be
helpful to have a different therapis t conduct exposure th~rap~ while the
individual therapist continues his or her us ual DBT sess1ons m tandem .
with the exposure work. . , .
By staging trea tment based on the extent of th~ chent s disorder and
prioritizing client behavioral problems, the therap~_t_s!ays clear on th~
highest priorities, e ven in chao tic cir~u~tan:es. Across all: st~ges, .DIJT
emphasizes Ieaming to regulate emoton. W~e-the ~mo:~t _C?{ s~c!U{e
in the treatment environment deperids on the extent o( ,client_d~sorder.,
the biosocial theory and core strategies remain_ stea~y. Applr_m_g_ the
core strategies of DBT-change, validation, and d1a!ectics-may 1ruh~lly
appear straightforward, but the devil is in the details._ In ~ver-chang1:g,
often high-risk and emotionally challenging clinical s1tuahons, 1:>Pl.y1~g
even straightforward concepts becomes complicated. The. nearly infn:i e
if-then circumstances of clnica! work mean that you often are workm?