Cognitive-Behavioral Treatment of Borderline Personality Disorder

by Linehan, Marsha M.

• ISBN13: 9780898621839
• ISBN10: 0898621836
• eBook ISBN(s): 9781606237786
• Edition: 1st
• Format: Hardcover
• Copyright: 1993-05-14
• Publisher: The Guilford Press
• More Book Details

Summary

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 psychosocial 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.

Author Biography

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.

Table of Contents

PART I. THEORY AND CONCEPTS
Borderline Personality Disorder: Concepts, Controversies, and Definitions	3	(25)
The Concept of Borderline Personality Disorder	5	(8)
The Concept of Parasuicidal Behaviors	13	(2)
The Overlap Between Borderline Personality Disorder and Parasuicidal Behavior	15	(4)
Therapy for Borderline Personality Disorder: A Preview	19	(6)
Concluding Comments	25	(1)
Notes	26	(2)
Dialectical and Biosocial Underpinnings of Treatment	28	(38)
Dialectics	28	(7)
Borderline Personality Disorder as Dialectical Failure	35	(2)
Case Conceptualization: A Dialectical Cognitive--Behavioral Approach	37	(5)
Biosocial Theory: A Dialectical Theory of Borderline Personality Disorder Development	42	(20)
Implications of the Biosocial Theory for Therapy with Borderline Patients	62	(2)
Concluding Comments	64	(1)
Notes	65	(1)
Behavioral Patterns: Dialectical Dilemmas in the Treatment of Borderline Patients	66	(31)
Emotional Vulnerability versus Self-Invalidation	67	(11)
Active Passivity versus Apparent Competence	78	(7)
Unrelenting Crises versus Inhibited Grieving	85	(8)
Concluding Comments	93	(1)
Notes	94	(3)
PART II. TREATMENT OVERVIEW AND GOALS
Overview of Treatment: Targets, Strategies, and Assumptions in a Nutshell	97	(23)
Crucial Steps in Treatment	97	(4)
Setting the Stage: Getting the Patient's Attention	97	(1)
Staying Dialectical	98	(1)
Applying Core Strategies: Validation and Problem Solving	99	(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