Dialectical Behavior Therapy in Private Practice

310 Pages·2005·1.689 MB·English

by  Thomas Marra

“Marra has produced a first-rate book that takes the reader, step-by-step,
through the theory and practice of dialectical behavior therapy (DBT).
He is a wonderful guide, leading us by the hand, pointing out where we
need to attend to theory, empirical research, and clinical observation and
intuition. Drawing on the latest acceptance-based and mindfulness
approaches, he mixes personal observation with literature review and
clinical cases and provides a superb synthesis of the way DBT can be
applied to many different psychological problems. Many therapists who
have been intrigued by Marsha Linehan’s pioneering work will be glad of
Thomas Marra’s expert guidance in applying it to help a wide variety of
their patients.”
—J. Mark G. Williams, professor of clinical psychology
and Wellcome Principal Research Fellow in the
University of Oxford Department of Psychology,
Werneford Hospital, in Oxford, UK, and coauthor of
Mindfulness-Based Cognitive Therapy for Depression
“Dialectical Behavior Therapy in Private Practice is a wonderful addition to
the busy clinician’s resource library for evidence-based clinical practice.
Marra summarizes the research to date on DBT and mindfulness
applications, and provides the clinical tools for readers to transport this
treatment technology into their own clinical practices. Key features of
DBT are articulated for a range of clinical problems. Practitioners will
likely find the illustrations of subtle distinctions between DBT and other
cognitive behavioral interventions extremely useful. Clinical strategies for
combining individual therapy and skills training in a private practice
setting are also thoroughly considered. The text even comes with
PowerPoint presentations and handouts for conducting skills training
sessions. DBT in Private Practice aptly encompasses both scholarly and
practical issues of essential concern to today’s providers.”
—Denise D. Davis, Ph.D., clinical psychologist
and assistant director of clinical training in the
Department of Psychology at Vanderbilt University
in Nashville, TN
“While many are intrigued by DBT, few practice it. This book will
change that as therapists in any practice setting can apply DBT to several
diagnoses thanks to the author’s guidelines, case transcriptions, and
downloadable materials. Written by a masterful clinician, this exciting
clinical text represents the cutting edge in cognitive behavior therapy.”
—Len Sperry, MD, Ph.D., author of Cognitive Behavior
Therapy of DSM-IV Personality Disorders and Handbook
of Diagnosis and Treatment of DSM-IV-TR Personality
Disorders, Second Edition
“This book is a valuable compendium of information on how to practice
DBT. Marra has succeeded in expanding the focus of DBT to include
most forms of psychopathology and provides everything therapists need
to begin using DBT in their own practice.”
—Susan Bradley MD, FRCP, professor of psychiatry
at the University of Toronto and author of Affect
Regulation and the Development of Psychopathology
“Marra’s book, Dialectal Behavior Therapy in Private Practice, makes this
especially powerful and useful model easily accessible to the practicing
clinician. The volume’s strength and value come in the clear exposition
of the model that is required for the uninitiated, and it is a valuable
review for those experienced in DBT. This presentation is essential so
that the clinician is not simply mechanically applying techniques without
a clear theoretical, philosophical, and conceptual basis for the DBT
treatment model. This is a book written by a skilled and knowledgeable
clinician for the practicing therapist. The text is clear, the prose easily
digested, and the content immediately useful. Worth twice the price of
the book are the downloadable forms and worksheets for use with
patients and a series of PowerPoint presentations that visually presents
the model. This volume has great potential as a teaching text for graduate
students in the broad range of clinical education.”
—Arthur Freeman, Ed.D., ABPP, professor of psychology
and dean of the School of Professional Studies at the
University of Saint Francis, Fort Wayne, IN
Dialectical
Behavior
Therapy
in
Private Practice
A Practical and Comprehensive Guide
THOMAS MARRA, P D
h
New Harbinger Publications, Inc.
Pub lisher’s Note
This publ i ca tion is designed to prov ide accu rate and authori t at ive inform a tion in regard to the subj ect mat ter
cov ered. It is sold with the unders tand ing that the publ isher is not engaged in rend eri ng psyc ho log ic al, finan cial,
legal, or other prof ess ional serv ices. If expert assis tance or coun sel ing is needed, the serv ices of a com pet ent pro-
fes sional should be sought.
Dis trib uted in Can ada by Raincoast Books
Copyr ight © 2005 by Thomas Marra
New Harb ing er Publ ic at ions, Inc.
5674 Shattuck Ave nue
Oak land, CA 94609
No part of this publ ic at ion may be reprod uced, stored in a retrieval syst em, or transm itt ed in any form
or by any means witho ut prior writt en per miss ion. Reprod uct ion proh i bi tions do not apply to the forms
cont ained in this produ ct when repro duced for the per sonal use of the orig i nal pur chaser.
PowerPoint ® Viewer copyr ight © 2004. All rights reserved. Microsoft and PowerPoint are reg ist ered
trade marks of Microsoft Cor por at ion.
Cover design by Amy Shoup
Text design by Michele Waters-Kermes
Acquired by Catha r ine Sutker
The Library of Cong ress has cata loged the hard cover edit ion as:
ISBN 1-57224-420-8
All Rights Reserved
New Har bin ger Pub li ca tions’ website address: www.newharbinger.com
Contents
Acknowl edg ments vii
INTRODUCTION
How to Use This Book 1
CHAPTER 1
Dia lec ti cal Behav ior Ther apy: A New The o ret i cal Ori en ta tion 5
CHAPTER 2
Evi dence for the Effec tive ness of DBT 17
CHAPTER 3
Pathogenesis: Emo tion Reg u la tion as a Core Ther a peu tic 43
Tar get
CHAPTER 4
Pathotopology: Dia lec tic Con flict as a Core Ther a peu tic 67
Tar get
iv Dialectical Behavior Therapy in Private Practice
CHAPTER 5
Dia lec tic Psy cho ther apy: Bal anc ing Accep tance with Change 89
CHAPTER 6
DBT: Not Just for Bord erl ines Anym ore 115
CHAPTER 7
Psyc ho logi c al Copi ng Skills Replace Escape and Avoida nce 177
CHAPTER 8
Con duct ing DBT in Pri vate Prac tice 217
APPENDIX
How to Use the Downloads 253
Ref er ences 267
Index 289
Tables and Figures
TABLE 1: Expos ure as Treatm ent of Choice for Avoidant and Escape 19
Defenses
TABLE 2: Neuroanatomic Func tions 52
TABLE 3: Neu ro trans mit ters and Their Func tions 55
FIGURE 1: Slow return to emot ional basel ine foll owi ng threat 71
TABLE 4: Comp ari s on of CBT and DBT Cogn it ive Reframing 81
Strat egies
TABLE 5: Summ ary of DBT Gene ral Strate gies 87
TABLE 6: Dia lec tics of the Psy cho ther apy Rela tion ship 91
TABLE 7: Dia lec ti cal Issues in Stra te gic Behav ior 110
TABLE 8: Dia lec tics with Mood Dis or ders 117
TABLE 9: Dia lec tics with Anx i ety Dis or ders 124
TABLE 10: Dia lec tics with Eating Dis or ders 129
TABLE 11: Dia lec tics with Sub stance Abuse Dis or ders 132
TABLE 12: Dia lec tics with Inter mit tent Explo sive Dis or der 136
vi Dialectical Behavior Therapy in Private Practice
TABLE 13: Dia lec tics with His tri onic Per son al ity Dis or der 146
TABLE 14: Dia lec tics with Avoidant Per son al ity Dis or der 148
TABLE 15: Dia lec tics with Obses sive Com pul sive Per son al ity Dis or der 155
TABLE 16: Dia lec tics with Nar cis sis tic Per son al ity Dis or der 160
TABLE 17: Dia lec tics with Schiz oid Per son al ity Dis or der 168
TABLE 18: Dia lec tics with Para noid Per son al ity Dis or der 174
TABLE 19: Funct ion of DBT Skills Modu les 184
TABLE 20: Dia lec tics of Stra te gic Behav ior 208
FIGURE 2: Wisd om attends to all forms of know ing avail able 211
TABLE 21: Exam ples of DBT Interv ent ions 228
TABLE 22: DBT Examp les of Shifting Strate gies 231
TABLE 23: Trans fer ence Exam ples 245
TABLE 24: Dis rup tive Ther apy Prob lems and Solu tions 247
TABLE 25: Dial ect ic al Behavi or Thera py Psyc hol ogi c al Coping Skills 253
Pro gram
TABLE 26: Worksheets for DBT Psyc hol ogi c al Coping Skills Pro gram 254
TABLE 27: Mind ful ness Skills Training 258
TABLE 28: Mean ing-Making Skills Training 259
TABLE 29: Emo tion Reg u la tion Skills Training 260
TABLE 30: Dis tress Tol er ance Skills Training 262
TABLE 31: Strat eg ic Behavi or Skills 263
TABLE 32: Dia lec tic Teaching Points 264
Acknowledgments
As with the patient work book for mat (Depressed & Anxi ous: The Dial ect ic al Behav ior
Ther apy Work book, New Har bin ger Pub li ca tions, 2004) of this expanded use of DBT
to mul ti ple diag no ses, the intel lec tual con tri bu tions of Dr. Mar sha Linehan are greatly
acknowle dged. The neur op syc hia tr ic underp inn ings of affect regu l at ion and the
devel opm ent of psychopathology are sub stan tially con trib uted to by the schol ar ship of
Susan Bradley. Zindel Segal, Mark Wil liams, and John Teasdale’s expans ion of mind-
ful ness-b ased thera py subs tan tially influe nced my work, as did those who have
expanded the cog ni tive behav ioral tra di tion to the treat ment of per son al ity dis or ders
(such as Aaron Beck, Arthur Freem an, Denise Davis, and Len Sperry). The macro
ana lytic think ing of Dan iel Goleman, S. C. Hayes, and Paul Wachtel is also appre ci -
ated. To the pub lisher, Dr. Matt McKay, edi tor Carole Honeychurch, acqui si tions
direc tor Cath ar ine Sutker, and the entire pro duc tion staff of New Har bin ger Pub li ca -
tions who tole r ate my fix at ions, I owe great debt.
As with the first book, my wife Judy and boys (Ste ven and Dan iel) are due grat i -
tude for their per se ver ance with me in this con tin ued effort.