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An edition of Cognitive-behavioral treatment of borderline personality disorder (1993)

Cognitive-behavioral treatment of borderline personality disorder

by Marsha Linehan

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An edition of Cognitive-behavioral treatment of borderline personality disorder (1993)

Cognitive-behavioral treatment of borderline personality disorder

by Marsha Linehan

15 Want to read
1 Currently reading

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Publish Date

1993

Publisher

Guilford Press

Language

English

Pages

558

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Table of Contents

Part I. Theory and Concepts

1. Borderline Personality Disorder: Concepts, Controversies, and Definitions

The Concept of Borderline Personality Disorder

The Concept of Parasuicidal Behaviors

The Overlap Between Borderline Personality Disorder and Parasuicidal Behavior

Therapy for Borderline Personality Disorder: A Preview

Concluding Comments

2. Dialectical and Biosocial Underpinnings of Treatment

Borderline Personality Disorder as Dialectical Failure

Case Conceptualization: A Dialectical Cognitive-Behavioral Approach

Biosocial Theory: A Dialectical Theory of Borderline Personality Disorder Development

Implications of the Biosocial Theory for Therapy with Borderline Patients

Concluding Comments

3. Behavioral Patterns: Dialectical Dilemmas in the Treatment of Borderline Patients

Emotional Vulnerability versus Self-Invalidation

Active Passivity versus Apparent Competence

Unrelenting Crises versus Inhibited Grieving

Concluding Comments

Part II. Treatment Overview and Goals

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

Crucial Steps in Treatment

Setting the Stage: Getting the Patient's Attention

Staying Dialectical

Applying Core Strategies: Validation and Problem Solving

Balancing Interpersonal Communication Styles

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

Treating the Therapist

Modes of Treatment

Individual Outpatient Psychotherapy

Skills Training

Supportive Process Group Therapy

Telephone Consultation

Case Consultation Meetings for Therapists

Ancillary Treatments

Assumptions About Borderline Patients and Therapy

1. Patients Are Doing the Best They Can

2. Patients Want to Improve

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

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

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

6. Patients Must Learn New Behaviors in All Relevant Contexts

7. Patients Cannot Fail in Therapy

8. Therapists Treating Borderline Patients Need Support

Therapist Characteristics and Skills

Stance of Acceptance versus Change

Stance of Unwavering Centeredness versus Compassionate Flexibility

Stance of Nurturing versus Benevolent Demanding

Agreements of Patients and Therapists

Patient Agreements

Therapist Agreements

Therapist Consultation Agreements

Dialectical Agreement

Consultation-to-the-Patient Agreement

Consistency Agreement

Observing-Limits Agreement

Phenomenological Empathy Agreement

Fallibility Agreement

Concluding Comments

5. Behavioral Targets in Treatment: Behaviors to Increase and Decrease

The Overall Goal: Increasing Dialectical Behavior Patterns

Dialectical Thinking

Dialectical Thinking and Cognitive Therapy

Dialectical Behavior Patterns: Balanced Lifestyle

Primary Behavioral Targets

Decreasing Suicidal Behaviors

Decreasing Therapy-Interfering Behaviors

Decreasing Behaviors That Interfere with Quality of Life

Increasing Behavioral Skills

Decreasing Behaviors Related to Posttraumatic Stress

Increasing Respect for Self

Secondary Behavioral Targets

Increasing Emotion Modulation; Decreasing Emotional Reactivity

Increasing Self-Validation; Decreasing Self-Invalidation

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

Increasing Emotional Experiencing; Decreasing Inhibited Grieving

Increasing Active Problem Solving; Decreasing Active-Passivity Behaviors

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

Concluding Comments

6. Structuring Treatment Around Target Behaviors: Who Treats What and When

The General Theme: Targeting Dialectical Behaviors

The Hierarchy of Primary Targets

Treatment Targets and Session Agenda

Treatment Targets and Modes of Therapy

The Primary Therapist and Responsibility for Meeting Targets

Progress Toward Targets Over Time

Pretreatment Stage: Orientation and Commitment

Stage 1: Attaining Basic Capacities

Stage 2: Reducing Posttraumatic Stress

Stage 3: Increasing Self-Respect and Achieving Individual Goals

Setting Priorities within Target Classes in Outpatient Individual Therapy

Decreasing Suicidal Behaviors

Decreasing Therapy-Interfering Behaviors

Decreasing Quality-of-Life-Interfering Behaviors

Increasing Behavioral Skills

Reducing Posttraumatic Stress

Increasing Self-Respect and Achieving Individual Goals

Using Target Priorities to Organize Sessions

Patient and Therapist Resistance to Discussing Target Behaviors

Individual Therapy Targets and Diary Cards

Skills Training: Hierarchy of Targets

Supportive Process Groups: Hierarchy of Targets

Telephone Calls: Hierarchy of Targets

Calls to the Primary Therapist

Calls to Skills Trainers and Other Therapists

Target Behaviors and Session Focus: Who Is in Control?

Modification of Target Hierarchies in Other Settings

Responsibility for Decreasing Suicidal Behaviors

Responsibility for Other Targets

Specifying Targets for Other Modes of Treatment

Turf Conflicts with Respect to Target Responsibilities

Concluding Comments

Part III. Basic Treatment Strategies

7. Dialectical Treatment Strategies

Defining Dialectical Strategies

Balancing Treatment Strategies: Dialectics of the Therapeutic Relationship

Teaching Dialectical Behavior Patterns

Specific Dialectical Strategies

1. Entering the Paradox

2. The Use of Metaphor

3. The Devil's Advocate Technique

5. Activating 'Wise Mind'

6. Making Lemonade Out of Lemons

7. Allowing Natural Change

8. Dialectical Assessment

Concluding Comments

8. Core Strategies: Part I. Validation

Defining Validation

Emotional Validation Strategies

1. Providing Opportunities for Emotional Expression

2. Teaching Emotion Observation and Labeling Skills

3. Reading Emotions

4. Communicating the Validity of Emotions

Behavioral Validation Strategies

1. Teaching Behavior Observation and Labeling Skills

2. Identifying the 'Should'

3. Countering the 'Should'

4. Accepting the 'Should'

5. Moving to Disappointment

Cognitive Validation Strategies

1. Eliciting and Reflecting Thoughts and Assumptions

2. Discriminating Facts from Interpretations

3. Finding the 'Kernel of Truth'

4. Acknowledging 'Wise Mind'

5. Respecting Differing Values

Cheerleading Strategies

1. Assuming the Best

2. Providing Encouragement

3. Focusing on the Patient's Capabilities

4. Contradicting/Modulating External Criticism

5. Providing Praise and Reassurance

6. Being Realistic, but Dealing Directly with Fears of Insincerity

7. Staying Near

Concluding Comments

9. Core Strategies: Part II. Problem Solving

Levels of Problem Solving

Mood and Problem Solving

Overview of Problem-Solving Strategies

Behavioral Analysis Strategies

1. Defining the Problem Behavior

2. Conducting a Chain Analysis

3. Generating Hypotheses about Factors Controlling Behavior

Insight (Interpretation) Strategies

What and How to Interpret: Guidelines for Insight

1. Highlighting

2. Observing and Describing Recurrent Patterns

3. Commenting on Implications of Behavior

4. Assessing Difficulties in Accepting or Rejecting Hypotheses

Didactic Strategies

1. Providing Information

2. Giving Reading Materials

3. Giving Information to Family Members

Solution Analysis Strategies

1. Identifying Goals, Needs, and Desires

2. Generating Solutions

3. Evaluating Solutions

4. Choosing a Solution to Implement

5. Troubleshooting the Solution

Orienting Strategies

1. Providing Role Induction

2. Rehearsing New Expectations

Commitment Strategies

Levels of Commitment

Commitment and Recommitment

The Need for Flexibility

1. Selling Commitment: Evaluating the Pros and Cons

2. Playing the Devil's Advocate

3. 'Foot-in-the-Door' and 'Door-in-the-Face' Techniques

4. Connecting Present Commitments to Prior Commitments

5. Highlighting Freedom to Choose and Absence of Alternatives

6. Using Principles of Shaping

7. Generating Hope: Cheerleading

8. Agreeing on Homework

Concluding Comments

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

The Rationale for Contingency Procedures

The Distinction Between Managing Contingencies and Observing Limits

The Therapeutic Relationship as Contingency

Contingency Management Procedures

Orienting to Contingency Management: Task Overview

1. Reinforcing Target-Relevant Adaptive Behaviors

2. Extinguishing Target-Relevant Maladaptive Behaviors

3. Using Aversive Consequences ... with Care

Determining the Potency of Consequences

Using Natural Over Arbitrary Consequences

Principles of Shaping

Observing-Limits Procedures

Rationale for Observing Limits

Natural versus Arbitrary Limits

1. Monitoring Limits

2. Being Honest About Limits

3. Temporarily Extending Limits When Needed

4. Being Consistently Firm

5. Combining Soothing, Validating, and Problem Solving with Observing Limits

Difficult Areas for Observing Limits with Borderline Patients

Concluding Comments

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

Skills Training Procedures

Orienting and Committing to Skills Training: Task Overview

Skill Acquisition Procedures

Skill Strengthening Procedures

Skill Generalization Procedures

Exposure-Based Procedures

Orienting and Commitment to Exposure: Task Overview

1. Providing Nonreinforced Exposure

2. Blocking Action Tendencies Associated with Problem Emotions

3. Blocking Expressive Tendencies Associated with Problem Emotions

4. Enhancing Control Over Aversive Events

Structured Exposure Procedures

Cognitive Modification Procedures

Orienting to Cognitive Modification Procedures

Contingency Clarification Procedures

Cognitive Restructuring Procedures

Concluding Comments

12. Stylistic Strategies: Balancing Communication

Reciprocal Communication Strategies

Power and Psychotherapy: Who Makes the Rules?

1. Responsiveness

2. Self-Disclosure

3. Warm Engagement

The Need for Therapist Invulnerability

Irreverent Communication Strategies

Dialectical Strategies and Irreverence

1. Reframing in an Unorthodox Manner

2. Plunging in Where Angels Fear to Tread

3. Using a Confrontational Tone

4. Calling the Patient's Bluff

5. Oscillating Intensity and Using Silence

6. Expressing Omnipotence and Impotence

Concluding Comments

13. Case Management Strategies: Interacting with the Community

Environmental Intervention Strategies

Case Management and Observing Limits

1. Providing Information Independently of the Patient

2. Patient Advocacy

3. Entering the Patient's Environment to Give Her Assistance

Consultation-to-the-Patient Strategies

Rationale and Spirit of Consultation to the Patient

The 'Treatment Team' versus 'Everyone Else'

1. Orienting the Patient and the Network to the Approach

2. Consultation to the Patient about How to Manage Other Professionals

3. Consultation to the Patient about How to Handle Family and Friends

Arguments Against the Consultation Approach

Therapist Supervision/Consultation Strategies

The Need for Supervision/Consultation

1. Meeting to Confer on Treatment

2. Keeping Supervision/Consultation Agreements

3. Cheerleading

4. Providing Dialectical Balance

Working Out Problems of 'Staff Splitting'

Dealing with Unethical or Destructive Therapist Behavior

Keeping Information Confidential

Concluding Comments

Part IV. Strategies for Specific Tasks

14. Structural Strategies

Contracting Strategies: Starting Treatment

1. Conducting a Diagnostic Assessment

2. Presenting the Biosocial Theory of Borderline Behavior

3. Orienting the Patient to Treatment

4. Orienting the Network to Treatment

5. Reviewing Treatment Agreements and Limits

6. Committing to Therapy

7. Conducting Analyses of Major Target Behaviors

8. Beginning to Develop the Therapeutic Relationship

Caveats in the Real World

Session-Beginning Strategies

1. Greeting the Patient

2. Recognizing the Patient's Current Emotional State

3. Repairing the Relationship

Targeting Strategies

1. Reviewing Target Behaviors Since the Last Session

2. Using Target Priorities to Organize Sessions

3. Attending to Stages of Therapy

4. Checking Progress in Other Modes of Therapy

Session-Ending Strategies

1. Providing Sufficient Time for Closure

2. Agreeing on Homework for the Coming Week

3. Summarizing the Session

4. Giving the Patient a Tape of the Session

5. Cheerleading

6. Soothing and Reassuring the Patient

7. Troubleshooting

8. Developing Ending Rituals

Terminating Strategies

1. Beginning Discussion of Terminating: Tapering Off Sessions

2. Generalizing Interpersonal Reliance to the Social Network

3. Actively Planning for Termination

4. Making Appropriate Referrals

Concluding Comments

15. Special Treatment Strategies

Crisis Strategies

1. Paying Attention to Affect Rather Than Content

2. Exploring the Problem Now

3. Focusing on Problem Solving

4. Focusing on Affect Tolerance

5. Obtaining Commitment to a Plan of Action

6. Assessing Suicide Potential

7. Anticipating a Recurrence of the Crisis Response

Suicidal Behavior Strategies

The Therapeutic Task

Previous Suicidal Behaviors: Protocol for the Primary Therapist

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

Ongoing Parasuicidal Act: Protocol for the Primary Therapist

Suicidal Behaviors: Protocol for Collateral Therapists

Principles of Risk Management with Suicidal Patients

Therapy-Interfering Behavior Strategies

1. Defining the Interfering Behavior

2. Conducting a Chain Analysis of the Behavior

3. Adopting a Problem-Solving Plan

4. Responding to the Patient Who Refuses to Modify Interfering Behavior

Telephone Strategies

1. Accepting Patient-Initiated Phone Calls Under Certain Conditions

2. Scheduling Patient-Initiated Phone Calls

3. Initiating Therapist Phone Contacts

4. Giving Feedback About Phone Call Behavior During Sessions

Therapist Availability and Management of Suicidal Risk

Ancillary Treatment Strategies

1. Recommending Ancillary Treatment When Needed

2. Recommending Outside Consultation for the Patient

Medication Protocol

Hospital Protocol

Relationship Strategies

1. Relationship Acceptance

2. Relationship Problem Solving

3. Relationship Generalization

Concluding Comments

Appendix 15.1. Scale Points for Lethality Assessment

Appendix: Suggested Reading

Edition Notes

Includes bibliographical references (p. 527-546) and index.

Published in: New York
Series: Diagnosis and treatment of mental disorders

Classifications

Dewey Decimal Class: 616.85/8520651
Library of Congress: RC569.5.B67 L56 1993, RC569.5.B67L56 1993, RC569.5.B67 L56 1993eb

The Physical Object

Pagination: xvii, 558 p. :
Number of pages: 558

Edition Identifiers

Open Library: OL1411643M
ISBN 10: 0898621836
LCCN: 93020483
OCLC/WorldCat: 213444085, 27854187
LibraryThing: 35416
Goodreads: 421520

Work Identifiers

Work ID: OL3919115W

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