ebook THE GUILFORD PRESS CHANGING BEHAVIOR IN DBT® CHANGING BEHAVIOR in DBT® Problem Solving in Action Heidi L. Heard Michaela A. Swales Foreword by Marsha M. Linehan THE GUILFORD PRESS New York London © 2016 The Guilford Press A Division of Guilford Publications, Inc. 370 Seventh Avenue, Suite 1200, New York, NY 10001 www.guilford.com All rights reserved No part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. Last digit is print number: 9 8 7 6 5 4 3 2 1 The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the authors, nor the editors and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources. Library of Congress Cataloging-in-Publication Data is available from the publisher. ISBN 978-1-4625-2264-4 DBT is a registered trademark of Marsha M. Linehan. For those family and friends who provided abundant support throughout this project —H. L. H. For Richard, Thomas, and Caitlin —M. A. S. AbOUT THE AUTHORS Heidi L. Heard, PhD, is a Senior Trainer for Behavioral Tech, which provides advanced training in DBT, and Clinical Instructor at the Uni- versity of Washington in Seattle. Based in St. Louis, she is the founder and former director of British Isles DBT Training and provides consulta- tion to DBT therapists and teams in North America and Europe. After collaborating with Marsha M. Linehan on the initial outcome trials for standard DBT and the adaptation for substance abuse and dependence, Dr. Heard has focused her research on the cost-effectiveness of DBT. She has published numerous articles and chapters related to borderline personality disorder and DBT and is coauthor (with Michaela A. Swales) of Dialectical Behaviour Therapy: Distinctive Features. Michaela A. Swales, PhD, is a Consultant Clinical Psychologist with Betsi Cadwaladr University Health Board, the largest health organization in Wales, and Senior Lecturer at the North Wales Clinical Psychology Pro- gramme, School of Psychology, Bangor University. She is also Director of British Isles DBT Training. Dr. Swales has trained more than a thousand professionals in DBT, seeding over 350 programs. Her research interests are primarily in the effective implementation of evidence-based psycho- logical therapies in routine clinical practice; she is currently involved in a clinical trial of DBT for treatment-resistant depression. Dr. Swales is a participant in the Working Group on Classification of Personality Disorders that reports to the World Health Organization’s International Advisory Group for the revision of the ICD-10 classification of mental and behavioral disorders. vii FOREWORD Heidi Heard and Michaela Swales first met at one of my early inten- sive trainings in Seattle in the early 1990s. Heidi was then my graduate student; having been closely involved in the first randomized controlled trial of DBT, she was developing her skills as a trainer in DBT alongside me. Michaela was part of the first U.K. team to learn DBT. Inspired by her mentor, Mark Williams, who later went on to develop mindfulness- based cognitive therapy with John Teasdale and Zindel Segal, she had come to Seattle to learn how to treat adolescents with suicidal and self- harm behaviors. Heidi and Michaela’s meeting was to prove auspicious for the dissemination of DBT outside the United States. They gave a presentation together at a conference in Dublin the following year, and during their visit there, they hatched the plan that would take Heidi to work alongside Michaela and Mark Williams in North Wales. During Heidi’s time in the United Kingdom, she used her already considerable skills and expertise to found the British Isles DBT Training Team, which Michaela would go on to lead. Together they have crossed the length and breadth of the United Kingdom and Ireland to train mental health professionals in DBT, eventually developing a national training team that delivers high-quality training in DBT throughout the British Isles, in partnership with the Linehan Institute. Their skills in mentoring trainers to achieve similar levels of precision and clarity in the conceptualization and treatment of clients’ problems have informed the development of our own U.S. mentorship program for DBT trainers. As well as being adherent and highly competent therapists them- selves, Heidi and Michaela have developed a wealth and breadth of knowledge both in training therapists and developing their skills toward ix x Foreword adherence to DBT, and in effectively implementing DBT in various health care systems. Their skills in training and consultation were recognized by the International Society for the Improvement of Training in DBT in 2009 with the Cindy Sanderson Outstanding Educator Award. This accolade came soon after the publication of their first book. Dialecti- cal Behaviour Therapy: Distinctive Features provided an introductory overview of the treatment, helping those new to the therapy to develop a structural basis for more comprehensive learning of DBT. This fabulous new book distills the knowledge Heidi and Michaela have gained in helping therapists learn and deliver the problem-solving component of DBT. Clients who come for treatment with DBT have complex and challenging problems. Their therapists have to work with them to change these previously intractable problems in a context of high risk and intense despair. Those therapists need this book. Precision and clarity in conceptual analysis and practical implementation are dem- onstrated on every page. In each chapter, Heidi and Michaela explicitly and succinctly highlight the principles of each step in problem solving in DBT. In their extensive experience, they have discerned the most common ways in which problem solving in DBT can go awry. Each of these common problems is described here with detailed illustrative case examples, and, crucially, Heidi and Michaela highlight how to resolve these issues in ways that promote the effectiveness of the treatment. Though what is written here is within the framework of DBT, therapists of many different cognitive-behavioral perspectives and persuasions will find much of practical relevance in this wonderful volume. Heidi and Michaela have written a book that will assist not only therapists new to DBT, but those more experienced as therapists or supervisors, in identi- fying and resolving typical problems in the execution of DBT—and thus improving clinical outcomes and the lives of our clients. Readers are lucky to get a book by these two fabulous DBT thera- pists and trainers. This is particularly true when the topic is problem solving. We all know that this is often the significant challenge facing our clients: They cannot solve the major problems of their lives. But help- ing a client solve life problems isn’t easy. This book by two therapists who know what they are doing is going to help you immensely. MARSHA M. LINEHAN, PHD, ABPP Professor and Director Behavioral Research and Therapy Clinics University of Washington AcKNOWLEDGMENts When we first learned DBT we were struck by its compassion, opti- mism, and encouragement to persevere in changing the troubled lives of the people it seeks to treat. All of those things still hold true and, after 20 years of using the treatment, we continue to be amazed by its richness and flexibility in creatively deploying the principles of behavior change to address seemingly intractable problems. In treating patients in a myr- iad of different settings and training therapists in different cultures and settings, the principles initially described in Marsha M. Linehan’s origi- nal manual have never let us down. As a result, our respect for Marsha’s achievements in developing and testing the treatment has only increased. We wholeheartedly thank Marsha for the gift she gave us by training us in DBT and promoting our proficiency in its execution. We particularly want to thank her for contributing the foreword to this book. We would like to express our sincerest gratitude to the delightful staff at The Guilford Press, who have been so supportive throughout the process. We especially want to thank Kitty Moore, who guided the book from its conception; Barbara Watkins, who provided significant suggestions on the manuscript; and Nina Hnatov, who copyedited the manuscript. When we received Kitty’s feedback on the initial outline for the book, we were delighted to discover that we had an editor whom we could respect and trust. Over time we also learned that we had an editor who has extensive patience, infinite sympathy, and a sophisticated sense of humor. Barbara’s feedback on the manuscript indicated that she had read every word from the first page through the last, one of the most val- idating things that any editor can do. We are eternally grateful for all of her corrections and comments, which will enhance the effectiveness of xi xii Acknowledgments the book for readers. We are equally appreciative of Nina’s copyediting. She caught our incidents of unmindful writing, corrected our errors, and minimized the likelihood that we would humiliate ourselves in public.