Dialectical Behavior Therapy in Private Practice

Manualized therapies continue to gain in popularity among therapists. These “newer” therapies have a growing body of evidence documenting their effectiveness in treating mental illness. These burgeoning efficacy data and the typically limited number of treatment sessions have not escaped third-party payers. In fact, insurance pressure has contributed to the momentum enjoyed recently by therapies such as interpersonal therapy (IPT), cognitive-behavioral therapy (CBT), and dialectical behavior therapy (DBT). Dialectical behavior therapy is the brainchild of Marsha Linehan, who created it to treat patients with borderline personality disorder. The central idea is that such patients have competing dialects that cause significant emotional stress. As a means of coping, these patients often engage in self-harm as a maladaptive means of regulating emotions. Traditional DBT requires significant resources as patients undergo both individual and group therapy during a course of treatment. The group component is psychoeducational and primarily didactic in nature. Several core modules of skill sets focusing on emotion regulation, distress tolerance, and mindfulness are presented to the patients. During individual sessions, parasuicidal behaviors are normally the primary target. Additionally, patients are coached in the application of skills taught during the group sessions with emphasis on practice to obtain skill mastery. Typically, a team of therapists skilled in DBT are required to coordinate both the group and individual sessions. These logistical challenges can restrict the practice of DBT to academic centers where educational or research subsidies are provided. Dialectical Behavior Therapy in Private Practice challenges the above assertions. The book provides an argument that DBT is not beyond the reach of a solo practitioner. Breaking with tradition, the author suggests that DBT can be used in a more piecemeal approach where limited resources require such an adaptation. Moreover, extensive research is presented that documents DBT's efficacy well beyond its original target of patients with borderline personality disorder. The book is designated for both seasoned as well as novice DBT therapists. In the first 2 chapters, the theoretical underpinnings of DBT are compared with other psychotherapy frameworks and evidence for the DBT approach is presented. Chapter 3 examines the possible psychological and neurobiological factors underlying a patient's emotional sensitivity. DBT's central thesis that emotional sensitivity (high emotional arousal, delayed return to baseline, and hypervigilance to threats) leads to maladaptive avoidance and escape behaviors is developed in the next chapter. This is followed by a chapter that establishes the goal of DBT as balancing acceptance of emotional problems and pain with specific skill strategies to change them. The author then illustrates the generalizability of DBT by applying it to various mental disorders outside of the traditional personality disorders. The final 2 chapters focus on the nuts and bolts of the specific skill sets patients need to master in DBT. Thomas Marra is obviously quite versed in the practice of DBT and has developed an exhaustive list of mnemonics aimed at assisting both clinicians and patients in remembering the specific skills. Typical patient dialects as well as excerpts of therapy sessions illustrating key conflicts are utilized to demonstrate how DBT can be used to understand a wide array of patients. These vignettes make the theory and practical skills much more understandable for the reader. Furthermore, the extensive citations to authority and research studies examining DBT across the mental health spectrum make the book a valuable addition to a reference library. However, these citations and instructional comments render the text quite dense and thus not appropriate for patients or individuals who want a brief introduction to DBT. Perhaps one of the greatest assets of the book is that Dr. Marra has included a CD-ROM with PowerPoint presentations for all of the key modules, which are turnkey for those interested in implementing a group therapy component. This CD-ROM also provides worksheets and handouts for individual therapy sessions aimed at skill building. Although the PowerPoint slides appear “homemade,” lacking slick graphics or animation, and carry an admonition that they cannot be changed or adapted by the purchaser, for the novice therapist they serve as an invaluable starting point. The countless hours of preparation they save make it possible to initiate a DBT program with only minimal additional outlay in terms of materials and are well worth the price of the text.