Why Learn A New Treatment?: Why Dialectical Behavior Therapy (DBT) ?

Why Learn a New Treatment?
x Old one doesn’t work (or doesn’t work well)
x Alternative has better outcomes
x Alternative is more efficient (financial or human resources)
x Alternative is preferred by providers (lower burnout) or is more humane and is at

least as effective and efficient
WHY DIALECTICAL BEHAVIOR THERAPY (DBT)?
Patient Outcomes
x Other treatments do not have established efficacy for individuals who are
chronically suicidal and meet criteria for Borderline Personality Disorder
x DBT patient outcomes
x reduces suicidal behaviors
x reduces substance abuse
x improves social functioning
x reduces anger
x global improvements
Efficiency & Costs
x Cost for DBT is approximately 50% of treatment as usual

1. significantly fewer inpatient days
2. fewer and less severe intentional self-injurious behaviors
3. fewer emergency medical visits
4. less therapy dropout
© 2016 Marsha M. Linehan, PhD, ABPP ▪ For educational use only. Do not copy or distribute without permission
Linehan Institute – Behavioral Tech | 1107 NE 45th Street, Suite 230 | Seattle, WA 98105 | Phone 206.675.8588 | www.behavioraltech.org
Behavioral Tech, LLC is a wholly owned subsidiary of the Linehan Institute, a nonprofit organization.
A1
DSM-IV Diagnostic Criteria
for Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity
beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the
diagnostic criteria.
AT LEAST FIVE OF THE FOLLOWING:
1. A pattern of intense and unstable interpersonal relationships
2. Frantic efforts to avoid real or imagined abandonment
3. Identity disturbance or problems with sense of self
4. Impulsivity that is potentially self-damaging
5. Recurrent suicidal or intentional self-injurious behavior
6. Affective instability
7. Chronic feelings of emptiness
8. Inappropriate intense or uncontrollable anger
9. Transient stress-related paranoid ideation or severe dissociative symptoms
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition. Washington, DC: American Psychiatric Association Press.
© 2016 Marsha M. LLQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission
A2
Borderline Personality Disorder (BPD) Facts Sheet
WHAT IS BORDERLINE PERSONALITY DISORDER (BPD)?
BPD is an Axis II personality disorder characterized by a pervasive inability to regulate emotions and
control behaviors linked to emotions. Intense negative emotions commonly include depression, anger,
self-hatred, and hopelessness.
PREVALENCE OF BPD
BPD occurs in 0.2 to 1.8% of the general population, in 8 to 11% of psychiatric outpatients 1 2 and 14 to
20% of inpatients. 3 4
SUICIDAL BEHAVIORS ARE VERY COMMON AMONG INDIVIDUALS WITH BPD.

Suicide is among the top ten causes of death in the United States and in the world. Up to 40% of
those committing suicide meet clinical criteria for a personality disorder at the time of their death. An
even higher percentage of those attempting suicide have a personality disorder. The personality
disorder most associated with both completed and attempted suicide is BPD.
BPD is the only DSM-IV diagnosis for which intentional self-injury (i.e., suicide attempts and/or other
intentional, non-fatal, self-injurious behaviors) is a criterion and intentional self-injury is thus
considered a “hallmark” of BPD.
Rates of intentional self-injury among clients diagnosed with BPD range from 69 to 80%. 5 6 7
Rates of suicide among all individuals meeting criteria for BPD (including those with no intentional
self-injury) is 5 to 10% and double that when only those with a history of intentional self-injury are
included. 8
BPD INDIVIDUALS ARE HIGH UTILIZERS OF SERVICES AT COMMUNITY MENTAL HEALTH AGENCIES.
Between 6 to 18% of all persons admitted to inpatient psychiatric treatment account for 20 to 42% of
all admissions. 9 10 11 12 13 14
Seventy-five to 80% of inpatient treatment dollars are spent on 30 to 35% of clients receiving inpatient
treatment services.
People with BPD are commonly among the highest utilizers of inpatient psychiatric services. Between
9 to 40% of high utilizers of inpatient psychiatric services are diagnosed with BPD. 15 16 17 18 19
BPD IS A CHRONIC DEBILITATING PROBLEM.

Follow-up studies consistently indicate the diagnosis of BPD is a chronic condition, although the
number of individuals who continue to meet diagnostic criteria slowly decreases over the life span.
Two to three years after index assessment, 60 to 70% of clientss continued to meet criteria. 20 Other
follow-up studies found little change in level of functioning and consistently high rates of psychiatric
hospitalization over two to five years. 21 22 Four to seven years after index assessment, 57 to 67% of
clientss continued to meet criteria. 23 24 An average of 15 years after index assessment, 25 to 44%
continued to meet criteria. 25 26
ACHIEVING TREATMENT SUCCESS WITH BPD HAS BEEN NOTORIOUSLY DIFFICULT.

BPD has been associated with worse outcome in treatments of Axis I disorders including major
depression, 27 OCD, 28 bulimia, 29 30 and substance abuse. 31
Follow-up studies of individuals diagnosed with BPD who have received standard community-based
inpatient and outpatient psychiatric treatment demonstrate that traditional approaches are marginally
effective at best when outcomes are measured two to three years following treatment.
In studies investigating pharmacotherapy for BPD, drop out rates are commonly very high 32 33 and
medication compliance has been problematic, with upwards of 50% of clients 34 and 87% of therapists
reporting medication misuse, including use of overdose as a method of attempting suicide. 35
0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

A3
Borderline Personality Disorder (BPD) Facts Sheet
1
Widiger, T.A. & Frances, A.J. (1989). Epidemiology, Diagnosis, and Co-morbidity of Borderline Personality Disorder. In A. Tasman, R. E. Hales, & A.
J. Frances (Eds.), American Psychiatric Press Review of Psychiatry, Vol. 8. (pp. 8-24). D.C.: American Psychiatric Press.
2
Widiger, T.A. & Weissman, M.M. (1991). Epidemiology of Borderline Personality Disorder. Hospital and Community Psychiatry, 42, 1015-1021.
3
Kroll, J.L., Sines, L.K., & Martin, K. (1981). Borderline Personality Disorder: Construct validity of the concept. Archives of General Psychiatry, 39,
60-63.
4
Modestin, J., Abrecht, I., Tschaggelar, W., & Hoffman, H. (1997). Diagnosing Borderline: A Contribution to the Question of its Conceptual Validity.
Archives Psychiatrica Nervenkra, 233, 359-370.
5
Clarkin, J.F., Widiger, T.A., Frances, A.J., Hurt, F.W., & Gilmore, M. (1983). Prototypic Typology and the Borderline Personality Disorder. Journal of
Abnormal Psychology, 92, 263-275.
6
Cowdry, R.W., Pickar, D., & Davies, R. (1985). Symptoms and EEG findings in the Borderline Syndrome. International Journal of Psychiatry
Medicine, 15, 201-211.
7
Gunderson, J.G. (1984). Borderline Personality Disorder. Washington D.C.: American Psychiatric Press.
8
Frances, A.J., Fyer, M.R., & Clarkin, J.F. (1986). Personality and Suicide. Annals of the New York Academy of Sciences, 487, 281-293.
9
Surber, R.W., Winkler, E.L., Monteleone, M., Havassy, B.E., Goldfinger, S.M., & Hopkin, J.T. (1987). Characteristics of High Users of Acute Inpatient
Services. Hosp Community Psychiatry, 38, 1112-1116.
10
Woogh, C.M. (1986). A Cohort through the Revolving Door. Can J Psychiatry, 31, 214-221.
11
Carpenter, M.D., Mulligan, J.C., Bader, I.A., & Meinzer, A.E. (1985). Multiple Admissions to an Urban Psychiatric Center: A Comparative Study.
Hosp Community Psychiatry, 36, 1305-1308. Geller, J.L. (1986).
12
Green, J.H. (1988). Frequent Re-hospitalization and Noncompliance with Treatment. Hosp Community Psychiatry, 39, 963-966.
13
Hadley, T.R., McGurrin, M.C., Pulice, R.T., & Holohean, E.J. (1990). Using Fiscal Data to Identify Heavy Service Users. Psychiatric Quarterly, 61,
41-48.
14
Geller, J.L. (1986). In again, out again: Preliminary Evaluation of a State Hospital's Worst Recidivists. Hosp Community Psychiatry, 37, 386-390.
15
Widiger, T.A. & Weissman, M.M. (1991). Epidemiology of Borderline Personality Disorder. Hospital and Community Psychiatry, 42, 1015-1021.
16
Geller, J.L. (1986). In again, out again: Preliminary Evaluation of a State Hospital's Worst Recidivists. Hospital and Community Psychiatry, 37, 386-
390.
17
Surber, R.W., Winkler, E.L., Monteleone, M., Havassy, B.E., Goldfinger, S.M., & Hopkin, J.T. (1987). Characteristics of High Users of Acute
Inpatient Services. Hospital and Community Psychiatry, 38, 1112-1116.
18
Swigar, M.E., Astrachan, B.M., Levine, M.A., Mayfield, V., & Radovich, C. (1991). Single and Repeated Admissions to a Mental Health Center. The
International Journal of Social Psychiatry, 37, 259-266.
19
Woogh, C.M. (1986). A Cohort through the Revolving Door. Canadian Journal of Psychiatry, 31, 214-221.
20
Barasch, A., Frances, A.J., & Hurt, S.W. (1985). Stability and Distinctness of Borderline Personality Disorder. American Journal of Psychiatry, 142,
1484-1486.
21
Dahl, A.A. (1986). Prognosis of the Borderline Disorders. Psychopathology, 19, 68-79.
22
Richman, J. & Charles, E. (1976). Patient Dissatisfaction and Attempted Suicide. Community Mental Health Journal, 12, 301-305.
23
Kullgren, G. (1992). Personality Disorders among Psychiatric Inpatients. Nordisk Psykiastrisktidsskrift, 46, 27-32.
24
Pope, H.G., Jonas, J.M., Hudson, J.I., Cohen, B.M., & Gunderson, J.G. (1983). The Validity of DSM-III Borderline Personality Disorder: A
Phenomenologic, Family History, Treatment Response, and Long Term Follow-up Study. Archives of General Psychiatry, 40, 23-30.
25
Perry, J.C. & Cooper, S.H. (1985). Psychodynamics, Symptoms, and Outcome in Borderline and Antisocial Personality Disorders and Bipolar type II
Affective Disorder. In T. H. McGlashan (Ed.), The Borderline: Current empirical research. (pp. 19-41). Washington, D.C.: American Psychiatric
Press.
26
Tucker, L., Bauer, S.F., Wagner, S., Harlam, D., & Shear, I. (1987). Long-term Hospital Treatment of Borderline Patients: A Descriptive Outcome
Study. American Journal of Psychiatry, 144, 1443-1448.
27
Phillips, K. A. & Nierenberg, A. A. (1994). The Assessment and Treatment of Refractory Depression. Journal of Clinical Psychiatry, 55, 20-26.
28
Baer, L., Jenike, M. A., Black, D. W., Treece, C., Rosenfeld, R., & Greist, J. (1992). Effect of axis II Diagnoses on Treatment Outcome with
Clomipramine in 55 Patients with Obsessive-Compulsive Disorder. Archives of General Psychiatry, 49, 862-866.
29
Ames-Frankel, J., Devlin, M. J., Walsh, T., Strasser, T. J., Sadik, C., Oldham, J. M., & Roose, S. P. (1992). Personality Disorder Diagnoses in
Patients with Bulimia Nervosa: Clinical correlates and changes with treatment. Journal of Clinical Psychiatry, 53, 90-96.
30
Coker, S., Vize, C., Wade, T., & Cooper, P. J. (1993). Patients with Bulimia Nervosa who Fail to Engage in Cognitive Behavior therapy. International
Journal of Eating Disorders, 13, 35-40.
31
Kosten, R. A., Kosten, T. R., & Rounsaville, B. J. (1989). Personality Disorders in Opiate Addicts show Prognostic Specificity. Journal of Substance
Abuse and Treatment, 6, 163-168.
32
Kelly, T., Soloff, P.H., Cornelius, J., George, A., Lis, J.A., & Ulrich, R. (1992). Can we study (treat) Borderline Patients? Attrition from research and
open treatment. Journal of Personality Disorders, 6, 417-433.
33
Soloff, P.H. (1994). Is there any Drug Treatment of Choice for the Borderline Patient? ACTA Psychiatrica Scandinavica, 89, 50-55.
34
Waldinger, R.J. & Frank, A.F. (1989). Clinicians' Experiences in Combining Medication and Psychotherapy in the Treatment of Borderline Patients.
Hospital and Community Psychiatry, 40, 712-718.
35
Dimeff, L.A., McDavid, J., & Linehan, M.M. (1999). Pharmacotherapy for Borderline Personality Disorder. Clinical Psychology in Medical Settings, 6,
113-138.

A4
Diagnosing BPD
PAPER & PENCIL
Personality Interview Questionnaire II (PIQ II)

Widiger, T. A. (1987). Personality Interview Questionnaire II (PIQ II). White Plains, NY: Department
of Psychiatry, Cornell Medical Center, Westchester Division.
Borderline Personality Disorder Scale

Perry, J. (1982). The Borderline Personality Disorder Scale (BPD Scale). Cambridge, MA: Cambridge
Hospital.
Personality Diagnostic Questionnaire-4th Edition (PDQ-4)

Hyler, S.E., Oldham, J.M, Kellman, H.D., & Doidge, N. (1992). Validity of the Personality Diagnostic
Questionnaire-Revised: A Replication in an Outpatient Sample. Comprehensive Psychiatry, 33, (pp.
73-77).
To order, call: 800-424-9537.
The Personality Diagnostic Questionnaire-is a 100 item, self-administered, true/false questionnaire

that yields personality diagnoses consistent with the DSM-IV diagnostic criteria for the axis II
disorders. It takes approximately 20-3 0 minutes to complete. In the past, this instrument has been
criticized for resulting in a high rate of false positives. The authors have attempted to address this
weakness with the current version of the instrument. There are both paper-and pencil and computer-
administered and scored versions available.
Millon Clinical Multi-axial Inventory II (MCMI-II); MCMI-II Manual 4

Millon, T. (1977). MCMI-II Manual. Minneapolis, MN: National Computer Systems.
Contact: NCS Assessments (800-627-7271, xt. 5151); http://assessments.ncs.com; Email:
assessment@ncs.com
This instrument is designed to help assess both Axis I and Axis II disorders.
Wisconsin Personality Disorders Inventory (WISPI)

Klein, M. H., Benjamin, L. S., Rosenfeld, R., Treece, C., Husted, J., & Griest, J.H. (1993). The
Wisconsin Personality Disorders Inventory: I. Development, Reliability, and Validity. Journal of
Personality Disorders, 7 (4), (285-303).
Contact: Madison, WI: Department of Psychiatry, University of Wisconsin.
This is a self-report questionnaire derived from an interpersonal perspective on the Diagnostic and
Statistical Manual of Mental Disorders-III-Revised (DSM-III-R) personality disorders (PDs). Internal
consistency for 11 PD scales was very high in a sample of 1,230 psychiatric patients and normal
disorders (PDs). Internal consistency for 11 PD scales was very high in a sample of 1,230 psychiatric
patients and normal non-patient control Ss. Two-week test-retest reliability in 80 additional patients
and non-patients was also high.
Schedule for Normal and Abnormal Personality (SNAP)

Clark, L. A. (1989). Preliminary manual for the Schedule for Normal and Abnormal Personality.
Dallas, TX: Department of Psychology, Southern Methodist University.
Contact publisher: University of Minnesota Press, Test Division, 800-621-2736; Email: Ump@tc.umn.edu.
Screening questions for Structured Clinical Interview

This is a screening measure used in conjunction with the SCID-II (see below). Would give
indication if diagnosis of BPD is likely but should not be used alone as a diagnostic tool.

A5
Diagnosing BPD
STRUCTURED INTERVIEW
Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)

First, M.B. Gibbon, M., Spitzer, R.L., Williams, J.B.W., & Benjamin, L. (1996). User's guide for the
Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). New York: Biometrics
Research Department, New York State Psychiatric Institute.
Contact: American Psychiatric Press, Inc. 800-368-5777; http://www.appi.org/index.html.
This diagnostic interview can be used to obtain Axis II diagnosis of BPD. Previous studies with the
DSM III-R version of the SCID have shown reliabilities by diagnosis over .60. This is the best scale for
clinician use; it is easier, briefer, but does require clinical expertise in noticing clinically relevant
criteria.
Diagnostic Interview for Borderlines-Revised (DIB-R) (Psychodynamic)

Zanarini, M.C., Gunderson, J.G., Frankenburg, F.R., & Chauncey, D.L. (1989). The Revised
Diagnostic Interview for Borderlines: Discriminating BPD from Other Axis II Disorders. Journal of
Personality Disorders, 3, (10-18).
Contact: Mary Zanarini by fax request to 617-855-3580.
This semi-structured interview includes subscales assessing personality dimensions of BPD as well
as a scale which measures "borderline-ness." This instrument has been used in numerous research
studies with borderline clients. An important caveat in considering its use however, is that it is over-
inclusive and therefore cannot be used to give a DSM diagnosis of BPD.
International Personality Disorders Examination (IPDE) (research)

Loranger, A. W. (1995). International Personality Disorder Examination (IPDE) Manual. White Plains,
NY: Cornell Medical Center.
Contact: Armand Loranger @ NY Hospital, White Plains, NY. 914- 997-5922.
This measure obtains Axis II diagnoses including BPD. The IPDE is the most widely established
measure of personality disorders currently available and is used by the World Health Organization.
Inter-rater reliability for BPD diagnosis on the IPDE has been found to be from .73 to .89 and
temporal stability from .56 to .84, clearly in the acceptable range. Reliabilities for other disorders are
.81 to .89 for inter-rater reliability and .67 to .75 for temporal stability. This measure may not be useful
for clinicians; it is long and somewhat cumbersome, and requires more training than the SCID. It is
however, the accepted research instrument for those interested in publishing.
CLINICAL INTERVIEW
Use DSM IV criteria, observations, informants; Use consensus diagnosis

Structured Clinical Interview for DSM-IV, Axis I (SCID)
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1995). Structured Clinical Interview for
Axis I DSM-IV Disorders - Patient Edition (SCID-I/P). New York: Biometrics Research Department,
NY State Psychiatric Institute.
Contact: Michael First, NY State Psych Institute; 212- 960-5531.
This instrument is the standard in the field for DSM diagnoses. Training tapes are available by
contacting author directly.

A6
Defining Problems Behaviorally
© 2002-2016 Marsha M. Linehan, Ph.D., ABPP; Published by Behavioral Tech, LLC. For educational use only. Do not copy or
distribute without permission. Behavioral Tech, LLC ● ϭϭϬϳEϰϱƚŚ^ƚƌĞĞƚ͕^ƵŝƚĞϮϯϬ͕ ^eattle, WA 98105
Ph. (206) 675-8588 ● Fax (206) 675-8590 ● www.behavioraltech.org
A7
Geƫng from Assessment to Treatment
Is problem behavior primary
or secondary target?
Secondary
Establish link to
Primary
primary targets
ConƟngency ClarificaƟon
(CogniƟve Strategy)
Behavior is under
Consequences
control of:
ConƟngency Management
Problem Solving:
Analyze chain Skills
PrompƟng Event
of events CogniƟve ModificaƟon
Exposure
Exposure Response
PrevenƟon & Opposite
Secondary
AcƟon FuncƟonal AnalyƟc
Targets Psychotherapy:
Self-Involving Self-Disclosure
Problem-Solving EmoƟon Vulnerability/ & Observing Limits
Mood Dependent
UnrelenƟng Crises AcƟve Passivity
Evaluate for:
Apparent Competence Inhibited Grieving
Self-InvalidaƟon Exposure &

Feedback
EmoƟonal Experiencing
Behavior Rehearsal
© 2016 Marsha M. Linehan, Ph.D., ABPP For educational use only. Do not copy or distribute without permission.
Behavioral Tech, LLC  ϭϭϬϳEϰϱƚŚ^ƚƌĞĞƚ͕^ƵŝƚĞϮϯϬ, Seattle, WA 981Ϭϱ  Ph. (206) 675-8588  Fax (206) 675-8590  www.behavioraltech.org
A8
Emotion Dysregulation
Intense Response Slow Return to

Cue High Sensitivity to
to Emotional Emotional
Emotional Stimuli
Stimuli Baseline
EMOTIONAL
RESPONSE
Cannot Regulate Cannot Turn

Physiological Arousal Attention Away from
Up or Down Emotional Stimuli
Information Cannot Organize and Cannot Control

Processing is Coordinate Activities Impulsive Behavior Shuts Down,
Dysregulation/ to Achieve Non-Mood Related to Strong “Freezes”
Distorted Dependent Goals Negative Affect
©6 Marsha M. Linehan, PhD, ABPP
A9
Diary Card Instructions
INITIALS / NAME
Enter your name or your initials. Your initials are typically the first letter of your first and last name.
FILLED OUT IN SESSION?
If the card was filled out during the session, circle “Y” for “yes,” otherwise circle “N” for “no.”
HOW OFTEN DID YOU FILL OUT THIS SIDE?
In the past week, did you fill out the card daily, 2-3 times, 4-6 times, or once?
LAST DAY FILLED OUT
Note the last date the card was filled out (include Month, Year, and Day).
DAY AND DATE
Record the calendar date under the day of the week.
DAY OF THE WEEK

Enter your ratings for each day of the week. Remember to circle the day you started this diary card.
USING THE 0-5 RATING SCALE
You’ll notice that many of the columns require you to record a numeric value, from 0 to 5. This is a
subjective continuous scale intended to communicate your experience. The anchor point “0”
represents the absence of a particular experience (e.g., no urge). A high score can represent the
frequency/pervasiveness of a particular experience (e.g., “5” represents experience where the
intensity of the urge wasn’t so bad, but it persisted throughout the entire day). It can also represent
the intensity of the experience (e.g., strongest urge imaginable). Choose whichever method of
defining the experience (intensity or pervasiveness) that is most effective in communicating your
experience. No one way is better than the other. It is important, however, that the same method is
used consistently throughout and that the therapist knows which method you have chosen to use.
HIGHEST URGES TO…
The column “Highest Urge To” is divided into three columns. “Commit Suicide” column refers to any
urges to kill yourself. The “Self-Harm” column refers to urges to self-harm or engage in intentional
self-injurious behaviors. The “Use Drugs” column refers to use of any drug of abuse (e.g., over-the-
counter meds, prescription meds, street/illicit drugs)..
HIGHEST RATING FOR EACH DAY
The column “Highest Rating for Each Day” is divided into three columns: Emotion Misery (e.g.,
sad, shame, anger, fear), Physical Misery (e.g., pain), and Joy (the joy you experienced for the
day). Record the highest rating for each day in all three columns using the 0 to 5 rating scale.
DRUGS/MEDICATIONS
For each category (Alcohol, Illegal Drugs, Meds as Prescribed, and PRN/Over the Counter
Meds) record the following information in each column:
“#” Specify the number of drugs (as described in the specify column) used on this day (e.g., “3” for 3
beers)
“What?” Specify the type of drug used (e.g., beer, mixed drinks, aspirins, heroin, LAAM, Prozac). It’s
acceptable to write “ditto” marks in subsequent “Specify” boxes, to indicate daily use.
An easier way: You can use vertical lines through columns to indicate no use (i.e., if you did not use
any prescription meds this week, write a “0” in the number space for the first day of non-use, followed
by a vertical line.

A10
Diary Card Instructions
ACTIONS
The column “Self-Harm” refers to whether you engaged in any self-harm or intentional self-injurious
behaviors for the day. Intentional self-injury is defined as any overt, acute, self-injurious act that,
without outside intervention, would result in tissue damage, illness, or death. The act of self-harm or
injury is intentional (i.e., not accidental). The “Lied” column refers to all overt and covert behaviors
that mask telling the truth. It is important to assume a non-judgmental stance in completing this. Put
the # of lies told per day in the column. Place an * in this column to signify a lie has been told
somewhere on the card for that day. “Used Skills” column is used to report the highest skill usage for
the day. When making this rating, please refer to the 0-7 “Used Skills” table at the bottom of the card.
EMOTIONS
Use this column to record emotions experienced this week.
OPTIONAL
This column may be used to keep a record of any additional behavior.
MED CHANGE THIS WEEK

Record any changes to your prescribed medications this week.
HOMEWORK ASSIGNED AND RESULTS THIS WEEK

Record the homework that was assigned to you this week along with the results of the homework.
URGE TO… COMING INTO SESSION (0-5)

Record your ratings in the columns for your Urge to Quit Therapy, Use Drugs, and Commit Suicide
as you are coming into your session.
BELIEF I CAN CHANGE / REGULATE MY…
Using the same 0-5 rating scale, rate your belief regarding your ability to change or regulate your
Emotions, Action, and Thoughts as you are coming into your session.
SKILLS FOCUS THIS WEEK

Check each of the skills listed and circle the day you practiced each skill.

A11
Filled out in Session? How often did you fill out? Last Day Filled Out
Dialectical Behavior Therapy Name: ____ Daily ____ 2-3x
Skills Diary Card Y N ____ 4-6x ____Once Month___ Year___ Day___
Circle Highest Rating Actions
Start Day Highest Urge To: Drugs/Medications Emotions Optional
For Each Day
Commit Self- Use Emotion Physical Illegal Meds. As PRN/ Over the Used
Day Suicide Harm Drugs Misery Misery Joy Alcohol Prescribed Counter Meds.
Self-Harm Lied
Drugs Skills
Of
Week 0-5 0-5 0-5 0-5 0-5 0-5 # What? # What? Y/N # What? Y/N. # 0-7
MON
TUE
WED
THUR
FRI
SAT
SUN
Med Change This Week * USED SKILLS:

0 = Not thought about or used 4 = Tried, could do them but they didn’t help
1 = Thought about, not used, didn’t want to 5 = Tried, could use them, helped
Homework Assigned and Results This Week: 2 = Thought about, not used, wanted to 6 = Automatically used them, didn’t help
3 = Tried but couldn’t use them 7 = Automatically used them, helped
Coming into Coming into
Belief I can change regulate my:
Urge to: Session (0-5) Session (0-5)
Quit Therapy Emotions:
Use Drugs Action:
Commit Suicide Thoughts:
Skills Focus this Week:
DBT Skills Filled out this card? ___ Daily ___ 2-3x ___ 4-6x Check skills; circle days skill was practiced
Diary Card ___Once ___In session
Wise mind MON TUE WED THUR FRI SAT SUN
Observe: just notice MON TUE WED THUR FRI SAT SUN
Describe: put words on, just the facts MON TUE WED THUR FRI SAT SUN
Mindfulness Participate: enter into the experience MON TUE WED THUR FRI SAT SUN
Non-judgmental stance MON TUE WED THUR FRI SAT SUN
MAN (M indful: Broken record, Ignore attack), Appear confident, Negotiate
One-mindfully: present moment MON TUE WED THUR FRI SAT SUN
ABC (Accumulate pleasant events work on goals, Build mastery, Cope
Effectiveness: focus on what works MON TUE WED THUR FRI SAT SUN
PLEASE (Care: PhysicaL ills, Eating, Avoid drugs, Sleep, Exercise)
DEAR MON TUE WED THUR FRI SAT SUN

MAN MON TUE WED THUR FRI SAT SUN
GIVE MON TUE WED THUR FRI SAT SUN
Interpersonal
Effectiveness FAST MON TUE WED THUR FRI SAT SUN
Walked the Middle Path Dialectics MON TUE WED THUR FRI SAT SUN
Validation MON TUE WED THUR FRI SAT SUN
FAST (Fair, no-Apologies, Stick to values, Truthful)
GIVE (Gentle, Interested, Validate, Easy manner)
Behaviorism to Change Behavior MON TUE WED THUR FRI SAT SUN
DEAR (Describe, Express, Assert, Reinforce)
Checked the Facts MON TUE WED THUR FRI SAT SUN
Opposite-to Emotion-Action MON TUE WED THUR FRI SAT SUN
Problem Solved MON TUE WED THUR FRI SAT SUN
Accumulated Positive Experiences A MON TUE WED THUR FRI SAT SUN
Emotion
Regulation Built Mastery B MON TUE WED THUR FRI SAT SUN
Coped Ahead C MON TUE WED THUR FRI SAT SUN
Reduced Vulnerability PLEASE MON TUE WED THUR FRI SAT SUN
Mindfulness of Current Emotion MON TUE WED THUR FRI SAT SUN
CRISIS STOP Skill MON TUE WED THUR FRI SAT SUN
SURVIVAL Pros and Cons MON TUE WED THUR FRI SAT SUN
TIP MON TUE WED THUR FRI SAT SUN
Distress Distracted MON TUE WED THUR FRI SAT SUN
Tolerance Self-Soothed MON TUE WED THUR FRI SAT SUN
ahead)
Improved the moment MON TUE WED THUR FRI SAT SUN
REALITY Radical Acceptance MON TUE WED THUR FRI SAT SUN
ACCEPT Half-smiling, Willing Hands MON TUE WED THUR FRI SAT SUN
Willingness, Mindfulness of Current Thoughts MON TUE WED THUR FRI SAT SUN
© 2016 Marsha M. Linehan, PhD, ABPP ƒ For educational use only. Do not copy or distribute without permission
A12
Chain Analysis of Problem Behavior
Name: _______________________ Date Filled Out: ________ Date of Problem Behavior: ________
Vulnerability
Links Consequences
Prompting Problem Behavior
Event
What exactly is the major PROBLEM BEHAVIOR that I am analyzing?
What PROMPTING EVENT in the environment started me on the Chain to my problem behavior?
Start day: ________________________
What things in myself and my environment made me VULNERABLE?

Start day:________________________

A13
Name: ____________________________________________ Date Filled Out: ____________________
Possible Types of Links

A = Actions
B = Body sensations
C = Cognitions
E = Events
F = Feelings
LINKS List actual, specific behaviors and then list new, more skillful behaviors to replace
ineffective behaviors:
1st ____________________________________________________________________
2nd ____________________________________________________________________
3rd ____________________________________________________________________
4th ____________________________________________________________________
5th ____________________________________________________________________
6th ____________________________________________________________________
7th ____________________________________________________________________
8th ____________________________________________________________________
9th ____________________________________________________________________
10th ___________________________________________________________________
11th ___________________________________________________________________
12th ___________________________________________________________________
13th ___________________________________________________________________
14th ___________________________________________________________________

A14
Name: ____________________________________________ Date Filled Out: ____________________
What exactly were the major CONSEQUENCES in the environment?
Immediate:
Delayed:
What exactly were the major CONSEQUENCES in myself?
Immediate:
Delayed:
Ways to reduce my VULNERABLITY in the future?
Ways to prevent PROMPTING EVENT from happening again?
What HARM did my PROBLEM BEHAVIOR cause?
Plans to REPAIR, CORRECT, AND OVER- CORRECT the harm:
My deepest thoughts and feelings about this (THAT I WANT TO SHARE):

A15
Example
Name: RE Date Filled Out: April 18 Date of Problem Behavior: April 17
Vulnerability
Links Consequences
Prompting Problem Behavior
Event
What exactly is the major PROBLEM BEHAVIOR that I am analyzing?
Cut my arm 5 times with a razor
What PROMPTING EVENT in the environment started me on the Chain to my problem behavior?
Start day: ________________________
Got into a big fight with Ann & we decided not be friends anymore
What things in myself and my environment made me VULNERABLE?

Start day:________________________
Med Change- Feeling depressed & Shaky

Case Manager John is out on vacation- don’t like that he’s not here.
Really tense cause I’m not using alcohol or drugs.

A16
Example
Name: RE Date Filled Out: April 18
What exactly were the major CONSEQUENCES in the environment?
Immediate: Not anything really
Delayed: Filling this out, talking to you about it
What exactly were the major CONSEQUENCES in the myself?
Immediate: felt less tense, felt less angry-better
Delayed: Just numb, maybe a little mad at myself
Ways to reduce my VULNERABLITY in the future?
Don’t get into a fight when I’m depressed

get a sponsor so I have somebody to help me stay off alcohol
Ways to prevent PROMPTING EVENT from happening again?
Ask Ann if we could talk about it later

Get friends who don’t push me around so much
What HARM did my PROBLEM BEHAVIOR cause?
I got new scars. I feel like I got a set back.

Think everybody is disappointed with me.
Plans to REPAIR, CORRECT, AND OVER- CORRECT the harm:
This B.A. promise I will try 3 skills next time & call you before cutting
Throw out razor blades
My deepest thoughts and feelings about this (THAT I WANT TO SHARE):
I’m tired of doing these things. I’m sick of myself.

A17
Example

A = Actions
B = Body sensations
C = Cognitions
E = Events
F = Feelings
1st Ann yelled at me about changing plans Stick to the plan even if I don’t feel like it
2nd I felt hurt and angry
3rd Ann is really a bitch Think about Ann’s point of view
4th Felt anger
5th Told her to shut up Walk away or listen
6th Well yelled about old problems Walk away or listen
7th She said, “You’re too much work” And walked out
8th I’ll be all alone this weekend Think I’ll find something to do
9th I Can’t Stand this Tell myself I can stand it
10th
11th
12th
13th
14th

A18
Example

A = Actions
B = Body sensations
C = Cognitions
E = Events
F = Feelings
1st Laid down on my bed and ruminated
2nd Felt scared and wanted to drink Call my sponsor
3rd I don’t want to do that
4th I’ll cut myself instead Call you for help, use skills
5th Got the razor and did it
6th Relief
7th Went to sleep
8th Realized I had to tell you in session
9th Felt “bad”
10th
11th
12th
13th
14th

A19
INSTRUCTIONS FOR CHAIN
ANALYSIS WORKSHEET
1) Describe the specific PROBLEM BEHAVIOR – e.g., throwing a chair, cutting, hearing voices, dissociating,
not coming to a therapy appointment, etc. (Behaviors that are targeted in the treatment plan, or diary card.)
a) Be very specific and detailed. No vague terms.
b) Identify exactly what you did, said, thought, or felt (if feelings are the targeted problem behavior).
c) Describe the intensity of the behavior and other characteristics of the behavior that are important.
d) Describe problem behavior in enough detail that an actor in a play or movie could recreate the behavior
exactly.
2) Describe the specific PROMPTING EVENT that started the whole chain of behavior.
a) Start with the environmental event that started the chain. A prompting event is an event outside the
person that triggers the chain of events leading to the problem behavior. Always start with some event in
your environment, even if it doesn’t seem to you that the environmental event “caused” the problem
behavior. Possible questions to get at this are:
b) What exact event precipitated the start of the chain reaction?
c) When did the sequence of events that led to the problem behavior begin? When did the problem start?
d) What was going on the moment the problem started?
e) What were you doing, thinking, feeling, imagining at that time?
f) Why did the problem behavior happen on that day instead of the day before?
3) Describe in general what things (both in yourself and in the environment) made you VULNERABLE to the
prompting event. What factors or events made you more vulnerable to a problematic chain? What gave the
prompting event such power? Areas to examine are:
a) Physical illness; unbalanced eating or sleeping; injury
b) Use of drugs or alcohol; misuse of prescription drugs
c) Stressful events in the environment (either positive or negative)
d) Intense emotions, such as sadness, anger, fear, loneliness
e) Previous behaviors of your own that you found stressful
4) Describe in excruciating detail THE LINKS IN THE CHAIN OF EVENTS that hooked the prompting event to
the problem behavior.
a) Links in the chain can be:
i) Actions or things you do;
ii) Body sensations or feelings;
iii) Cognitions, e.g., beliefs, expectations or thoughts;
iv) (the dash is here for D)
v) Events in the environment or things others do;
vi) Feelings and emotions that you experience.

A20
b) Imagine that your problem behavior is chained to the prompting event in the environment. How long is
the chain? Where does it go? What are the links? Write out all links in the chain of events, no matter
how small. Be very specific, as if you are writing a script for a play.
i) What exact thought (or belief), feeling, or action followed the precipitating event? What thought,
feeling, or action followed that? What next? What next? etc.
ii) Look at each link in the chain after you write it. Was there another thought, feeling, or action that
could have occurred? Could someone else have thought, felt, or acted differently at that point? If
so, explain how that specific thought, feeling, or action came to be.
iii) For each link in the chain, ask is there a smaller link you could describe.
5) What are the CONSEQUENCES of this behavior? Be specific. Examine both the immediate (in just
seconds) effects and the delayed or longer term effects. Figure out the reinforcers for the behavior.
a) How did other people react immediately and later?
b) How did you feel immediately following the behavior? Later?
c) What effect did the behavior have on you and your environment immediately and later?
6) Describe in detail different more skillful SOLUTIONS to the problem.

a) Go back to the chain of your behaviors following the prompting event.? Circle each point or link (or fill in
link with your pencil) where if you had done something different you would have avoided the problem
behavior.
b) What could you have done differently at each link in the chain of events to avoid the problem behavior?
What coping behaviors or skillful behaviors could you have used?
7) Describe in detail PREVENTION STRATEGY for how you could have kept the chain from starting by
reducing your vulnerability to the chain.
8) Describe a plan for SOLVING the prompting event (if it were to happen again) or keeping it from happening
again.
9) Think through the HARMFUL consequences of your behavior. Figure out what is harmed so you can figure
out what you need to repair or correct. Look at yourself, at your environment, and at people in your
environment to see if there are any harmful consequences.
10) Describe what you are going to do to REPAIR important or significant consequences of the problem
behavior? Describe what will you do to CORRECT the harm that resulted from your problem behavior.
Describe how you will make things just a little bit better than they were before, that is, how you will
OVERCORRECT the harm.
11) In this space, you can write whatever reflects your DEEPEST THOUGHTS AND FEELINGS about this
episode. Just start writing and continue for five minutes or so without stopping. If the topic gets upsetting to
you, shift topics and keep writing. Or, you can write out any comments that you have about the analysis.

A21
The 6 S’s in DBT Clinical Management
1. Safe: Drugs and administration.
2. Simple: Avoid drugs that cause cognitive disturbance or drug

interaction.
3. Specific: Target specific symptoms and use drugs with specific

actions.
4. Scientific: Use drugs with demonstrated efficacy with BPD first.
5. Super fast: Move quickly through drug-induction phase.
6. Supervised: Seek out consultation from experts as needed.

A22

Why Learn A New Treatment?: Why Dialectical Behavior Therapy (DBT) ?

Uploaded by

Copyright:

Available Formats

Why Learn A New Treatment?: Why Dialectical Behavior Therapy (DBT) ?

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Why Learn A New Treatment?: Why Dialectical Behavior Therapy (DBT) ?

Uploaded by

Copyright:

Available Formats

Why Learn a New Treatment?

x Old one doesn’t work (or doesn’t work well)

x Alternative has better outcomes

x Alternative is more efficient (financial or human resources)

x Alternative is preferred by providers (lower burnout) or is more humane and is at

WHY DIALECTICAL BEHAVIOR THERAPY (DBT)?

Efficiency & Costs

x Cost for DBT is approximately 50% of treatment as usual

AT LEAST FIVE OF THE FOLLOWING:

1. A pattern of intense and unstable interpersonal relationships

2. Frantic efforts to avoid real or imagined abandonment

3. Identity disturbance or problems with sense of self

4. Impulsivity that is potentially self-damaging

5. Recurrent suicidal or intentional self-injurious behavior

7. Chronic feelings of emptiness

8. Inappropriate intense or uncontrollable anger

9. Transient stress-related paranoid ideation or severe dissociative symptoms

SUICIDAL BEHAVIORS ARE VERY COMMON AMONG INDIVIDUALS WITH BPD.

BPD IS A CHRONIC DEBILITATING PROBLEM.

ACHIEVING TREATMENT SUCCESS WITH BPD HAS BEEN NOTORIOUSLY DIFFICULT.

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

 Personality Interview Questionnaire II (PIQ II)

 Borderline Personality Disorder Scale

 Personality Diagnostic Questionnaire-4th Edition (PDQ-4)

The Personality Diagnostic Questionnaire-is a 100 item, self-administered, true/false questionnaire

 Millon Clinical Multi-axial Inventory II (MCMI-II); MCMI-II Manual 4

 Wisconsin Personality Disorders Inventory (WISPI)

 Schedule for Normal and Abnormal Personality (SNAP)

 Screening questions for Structured Clinical Interview

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

 Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)

 Diagnostic Interview for Borderlines-Revised (DIB-R) (Psychodynamic)

 International Personality Disorders Examination (IPDE) (research)

 Use DSM IV criteria, observations, informants; Use consensus diagnosis

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

UnrelenƟng Crises AcƟve Passivity

Apparent Competence Inhibited Grieving

Self-InvalidaƟon Exposure &

Intense Response Slow Return to

Cannot Regulate Cannot Turn

Information Cannot Organize and Cannot Control

©6 Marsha M. Linehan, PhD, ABPP

DAY OF THE WEEK

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

MED CHANGE THIS WEEK

HOMEWORK ASSIGNED AND RESULTS THIS WEEK

URGE TO… COMING INTO SESSION (0-5)

SKILLS FOCUS THIS WEEK

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

Med Change This Week * USED SKILLS:

DEAR MON TUE WED THUR FRI SAT SUN

What exactly is the major PROBLEM BEHAVIOR that I am analyzing?

What things in myself and my environment made me VULNERABLE?

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

Name: ____________________________________________ Date Filled Out: ____________________

Possible Types of Links

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

What exactly were the major CONSEQUENCES in the environment?

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

Personality Interview Questionnaire II (PIQ II)

Borderline Personality Disorder Scale

Personality Diagnostic Questionnaire-4th Edition (PDQ-4)

Millon Clinical Multi-axial Inventory II (MCMI-II); MCMI-II Manual 4

Wisconsin Personality Disorders Inventory (WISPI)

Schedule for Normal and Abnormal Personality (SNAP)

Screening questions for Structured Clinical Interview

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II)

Diagnostic Interview for Borderlines-Revised (DIB-R) (Psychodynamic)

International Personality Disorders Examination (IPDE) (research)

Use DSM IV criteria, observations, informants; Use consensus diagnosis

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

©6 Marsha M. Linehan, PhD, ABPP

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

Name: ________________________ Date Filled Out:

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

60DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission

0DUVKD0/LQHKDQ3K'$%33ƒFor educational use only. Do not copy or distribute without permission