Abstract
Psychotherapists deal with the usually tacit processes of learning theory on a daily basis. Feelings and behaviours arise in response to stimuli (classical conditioning) and are reinforced or punished by consequences (operant conditioning). The patient who consistently cries throughout psychotherapy sessions may be avoiding the anxiety that might ensue if focusing on therapy tasks, crying that may be inadvertently reinforced when it leads to greater concern on the part of therapist and longer sessions. The therapist who changes topics in response to angry outbursts from her patient should not be surprised if angry outbursts in future sessions increase rather than decrease as both therapist and patient successfully avoid something painful (negative reinforcement). The skills trainer might find that a patient who has mastered self-assertion skills in office role-plays might quickly abandon them at home, in response to punishing consequences.
Behavioural learning theories underlie the process of changing behaviour in dialectic behavior therapy (DBT), a structured, multicomponent psychotherapy developed by Marsha Linehan 1 to treat people with borderline personality disorder (BPD). The approach is “dialectic” in that it balances the tension of the change processes of learning theory and problem solving with those of validation and acceptance-based strategies such as mindfulness.
Changing Behavior in DBT: Problem Solving in Action, by Drs Heard and Swales, is the first book to focus exclusively on the problem-solving component of DBT. The book is a practical one, beginning with the selection of behavioural targets and their conceptualisation using behavioral chain analyses and solution analyses. It goes on to discuss choice and implementation of therapeutic interventions: skills training, stimulus control and exposure, cognitive modification, and contingency management.
The authors are experienced DBT trainers, sensitive to the often missed but powerful effects of conditioning on the part of both patient and therapist in shaping therapeutic outcomes. They know the common ways problem solving in DBT can fail.
One pitfall, for example, is the failure to be specific in the setting of problems to target. Defining a behavioural target as aggression, for example, does not give enough behavioural specificity to guide treatment. Therapists should have “a sufficient description for someone to imagine the client’s specific actions, which could range from yelling to throwing furniture” (p. 48). Another poor target would be fear of abandonment, which is not, in itself, a behavioural target at all. As Heard and Swales put it, “Fearing abandonment did not directly destabilize anyone’s life, require intervention or lead to a low functioning” (p. 51). Better target behaviours in a client could be calling her husband repeatedly at work or crying intensely any time he wanted to do activities without her. Only in clarifying the exact behaviour target could one know what is needed for behavioural change.
The authors also highlight the common error made by clinicians in dealing with BPD patients by confusing the consequence of a behaviour with its intent. A suicidal attempt that lands a patient in the emergency room may have the consequence of bringing a concerned boyfriend home from a business trip, but it would be a mistake to conclude that this was what the patient had in mind (the intent) at the time of taking an overdose. Behavioural change analyses could reveal that the intent of the overdose was actually to relieve strong affect (e.g., guilt) experienced while ruminating about past sexual abuse while home alone. This distinction between consequence and intent is crucial if the suicidal behaviour is to be understood and modified.
While the book’s content is well organised and explanations thorough, some of the language can be a slog to read. From page 64: “Therapists distinguish between automatically elicited emotions (such as biologically based evolutionary adaptive responses or classically conditioned emotional responses derived from clients’ learning histories) and emotions that follow from a cognitive assumption or interpretation about an environmental or an internal event.” Effective editing might have reduced excess adjectives and clauses for readability. Fortunately, illustrative clinical examples are well chosen and add life to the narrative.
This book was designed to be used in the context of a functioning DBT program. DBT’s acronyms (such as “DEAR MAN” techniques) or interventions such as “dialectical thinking” or “acting opposite” are not explained in this volume, and the reader is referred to previous Linehan publications for clarification. A modest appendix explaining terms and interventions would have made it easier for non-DBT therapists looking to integrate aspects of DBT into their daily practices. Nonetheless, the wider audience of therapists—both new and experienced—interested in improving their effectiveness with difficult patients will not find another book quite as useful as this one.