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0. Radical behavioral help Katrina 1999- 2000

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Kohlenberg & Tsai
ries o f t h e p a s t t r a u m a t i z i n g e v e n t s ( A m e r i c a n P s y c h i a t r i c
A s s o c i a t i o n , 1994). So s o m e t i m e s p e o p l e cannot forget
t h e i r t r a u m a s . C o u p l e d w i t h w h a t we k n o w a b o u t t h e constructive n a t u r e o f h u m a n m e m o r y - - we d o n o t r e c o r d
o u r m e m o r i e s t h e way a c a m e r a takes a p i c t u r e ( B r a n s f o r d & J o h n s o n , 1973) - - t h e r e is r e a s o n to b e wary o f acc o r d i n g validity to all r e p o r t s b y p a t i e n t s o f h a v i n g b e e n
s e x u a l l y a b u s e d . Social scientists as well as t h e legal syst e m s h a r e a h e a v y r e s p o n s i b i l i t y in d e c i d i n g w h e t h e r a
g i v e n r e c o v e r e d m e m o r y o f a b u s e is a r e f l e c t i o n o f a n act u a l ( a n d c r i m i n a l ) e v e n t . E r r i n g i n e i t h e r d i r e c t i o n creates a n i n j u s t i c e f o r e i t h e r t h e a c c u s e d o r t h e accuser.
References
American Psychiatric Association. (1994). Diagnosticand statistical manual of mental disorders (4th ed.). Washington, DC: Author.
Bransford, J. D., & Johnson, M. K. (1973). Considerations of some
problems of comprehension. In W. G. Chase (Ed.), Visual information processing. NewYork: Academic Press.
Beck, A. T. (1967). Depression:Clinical, experimentaland theoreticalaspects.
New York: Harper & Row.
Beck, A. T. (1976). Cognitive therapyand the emotionaldisorders.New York:
International Universities Press.
D'Zurilla, T.J., & Goldfried, M. R. (1971). Problem-solving and behavior modification. Journal of Abnormal Psychology, 78, 107-126.
Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle
Stuart.
Fairburn, C. G. (1985). Cognitive-behavioral treatment for bulimia. In
D. M. Garner & E E. Garfinkel (Eds.), Handbook ofpsychotherapyfor
anorexia nervosa and bulimia. New York: Guilford Press.
Kanfer, E H., & Saslow, G. (1969). Behavioral diagnosis. In C. M.
Franks (Ed.), Behavior therapy: Appraisal and status. New York:
McGraw-Hill.
Lazo,J. (1995). True or false: Expert testimony on repressed memory.
Loyola of Los Angeles Law Review, 28, 1345-1413.
Linehan, M. M. (1993). Cognitivebehavioraltreatmentof borderlinepersonality disorder: The dialectics of effective treatment. New York: Guilford
Press.
Pirsig, R. M. (1974). Zen and the art of motorcyclemazntenance:An inquiry
into values. New York: Morrow.
Seligman, M. E. R (1974). Depression and learned helplessness. In
R.J. Friedman & M. M. Katz (Eds.), The psvchology of depression:
Contemporary theory and research.Washington, DC: Winston-Wiley.
Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and ClinicalPsychology,33, 448-457.
Weissman, A. N., & Beck, A. T. (1978). Developmentand validation of the
Dysfunctional Attitude Scale: A preliminary investigation. Paper presented at the annual meeting of the American Educational
Research Association, Toronto.
Address correspondence to Gerald C. Davison, Ph.D., Department of
Psychology, University of Southern California, Los Angeles, CA 900891061; e-mail: gdaviso@rcf.usc.edu
Received: August 25, 1999
Accepted: September30, 1999
Response Paper
Radical Behavioral Help for Katrina
RobertJ. Kohlenberg,
University o f W a s h i n g t o n
M a v i s T s a i , I n d e p e n d e n t Practice, Seattle, W a s h i n g t o n
Our treatment plan for Katrina is guided by the principles of functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991), an approach derived from radical
behaviorism. The fundamental assumption is that we
and our clients act the way we do because of the contingencies of reinforcement we have experienced in past relationships. It then follows that clinical improvements,
which are acts of the client, also involve contingencies of
reinforcement that occur in the relationship between the
client and therapist. Thus, our treatment of Katrina emphasizes the use of the client-therapist interaction as an
in-vivo learning opportunity. It is for this reason that
FAP views a caring, genuine, sensitive, and emotional
client-therapist relationship as the most important element in the change process. We describe a FAP case conceptualization form designed to help the therapist achieve
a curative therapeutic relationship. Our case conceptualization of Katrina includes an account of how Katrina's
history resulted in her current daily life problems, identification of Katrina's cognitive phenomena that might be related to her current problems, and most importantly the
prediction of how Katrina's clinically relevant behavior dailv life problems, dysfunctional thinking, and improvements~might occur during the session within the
therapist-client relationship.
UR COMMENTS a b o u t this case a r e f r o m t h e p e r s p e c tive o f p r a c t i c i n g r a d i c a l b e h a v i o r a l c l i n i c i a n s . T h e
t h e o r y t h a t g u i d e s o u r c l i n i c a l w o r k is d e c e p t i v e l y simple.
It is t h a t we a n d o u r c l i e n t s act t h e way we d o b e c a u s e o f
t h e c o n t i n g e n c i e s o f r e i n f o r c e m e n t we e x p e r i e n c e d i n
p a s t r e l a t i o n s h i p s . B i o l o g i c a l v a r i a b l e s s u c h as g e n e t i c
p r e d i s p o s i t i o n s a r e also i n f l u e n t i a l , b u t s i n c e t h e s e g i v e n s
c a n n o t h e c h a n g e d , o u r e m p h a s i s i n t r e a t m e n t is o n c o n tingencies of reinforcement. These contingencies are
c u r r e n t a n d a r e always h a p p e n i n g d u r i n g t h e give a n d
take o f t r e a t m e n t - - w h e n e v e r we i n t e r a c t w i t h o u r clients.
B a s e d o n this t h e o r y , c l i n i c a l i m p r o v e m e n t s , h e a l i n g , o r
p s y c h o t h e r a p e u t i c c h a n g e , all o f w h i c h a r e acts o f t h e clie n t , also i n v o l v e contingencies o f r e i n f o r c e m e n t t h a t o c c u r
in t h e r e l a t i o n s h i p b e t w e e n t h e c l i e n t a n d t h e r a p i s t . T h e
t r e a t m e n t b a s e d o n t h e s e p r i n c i p l e s is c a l l e d f u n c t i o n a l
a n a l y t i c p s y c h o t h e r a p y (FAP; K o h l e n b e r g & Tsai, 1991),
a n d s t e m s f r o m t h e f u n c t i o n a l analysis d e s c r i b e d b y B. E
S k i n n e r . I n c o n t r a s t to p o p u l a r m i s c o n c e p t i o n s a b o u t
O
Cognitive and Behavioral Practice 7, 500-505, 2000
1077-7229/00/500-50551.00/0
Copyright © 2000 by Association for A d v a n c e m e n t of Behavior
Therapy. All rights of reproduction in any form reserved.
Response: Radical Behavioral Help
radical behaviorism, FAP views a caring, genuine, sensitive, and emotional client-therapist relationship as the
most important element in the change process.
In applying this approach to Katrina, keep in mind
that "act" refers to anything a person does. This includes
private, beneath-the-skin acts, such as thinking, feeling,
seeing, hearing, experiencing, and knowing, as well as
public acts. Every aspect o f being h u m a n is included in
this definition, as long as it is expressed as a verb. Thus,
instead o f Katrina having a childhood "memory" of abuse
and "bad feelings" and associated beliefs, she is "remembering" it, "feeling" the feelings (see Chapter 3 of FAP for
a m o r e detailed account of how this happens), and thinking (e.g., "this is horrible" or "I am a screwed up freak
and not g o o d e n o u g h for Peter").
Because behaviorism is a theory of behavior change,
describing the client's problems as acts provides many
options about appropriate targets for change. For example, one option is based on the notion that the remembering, thinking, and feeling per se are not the problem;
instead, the problem is her struggling against these and
not getting on with her life. For this option, therapy
would focus on Katrina developing skills n e e d e d for accepting the intrusive remembering: thinking and feeling
as opposed to changing or eliminating them. Steve
Hayes's radical behavioral treatment, acceptance and
c o m m i t m e n t therapy (ACT; Hayes & Wilson, 1994), and
Marsha Linehan's dialectical behavioral therapy (DBT;
Linehan, 1993) have highly developed methods for accomplishing this; acceptance is also used in FAP.
A n o t h e r option is based on the notion that current situations evoke the remembering of early trauma, and that
Katrina is actually avoiding some of the detail in remembering. This avoidance prevents exposure and exposurebased extinction. This paradoxical interpretation o f intrusive memories and flashbacks is also consistent with
Katrina's report that she can r e m e m b e r the details o f her
abuse and "not feel" (for a more detailed explanation of
our account of flashbacks, see Kohlenberg & Tsai, 1998).
A third option is that Katrina's thinking does influence subsequent behavior, including feeling depressed
and suicidal ideation, and using cognitive therapy to
change her thinking would be called for. (For a discussion of cognitive therapy in FAP, see Kohlenberg & Tsai,
1991, Chapter 5; and Kohlenberg & Tsai, 1994a). For a
discussion on the process for deciding which of these
other options are most appropriate for a particular client, see Kohlenberg and Tsai (1994b).
501
scribed feeling better because of two behavioral repertoires: She had gone back to school and she was more engaged with family and friends. We will refer to these two
repertoires as "working" and "close interpersonal relating." We assume that Katrina would agree the primary
goals of treatment are to reestablish and maintain her going to school and being engaged with family and friends.
From this perspective, impulsive self-destructive behaviors (and subsequent hospitalization) are problematic
because they interfere with these goals. H e r feelings (depression, low self-esteem) and thinking are also problematic to the extent that they cause the impulsive behavior
and interfere with interpersonal relating. Given this perspective, treatment may or may not focus on changing
her thinking and feeling (depression, suicidal ideation,
and intrusive memories o f abuse). We will say m o r e about
this later.
A s s e s s m e n t and Consultation
Given Katrina's dangerous behaviors, our first task is to
consult an expert on BPD and suicide. Marsha Linehan
(the expert we consulted) had several suggestions. 1 First,
lethality of the self-injurious behaviors needs to be assessed. Based on the case material, Linehan's impression
is that Katrina's self-injurious behaviors present a significant risk of lethality. Thus, it is important that the client
receives medical treatment for self-inflicted injuries as
needed. Second, additional assessment is needed to determine if the client meets criteria for borderline personality
disorder. If so, there is empirical support for using DBT
(Linehan, 1993). It is important to assure that the therapist does not reinforce self-injurious behavior; instead, the
therapist should reinforce alternative, more adaptive behavior. For example, DBT calls for a 24-hour hiatus in
treatment after self-injurious behavior leading to hospitalization; a focus in the session on the chains of behavior
leading up to the self-injurious behavior, to the exclusion
of other, less aversive topics; and the availability of the
therapist between sessions for p h o n e contacts to reinforce
more adaptive alternatives to self-injurious behavior.
Consistent with DBT, FAP focuses on the therapistclient relationship as an opportunity for in-vivo learning.
Specifically, the therapist-client relationship is used as an
environment for building behaviors that result in decreasing impulsive and self-injurious behavior and increasing
intimate interpersonal relating and other skills.
Case Conceptualization
Katrina's Presenting Problems
As behaviorists, we begin by asking what actions (acts)
does Katrina take (or fail to take) that are problematic. In
Katrina's case, she reported that she was "better than
ever" prior to her last hospitalization. Further, she de-
FAP case conceptualization serves three purposes.
First, it generates an account of how the client's history
1Marsha Linehan did not review this manuscript, so we take
responsibility for an), misrepresentations.
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Kohlenberg & Tsai
resulted in the current daily life problems. Historical interpretations are preferred and include an explanation
of how the current problems were learned, and how they
were adaptive at the time they were acquired. Historical
interpretations set the scene for the client to learn new
ways of behaving.
Second, it identifies possible cognitive p h e n o m e n a
that might be related to current problems. In FAP, the
role of cognition in treatment and in accounting for daily
life problems lies on a continuum. O n one end of the
continuum, problems are more or less caused by the
thinking and believing that precede them. In this case,
cognitive therapy is appropriate. O n the other end of the
c o n t i n u u m , cognition does n o t play a causal role, and
in fact may even be absent. In the latter case, cognitive
therapy may not be effective and may even be countertherapeutic (see Kohlenberg & Tsai, 1991, Chapter 3).
Third, and most importantly, FAP case conceptualization identifies and predicts how clinically relevant behavior (CRB)--daily life problems, dysfunctional thinking,
and i m p r o v e m e n t s - - m i g h t occur during the session
within the therapist-client relationship. W h e n daily life
problems are manifested in the therapeutic relationship,
they represent special opportunities for significant therapeutic change because of the widely accepted notion that
in-vivo learning is superior. Hence, the case conceptualization helps therapists to notice CRB as they occur and
to use these opportunities to shape and reinforce improvements in-vivo. Since the case conceptualization consists of hypotheses, it changes as treatment progresses
and more information is gathered.
Katrina's Case Conceptualization
Katrina engages in impulsive, self-destructive behavior
that interferes with productive working (going to school)
and close interpersonal relating. She lacks skills to prevent the impulsive self-destructive behavior and those required for productive working and close interpersonal relating. Because of the overlap between increasing close
interpersonal relating and increasing productive work-
(1)
(2)
(3)
(4)
(s)
(6)
Corresponding
Daily Life In-Session
Daily Life Relevant Corresponding
Problems History
In-Session
Cognitive Concepts Goals
Goals
Problems
(Automatic
(CRB2)
Thoughts, Core
(CRBls)
Beliefs, Underlying
Assumptions)
FiS. 1. Case conceptualization form used during functional analytic
psychotherapy.
ing, our discussion will focus on the former. (As an aid to
formulating a FAP case conceptualization, the form
shown in Figure 1 is used.)
1. Daily Life Problems
a. Impulsive behavior due to being unaware of
early antecedents. Early antecedents include
lower intensity negative feeling and environmental events (such as failure at a task, perceived
rejection by others, absence of others who provide social support, lack of reciprocated affection from her husband, etc.).
b. In lieu of being aware of and attending to problems that are typically expected to occur with
those close to her, she puts on a g o o d front.
c. If she were aware of her feelings (early antecedents to impulsive behavior), Katrina doesn't
know what to do about low levels of negative
feeling (lack of problem-solving skills, skills in
describing and talking about negative feelings,
asking for what she wants, etc.).
d. Intrusive memories of childhood abuse.
e. Difficulties in close interpersonal relating related to above.
f. Depression.
2. Relevant History
History refers to childhood and significant lifespan events or more recent experiences that acc o u n t for the thinking, actions, and m e a n i n g that
may be implicated in daily life problems. In Katrina's case, her parents punished her expression of
negative thoughts or feelings and reinforced her
for acting normal and competent. As a means of
doing what her parents wanted, it is likely that Katrina learned not to be aware of her negative feelings (wants, unhappiness, anxiety, and fear) until
they became extremely intense (according to behaviorists, awareness is a behavior that is learned).
Hence, Katrina's impulsive behavior seems to be a
"sudden impulse," with Katrina being unaware of
any discernable antecedent. Because Katrina did
not learn to be aware of and express "normal" negative feelings, she did not learn to problem-solve before things got out of control.
3. Corresponding In-Session Problems
It is likely that Katrina will engage in some daily
life problematic behavior during the therapy, within
therapist-client relationship. These are referred to
as clinically relevant behaviors, Type 1 (CRBls).
The therapist needs to be aware of CRBs as they
occur such that improvements can be shaped and
naturally reinforced in vivo.
a. Katrina will not be aware of negative feelings
about the therapy or the therapist until they
reach intense levels and she acts impulsively.
Response: Radical Behavioral Help
Correspondingly, she will n o t be aware o f the environmental event that evoked the negative feelings. Evocative environmental events occur frequently during treatment, and may include the
therapist being momentarily inattentive, disagreeing with Katrina, not being supportive in a
way Katrina might prefer, taking a vacation,
turning down a sexual advance, and presenting
an assignment that she has difficulty doing.
b. In lieu of being aware of and attending to problems that occur with the therapist or the therapy,
Katrina "puts on a g o o d front."
c. If aware o f negative feelings and problems in the
therapy, Katrina will not discuss these or ask for
help in resolving the problems. She probably will
not discuss her negative feelings about evocative
events until they become very intense.
d. Katrina probably will have memories of early
abuse during the session, but will not identify the
events (topic being discussed, either warm or
angry feelings evoked by therapist-client relationship, etc.) that were the antecedents and
stimulus for the remembering.
e. Katrina will be limited in being open with the
therapist about her feelings and wants, may
become fearful and anxious if she "trusts" the
therapist too m u c h or may engage in relationship-sabotaging behaviors as a way o f avoiding
closeness.
f. Katrina will b e c o m e more depressed during sessions after certain types o f interpersonal interactions that involve perceived rejection by the therapist or failure on her part. She also may have
within-session depressogenic cognitions (see
below).
4. Corresponding Cognitive Concepts (Automatic
Thoughts, Core Beliefs, Underlying Assumptions)
Katrina's stated beliefs, such as "If I allow myself
to feel, the feeling will never stop" and "If I share
my pain with others, they will be freaked out,"
might play a role in her lack of contact with lowerintensity negative feelings.
Katrina's statement "I do not feel. I can tell you
anything about my abuse, without feeling a thing" is
probably a description of her avoidance of fully rem e m b e r i n g or describing early traumatic events
and is not a cognitive p h e n o m e n a that plays a
causal role in Katrina's problems.
Katrina makes depressogenic self-statements
such as "I am a total loser," "I'm not g o o d e n o u g h
for Peter (and to be a client)," and I cannot be
happy if I d o n ' t have "kids, jobs, fun things to
do . . . . " She might also make statements such as "if
I ask for what I want, I won't get it."
Katrina also might have beliefs such as "I must get
rid of my intrusive memories of abuse a n d / o r
feeling depressed before I can get on with my life"
that are targeted in acceptance therapy.
5. Daily Life Goals
a. Becoming aware of situations and feelings that
are problematic before they b e c o m e so intense
that they evoke impulsive self-destructive behavior.
b. Being able to "look bad" (e.g., be emotional, express negative feelings, make complaints with
family and friends).
c. Try to solve problems before they b e c o m e too intense (e.g., call the therapist or invoke other social support before self-injurious behavior occurs). Develop skills such as being able to verify if
an interpersonal rejection has occurred and, if
so, to find alternative, more adaptive coping behavior (other than extreme impulsive acts), and
m o r e effectively ask others for what she wants,
even if she may be rejected.
d. Reduce the frequency and intensity of intrusive
memories, and if they occur, still make progress
toward goals (have memories and get on with
life).
e. Become m o r e o p e n in close relationships about
her feelings and wants. Become m o r e tolerant o f
interpersonal fear and anxiety. Become m o r e
trusting of others. Detect and stop relationshipsabotaging behaviors.
f. Reduce the frequency and intensity o f depression, and if it occurs, make progress toward goals
(be depressed and get on with life).
6. In-Session Goals (CRB2)
a. Become aware of problems with the therapy or
therapist early in the sequence. Be m o r e aware
o f low-intensity feeling as it is occurring during
the session.
b. Be able to "look bad" (e.g., be emotional, express negative feelings with the therapist).
c. Develop skills during the therapy session, within
the context o f the therapist-client relationship,
to identify and discuss negative feeling. Be able
to directly talk about rejections (by the therapist) when they occur. Ask the therapist directly
for what she wants. Compromise in accepting
what the therapist can and cannot give.
d. Be m o r e open about her feelings and wants
within the context o f the client-therapy relationship. Trust the therapist and b e c o m e m o r e tolerant o f interpersonal fear and anxiety existing
within the therapist-client relationship. Detect
and stop relationship-sabotaging behaviors.
e. Learn to detect therapist-client interactions that
evoke intrusive memories and to develop better
ways to deal with these situations in session. Re-
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Kohlenberg & Tsai
duce the frequency and intensity of intrusive
memories occurring during the session. If intrusive memories do occur, remain on task while remembering (use in vivo acceptance procedures).
Reduce the frequency and intensity of depression occurring during the session and learn how
to stay on task even if depressed (use in vivo acceptance procedures).
Treatment
O u r treatment plan for Katrina occurs simultaneously
on two levels. The first level is cognitive therapy based on
Beck, Rush, Shaw, and Emery (1979), and consists of procedures such as defining and setting goals; structuring
the session with an agenda, eliciting feedback from client, and using homework assignments; presenting the rationale; and using cognitive behavioral strategies and
techniques. In FAP, many of the cognitive therapy procedures are modified to enhance the occurrence and detection of CRB. For example, the t h o u g h t record has been
modified to include an in vivo column that helps to call
attention to the parallels between the problems occurring in daily life and the therapist-client interaction.
At the same time we are using cognitive therapy, we
are looking for Katrina's daily life problems occurring in
the here and now, within the context of the therapistclient relationship. In particular, we look for CRBls and
CRB2s. For example, in assigning homework, we look for
unspoken negative feelings about the assignment or
about her sense of failure in not understanding it. We
would be particularly vigilant for indications that Katrina
reacts negatively to something the therapist has (or has
not) done, but hides her feelings by putting on a g o o d
front. The use of prompting and discrimination training
would be used to help Katrina detect and report on lowintensity negative feeling (see Kohlenberg & Tsai, 1991,
Chapter 4, for a more detailed description). Of equal importance, we would attempt to shape and naturally reinforce improvements (CRB2s). For example, whenever
possible, we would reinforce direct requests (saying directly what she wants) by acquiescing. If we are not able
to do what she wants, Katrina's request would be taken seriously, and compromises would be proposed. O u r two
levels of treatment are also consistent with and guided by
DBT (Linehan, 1993).
FAP Rationale P r e s e n t e d to Client
In conclusion, we will summarize the philosophy and
methods used to help Katrina by describing the rationale
that we would present to her. The rationale includes a
cognitive therapy c o m p o n e n t while at the same time embracing alternative noncognitive explanations. The importance of the therapy relationship and in-vivo learning
are also included. To help understand our approach, we
translated the radical behavioral concepts that underlie
our therapy into everyday language.
The FAP A p p r o a c h to Therapy
Clients come into therapy with complex life stories of
joy and anguish, dreams and hopes, passions and vulnerabilities, unique gifts and abilities. This therapy will be
conducted in an atmosphere of caring and respect in
which new ways of approaching life are learned. O u r
work will be a joint effort; your input is valued and will be
used in the treatment plan.
What We Will Focus on in Therapy
1. Learning More Empowering Ways of Thinkinff. We will
be teaching you the tools of cognitive therapy (CT).
These tools are powerful skills to have at one's disposal. In CT, the basis of negative feelings and ineffective ways of acting is considered to be your
thoughts and beliefs. That is, the way you think affects how you feel and what you do. In our treatment, however, we also believe that sometimes feelings can lead to thoughts and actions, or that
something else altogether can cause both negative
thoughts, negative feelings, and ineffective actions.
2. Increasing Activities That Bring You Pleasure and Mastery: You'll be using a chart to m o n i t o r your activities and moods, and we'll figure out what you can
do to increase a sense of accomplishment and enj o y m e n t of life.
3. Considering Other Causes of Negative Feelings and Ineffective Actinff. Some clients may benefit from considering other causes of negative feelings and ineffective acting, such as losses still needing to be grieved,
anger turned inward, true self unexpressed, not
having e n o u g h joy in relationships and work,
needing nurturance but not knowing how to get it,
being uncertain of who you are, or being fearful of
intimacy. The focus of your therapy will d e p e n d on
the causes of your problems. Thus, along with cognitive therapy, your treatment might also include
exploring your strengths and seeing the best of who
you are; grieving your losses, contacting your feelings, especially those that are difficult for you to experience; developing relationship skills; developing
mindfulness, acceptance, and an observing self;
and gaining a sense of mastery in your life.
4. Focusing on the Here and No~. The most powerful
kind of interaction is based on the present, where
something you say affects me, or something I say affects you. Therapy is m o r e impactful when you talk
about your experience in the present m o m e n t , like
feelings of being depressed and anxious, or
thoughts of being unsure of yourself, that are hap-
Response: A Dialectical Formulation
p e n i n g in the session r a t h e r than j u s t r e p o r t i n g
feelings f r o m the past week. W h e n we l o o k at something that is h a p p e n i n g right now, we can experience a n d u n d e r s t a n d it m o r e fully, a n d t h e r a p e u t i c
change is s t r o n g e r a n d m o r e i m m e d i a t e .
. Focusing on the Therapeutic Relationship as a Way to
Learn New Pattern~ T h e therapy relationship prorides o p p o r t u n i t i e s to learn how to express yourself
fully a n d create b e t t e r relationships. It will be
helpful to focus o n o u r interaction if you have issues or difficulties that c o m e u p with m e that also
c o m e u p with o t h e r p e o p l e in your life. W h e n you
express y o u r thoughts, feelings, a n d desires in an
authentic, caring, a n d assertive way, you are m o r e
likely to work productively a n d have closer interpersonal relationships.
Closing Comments
Above all, o u r t r e a t m e n t o f Katrina emphasizes the
use o f the client-therapist interaction as an in-vivo learn-
ing opportunity. Even t h o u g h this type o f work has b e e n
called for by some cognitive b e h a v i o r therapists (see
Goldfried, 1982), we feel its i m p o r t a n c e has b e e n overlooked. A n i n d i c a t i o n o f the potential for in vivo work is
illustrated by Marsha L i n e h a n ' s suggestion that the FAP
type o f use o f the t h e r a p e u t i c relationship as used in h e r
t r e a t m e n t m i g h t prove to be the most i m p o r t a n t e l e m e n t
in DBT efficacy (M. L i n e h a n , p e r s o n a l c o m m u n i c a t i o n ,
March 24, 1999).
References
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505
Response Paper
A Dialectical Behavioral Formulation:
The Case of Katrina
S h e l l e y M c M a i n , Centre f o r A d d i c t i o n a n d M e n t a l
H e a l t h a n d University o f Toronto
Katrina is a 25-year-old woman who presents with multiple problems, among them chronic suicidal behavior. Clients like Katrina, who impress diagnostically with a Borderline Personality Disord~ are particularly suited to
Dialectical Behavior Therapy (DBT). It is an appropriate
approach because it was developed in the context of working with such individuals, and is one of the few treatments for this population for which there is outcome data
to support its efficacy. A DBT approach helps the therapist identify the range of a client's problems and organize
problems in order of priority. Treatment interventions,
which are premised on a biosocial theory of the etiology
and maintenance of a client's difficulties, are guided by a
stage theory of treatment. The behavioral patterns that
characterize borderline individuals and that often become
obstacles to progress are an important focus of treatment.
A n overview of a D B T approach and the application of
D B T formulation to the case of Katrina is presented.
Y GENERAL APPROACH to p s y c h o t h e r a p y has b e e n
largely i n f l u e n c e d by my training in e x p e r i e n t i a l
t h e r a p y ( G r e e n b e r g & Paivio, 1997; G r e e n b e r g , Rice, &
Elliott, 1993) a n d dialectical behavior therapy (DBT;
L i n e h a n , 1993a, 1993b). A basic assumption that guides
my u n d e r s t a n d i n g is that e m o t i o n dysregulafion figures
centrally in the etiology a n d m a i n t e n a n c e o f psychopathology. T h e n a t u r e a n d e x t e n t o f a client's p r o b l e m s determines my decision a b o u t the relevance a n d a p p r o p r i ateness o f a specific therapy m o d e l in each case. T h e case
o f Katrina, a w o m a n who presents with multiple problems, a m o n g t h e m c h r o n i c suicidal behavior, impresses
diagnostically as B o r d e r l i n e Personality D i s o r d e r (BPD),
c o n c u r r e n t with o t h e r D S M disorders. DBT is an a p p r o priate a p p r o a c h to this case for two reasons: (1) DBT was
d e v e l o p e d within the c o n t e x t o f treating clients with
BPD; therefore, the p r o t o c o l is readily a p p l i e d to this
case, a n d (2) t h e r e is a growing b o d y o f o u t c o m e data to
s u p p o r t the efficacy o f this t r e a t m e n t with these clients
(Linehan, Armstrong, Suarez, Allmon, & H e a r d , 1991;
L i n e h a n , H e a r d , & Armstrong, 1993; L i n e h a n , Tutek,
H e a r d , & Armstrong, 1994).
Address correspondence to Robert J. Kohlenberg, Department of
Psychology351635, University of Washington, Seattle, WA98195-1635.
Cognitive and Behavioral Practice 7, 5 0 5 - 5 0 9 , 2 0 0 0
Received: August 25, 1999
Accepted: September30, 1999
1077-7229/00/505-50951.00/0
Copyright © 2000 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
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