Education Units and Method: Therapists register for the course by payment of registration fees of $245 and submission of name, address, and license number. They then be sent the hardbound textbook, CD that accompanies the textbook, and paper copies of the post-tests through snail-mail technology. All materials needed for completion of the CE are included in the registration fee, and the only additional cost to the registrant is postage for return of the post-tests. Registrants complete the post-tests, chapter by chapter or combination of chapters, and return then to the Center through snail-mail. A test response sheet and scoring template for each test have been developed. This is an “all or nothing” CE program: professionals take each test and must correctly answer 75% of the test questions on each test in order to be awarded the 16 units of continuing education. Since the goal in continuing education is learning, on only two of the five tests if the therapist scores below 75%, you will be given an opportunity to retake the test that they scored below 75%. You will not be given the correct answers nor told which items they incorrectly answered. This will encourage you to re-read the applicable portions of the text, thus encouraging learning. Professionals will not be offered “partial credit” for some chapter post-tests completed and others unanswered. Credit will be reported to your licensing board only upon 75% or above accurate completion of the entire course; either 16 units or 0 units of credit will be reported.

Since this textbook is both a scholarly and practical guide to DBT treatment, it is estimated that it will take the typical therapist more than 20 hours to read the textbook. 20 hours was chosen as a conservative estimate of time spent reading the textbook.

Refund and Course Completion Requirements: You will have one year from registration to completion of course requirements (submission of each of the 5 tests, having a total of 125 multiple choice questions). No refunds would be available after registration and shipment of the CD, text, and post-tests to the registrant.

The course syllabus appears below, as well as a few sample test questions so you can see what you will be “getting into” prior to registration.

Chapters 1 & 2 DBT as a New Theoretical Orientation and Research Evidence for the Effectiveness of DBT

The goal of this module is to introduce psychologists and other therapists to Dialectical Behavior Therapy (DBT). DBT was originally designed for the treatment of highly suicidal, parasuicidal, and self-destructive patients who are frequently in emotional crisis. Many of these patients are diagnosed with Borderline Personality Disorder. However, DBT technology and theory is applicable to most acute mental disorders. These chapters describe DBT assumptions regarding psychopathology, and compare DBT to other major schools of psychology (psychoanalytic, existential, client-centered, and behavioral theoretical orientations). The second chapter provides a scholarly review of the experimental research for the effectiveness of DBT (including research on the behavioral therapy aspects of DBT, acceptance and mindfulness aspects of DBT treatment, and experimental findings on the use of both partial and full-deployment of DBT with various patient populations).

Learning Objectives:

(1) Identify assumptions of DBT and patient pathotopography the DBT technology is designed to treat

(2) Identify how DBT is different from, and similar to, other major theoretical orientations in psychology

(3) Compare DBT to analytic approaches

(4) Compare DBT to humanistic approaches

(5) Compare DBT to gestalt or existential theories

(6) Compare DBT to behaviorist approaches

(7) Review of the professional literature on the effectiveness of DBT in a variety of clinical settings and with a variety of patient diagnostic populations

Post-Test: 25 multiple-choice questions

Chapter 3 Pathogenesis: Emotion Regulation as Core Therapeutic Target

Based upon research findings, the argument is made that most acute mental disorders consist of high emotionality or arousal. This “single factor” model of emotional sensitivity accounts for most therapeutic movement, regardless of theoretical orientation of the therapist. The combined or separate effects of psychological factors (such as attachment, trauma, and loss, including the critical factor of emotional invalidation), together with genetic factors (the neurobiological substrates underlying emotionality), predict emotional sensitivity (high baseline emotional arousal, slow return to baseline following treat that increases arousal, and inappropriate scanning of the environment for potential sources of threat). Knowledge of neuroanatomical activation demonstrates that prolonged emotional arousal results in changes in both neuroanatomy as well as neurochemistry causing essentially a permanent change in the sensitivity of the brain to environmental stimuli.

Learning Objectives:

(1) Review of the literature on effect of attachment issues during infancy on later psychological adjustment and emotion regulatory functions

(2) Review of the literature on the effect of trauma throughout the life cycle on later psychological adjustment and emotion regulatory functions

(3) Review of the literature on the effect of loss throughout the life cycle on later psychological adjustment and emotion regulatory functions

(4) Review the DBT understanding of the effects of invalidation of affect throughout the life cycle on later psychological adjustment and emotion regulatory functions

(5) Review of the literature on the neurobiological and neurochemical substrates of emotionality, including the role of prolonged versus acute stressors

(6) Review of the literature that either prolonged or highly acute arousal causes “kindling effects” that decrease arousal thresholds, thus creating the emotional sensitivity that DBT is designed to treat

Post-Test: 25 multiple-choice questions

Chapters 4 & 5 Pathotopology: Dialectic Conflict as Core Therapeutic Target and Dialectic Psychotherapy: Balancing Acceptance With Change

In these chapters attention is turned to dialectic conflict and its role in sustaining disorders. We also introduce general treatment strategies designed to reduce dialectic conflict, and thus to reduce suffering in our patients. Pathotopology, or the “look and feel” of patients in acute emotional turmoil, is reviewed, including emotional sensitivity, high emotional arousal, slow return to emotional baseline, hypervigilance, and the critical roles of emotional avoidance or emotional escape in sustaining pathology. DBT is differentiated, both in theory and practice, from CBT, where DBT involves self-management of affect rather than cognitions. Comparison of DBT and CBT cognitive reframing strategies are offered, and how dialectic failures contribute to high arousal and low problem-solving skills. Chapter 5 reviews the grand dialectic in psychotherapy of balancing acceptance with change, and the role of mindfulness skills as a form of exposure, desensitization, and acceptance (all with powerfully different theoretical assumptions) is reviewed.

Learning Objectives:

(1) Understanding the pathotopology of acute mental disorders (high emotional arousal, slow return to emotional baseline, and hypervigilance)

(2) Understanding how emotional avoidance and escape replaces emotion regulation in the acutely disordered patient

(3) Understanding the differences (both overt and subtle) between cognitive-behavioral interventions (CBT) and DBT interventions that involve self-management of affect rather than cognitions

(4) Able to identify how dialectic failures contribute to high arousal and low problem-solving skills

(5) Able to identify at least 4 (of 12) dialectics inherent in the psychotherapy relationship

(6) Able to discriminate affective acceptance from affective understanding

(7) Able to identify the difference between affect and behavior acceptance from behavior and affect change from a therapist’s perspective

(8) Able to identify how mindfulness skills can serve three separate but related psychological change functions: exposure, desensitization, and acceptance

(9) Able to identify how meaning-making skills can serve both as acceptance technologies and change technologies

(10) Able to identify how strategic behavior skills training can increase solution-focused coping

(11) Able to identify how DBT therapy involves equal emphasis on acceptance and change strategies in dealing with dialectic conflict

Post-Test: 25 multiple-choice questions

Chapter 6 DBT: Not Just for Borderlines Any More

Since most publications in the professional literature examine how DBT is effective with suicidal, parasuicidal, and borderline pathologies, this chapter reviews the dialectics with most other major mental disorders: mood disorders, anxiety disorders, impulse control disorders, addictive disorders, eating disorders, and personality disorders. Dialectic conflicts typical of each diagnosis are offered, and therapeutic strategies acceptable within a DBT framework of treatment are delineated.

Learning Objectives:

(1) Able to identify at least 3 (of 9) dialectic conflicts typical of mood disordered patients.

(2) Able to identify at least 3 (of 9) dialectic conflicts typical of anxiety disordered patients.

(3) Able to identify at least 3 (of 19) dialectic conflicts typical of eating disordered patients.

(4) Able to identify at least 3 (of 12) dialectic conflicts typical of substance abuse disordered patients.

(5) Able to identify at least 3 (of 14) dialectic conflicts typical of impulse control disordered patients.

(6) Able to identify at least 3 (of 14) dialectic conflicts typical of histrionic personality disordered patients.

(7) Able to identify at least 3 (of 14) dialectic conflicts typical of obsessive-compulsive personality disordered patients.

(8) Able to identify at least 3 (of 16) dialectic conflicts typical of narcissistic personality disordered patients.

(9) Able to identify at least 3 (of 15) dialectic conflicts typical of schizoid personality disordered patients.

(10) Able to identify at least 3 (of 15) dialectic conflicts typical of paranoid personality disordered patients.

Post-Test: 25 multiple-choice questions.

Chapters 7 & 8 Psychological Coping Skills Replace Escape and Avoidance and Conducting DBT in Private Practice

Chapter 7 reviews psychological coping skills typically deficient in patients with acute mental disorders, or skills that such patients have but frequently fail to use when they are in acute emotional distress: mindfulness, emotion regulation, distress tolerance, meaning-making, and strategic behavior skills. A brief review of each of these skill sets are provided, and a CD included with the text provides over 400 PowerPoint™ slides so the psychologist can lead individuals or groups of patients through each of the skill sets in psychoeducational sessions. The goal of the skill sets are to decrease emotional escape and avoidance strategies that make emotional distress linger. The final chapter provides clinical guidelines and suggestions on how to conduct DBT in a private practice setting (rather than the clinic or hospital setting where much DBT has previously been conducted). Learning Objectives:

(1) To be able to identify the major principles of mindfulness skills training from the mnemonic ONE MIND.

(2) To be able to identify the major principles of emotion regulation skills training from the mnemonic EMOTIONS

(3) To be able to identify the major principles of meaning-making skills training from the mnemonic SPECIFIC PATHS

(4) To be able to identify the major principles of distress tolerance skills training from the mnemonics DISTRACT and VISION (or, alternatively, from Dr. Linehan’s ACCEPTS and IMPROVE)

(5) To be able to identify the major principles of strategic behavior skills training from the mnemonics OBJECTIVES, TRUST, CARES and BEHAVIOR

(6) To understand the importance of consultation or a treatment team concept even while working in a solo private practice setting

(7) To be able to identify demand characteristics that can promote psychoeducation as separate from psychotherapy

(8) Able to identify dialectic conflict from patient histories

(9) Able to identify emotional escape and avoidance behaviors that patients in acute emotional pain demonstrate

(10)Able to identify mood-dependent behavior in response to symptoms

(11) Able to identify DBT strategies of shifting attention between major domains of functioning (attending to emotional stimuli, external cues, internal cues, cognitive cues, short- and long-term objectives, using avoidance and escape strategies intentionally rather than automatically, using acceptance and exposure to emotional pain and shifting between each of these as situations and goals change)

Post-Test: 25 multiple choice questions

Sample Multiple Choice Test Questions for CE Credit

2. One important behavioral notion from the intermittent or partial reinforcement effect research is that: (a) behavior is determined by prior affect regulatory processes (b) behavior need not be frequent to be important (c) infrequent reinforcement can have long-term consequences that are difficult to extinguish (d) cognitions are just as important as behavior in predicting outcome

3. Short-term (but intense) emotional experiences of threat tend to be processed in the: (a) cerebral cortex (b) heteromodal areas (c) hippocampus (d) gamma-aminobutyric acid receptors

4. DBT would endorse which of the following statements? (a) affect regulation is largely determined during the critical bonding stage of attachment during infancy (b) cognitive schemas that are faulty or misdirected determine most of human misery (c) emotional reasoning, arbitrary inference, and selective abstraction determine most of human misery (d) emotional escape and avoidance determine most of human misery

5. With both eating disorders and substance abuse the DBT therapist recognizes that these patient populations are engaging in _____, with difficulty shifting attention away from _____. (a) tolerability of affect; solution-focused coping (b) cognitive distortions; ruminative thoughts (c) urge-based behavior; strong physiological arousal (d) none of the above

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