New to This Edition
*Handouts and worksheets (available online and in the companion volume) have been completely revised and dozens more added--more than 225 in all.
*Each module has been expanded with additional skills.
*Multiple alternative worksheets to tailor treatment to each client.
*More extensive reproducible teaching notes (provided in the book and online), with numerous clinical examples.
*Curricula for running skills training groups of different durations and with specific populations, such as adolescents and clients with substance use problems.
*Linehan provides a concise overview of "How to Use This Book."
See also DBT® Skills Training Handouts and Worksheets, Second Edition, a spiral-bound 8 1/2" x 11" volume containing all of the handouts and worksheets and featuring brief introductions to each module written expressly for clients. Plus, Cognitive-Behavioral Treatment of Borderline Personality Disorder, the authoritative presentation of DBT. Also available: Linehan's instructive skills training videos for clients--Crisis Survival Skills: Part One, Crisis Survival Skills: Part Two, From Suffering to Freedom, This One Moment, and Opposite Action.
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About the Author
Read an Excerpt
Rationale for Dialectical Behavior Therapy Skills Training
What Is DBT?
The behavioral skills training described in this manual is based on a model of treatment called Dialectical Behavior Therapy (DBT). DBT is a broad-based cognitive-behavioral treatment originally developed for chronically suicidal individuals diagnosed with borderline personality disorder (BPD). Consisting of a combination of individual psychotherapy, group skills training, telephone coaching, and a therapist consultation team, DBT was the first psychotherapy shown through controlled trials to be effective with BPD. Since then, multiple clinical trials have been conducted demonstrating the effectiveness of DBT not only for BPD, but also for a wide range of other disorders and problems, including both undercontrol and overcontrol of emotions and associated cognitive and behavioral patterns. Furthermore, an increasing number of studies (summarized later in this chapter) suggest that skills training alone is a promising intervention for a variety of populations, such as persons with drinking problems, families of suicidal individuals, victims of domestic abuse, and others.
DBT, including DBT skills training, is based on a dialectical and biosocial theory of psychological disorder that emphasizes the role of difficulties in regulating emotions, both under and over control, and behavior. Emotion dysregulation has been linked to a variety of mental health problems stemming from patterns of instability in emotion regulation, impulse control, interpersonal relationships, and self-image. DBT skills are aimed directly at these dysfunctional patterns. The overall goal of DBT skills training is to help individuals change behavioral, emotional, thinking, and interpersonal patterns associated with problems in living. Therefore, understanding the treatment philosophy and theoretical underpinnings of DBT as a whole is critical for effective use of this manual. Such understanding is also important because it determines therapists' attitude toward treatment and their clients. This attitude, in turn, is an important component of therapists' relationships with their clients, which are often central to effective treatment and can be particularly important with suicidal and severely dysregulated individuals.
A Look Ahead
This manual is organized into two main parts. Part I (Chapters 1–5) orients readers to DBT and to DBT skills training in particular. Part II (Chapters 6–10) contains the detailed instructions for teaching the specific skills. The client handouts and worksheets for all of the skills modules can be found at a special website for this manual (www.guilford.com/dbt-manual). They can be printed out for distribution to clients, and modified as necessary to fit a particular setting. A separate, printed volume of handouts and worksheets, ideal for client use, which has its own website where clients can print their own forms, is also available for purchase.
In the rest of this chapter, I describe the dialectical world view underpinning the treatment, and the assumptions inherent in such a view. The biosocial model of severe emotion dysregulation (including BPD) and its development are then described, as well as how variations on the model apply to difficulties in emotion regulation in general. As noted above, the DBT skills presented in this manual are specifically designed to address emotion dysregulation and its maladaptive consequences. Chapter 1 concludes with a brief overview of the research on standard DBT (individual psychotherapy, phone coaching, consultation team, and skills training), as well as the research on DBT skills training minus the individual therapy component. In Chapters 2–5, I discuss practical aspects of skills training: planning skills training, including ideas for different skills curricula based on client population and the setting (Chapter 2); structuring session format and starting skills training (Chapter 3); DBT skills training treatment targets and procedures (Chapter 4); and applying other DBT strategies and procedures to behavioral skills training (Chapter 5). Together, these chapters set the stage for deciding how to conduct skills training in a particular clinic or practice. A set of Appendices to Part I consists of 11 different curricula for skills training programs.
In Part II, Chapter 6 begins the formal skills training component of DBT. It covers how to introduce clients to DBT skills training and orient them to its goals. Guidelines on how to teach specific skills then follow, grouped into four skills modules: Mindfulness Skills (Chapter 7), Interpersonal Effectiveness Skills (Chapter 8), Emotion Regulation Skills (Chapter 9), and Distress Tolerance Skills (Chapter 10).
Every skill has corresponding client handouts with instructions for practicing that skill. Every handout has at least one (usually more than one) associated worksheet for clients to record their practice of the skills. Again, all of these client handouts and worksheets can be found at the special Guilford website for this manual (see above for the URL), as well as in the separate volume. Descriptions of handouts and related worksheets are given in boxes at the start of each main section within the skill modules' teaching notes (Chapters 6–10).
I should note here that all skills training in our clinical trials was conducted in groups, although we do conduct individual skills training in my clinic. Many of the treatment guidelines in this manual assume that skills training is being conducted in groups, mainly because it is easier to adapt group skills training techniques for individual clients than vice versa. (The issue of group vs. individual skills training is discussed at some length in the next chapter.)
This manual is a companion to my more complete text on DBT, Cognitive-Behavioral Treatment of Borderline Personality Disorder. Although DBT skills are effective for disorders other than BPD, the principles underlying the treatment are still important and are discussed fully there. Because I refer to that book often throughout this manual, from here on I simply call it "the main DBT text." The scientific underpinnings and references for many of my statements and positions are fully documented in Chapters 1–3 of that text; thus I do not review or cite them here again.
The Dialectical World View and Basic Assumptions
As its name suggests, DBT is based on a dialectical world view. "Dialectics" as applied to behavior therapy has two meanings: that of the fundamental nature of reality, and that of persuasive dialogue and relationship. As a world view or philosophical position, dialectics forms the basis of DBT. Alternatively, as dialogue and relationship, dialectics refers to the treatment approach or strategies used by the therapist to effect change. These strategies are described in full in Chapter 7 of the main DBT text and are summarized in Chapter 5 of this manual.
Dialectical perspectives on the nature of reality and human behavior share three primary characteristics. First, much as dynamic systems perspectives do, dialectics stresses the fundamental interrelatedness or wholeness of reality. This means that a dialectical approach views analyses of individual parts of a system as of limited value unless the analysis clearly relates the parts to the whole. Thus dialectics directs our attention to the individual parts of a system (i.e., one specific behavior), as well as to the interrelatedness of the part to other parts (e.g., other behaviors, the environmental context) and to the larger wholes (e.g., the culture, the state of the world at the time). With respect to skills training, a therapist must take into account first the interrelatedness of skills deficits. Learning one new set of skills is extremely difficult without learning other related skills simultaneously — a task that is even more difficult. A dialectical view is also compatible with both contextual and feminist views of psychopathology. Learning behavioral skills is particularly hard when a person's immediate environment or larger culture do not support such learning. Thus the individual must learn not only self-regulation skills and skills for influencing his or her environment, but also when to regulate them.
Second, reality is not seen as static, but as made up of internal opposing forces (thesis and antithesis) out of whose synthesis evolves a new set of opposing forces. A very important dialectical idea is that all propositions contain within them their own oppositions. As Goldberg put it, "I assume that truth is paradoxical, that each article of wisdom contains within it its own contradictions, that truths stand side by side" (pp. 295–296, emphasis in original). Dialectics, in this sense, is compatible with psychodynamic conflict models of psychopathology. Dichotomous and extreme thinking, behavior, and emotions are viewed as dialectical failures. The individual is stuck in polarities, unable to move to syntheses. With respect to behavioral skills training, three specific polarities can make progress extremely difficult. The therapist must pay attention to each polarity and assist each client in moving toward a workable synthesis.
The first of these polarities is the dialectic between the need for clients to accept themselves as they are in the moment and the need for them to change. This particular dialectic is the most fundamental tension in any psychotherapy, and the therapist must negotiate it skillfully if change is to occur.
The second is the tension between clients' getting what they need to become more competent, and losing what they need if they become more competent. I once had a client in skills training who every week reported doing none of the behavioral homework assignments and insisted that the treatment was not working. When after 6 months I suggested that maybe this wasn't the treatment for her, she reported that she had been trying the new skills all along and they had helped. However, she had not let me know about it because she was afraid that if she showed any improvement, I would dismiss her from skills training.
A third very important polarity has to do with clients' maintaining personal integrity and validating their own views of their difficulties versus learning new skills that will help them emerge from their suffering. If clients get better by learning new skills, they validate their view that the problem all along was that they did not have sufficient skills to help themselves. They have not been trying to manipulate people, as others have accused them of doing. They are not motivated to hurt others, and they do not lack positive motivation. But the clients' learning new skills may also seem to validate others' opinions in other ways: It may appear to prove that others were right all along (and the client was wrong), or that the client was the problem (not the environment). Dialectics not only focuses the client's attention on these polarities, but also suggests ways out of them. (Ways out are discussed in Chapter 7 of the main DBT text.)
The third characteristic of dialectics is an assumption, following from the two characteristics above, that the fundamental nature of reality is change and process rather than content or structure. The most important implication here is that both the individual and the environment are undergoing continuous transition. Thus therapy does not focus on maintaining a stable, consistent environment, but rather aims to help the client become comfortable with change. An example of this is that we discourage people from sitting in exactly the same seats in a skills training group for the whole time they are in the group. Within skills training, therapists must keep aware not only of how their clients are changing, but also of how they themselves and the treatment they are applying are changing over time.
Biosocial Theory: How Emotion Dysregulation Develops
As noted earlier, DBT was originally developed for individuals who were highly suicidal, and secondarily for individuals who met criteria for BPD. Effective treatment, however, requires a coherent theory. My first task, therefore, was to develop a theory that would let me understand the act of suicide, as well as BPD. I had three criteria for my theory: It had to (1) guide treatment implementation, (2) engender compassion, and (3) fit the research data. The biosocial theory I developed was based on the premise that both suicide and BPD are, at their core, disorders of emotion dysregulation. Suicidal behavior is a response to unbearable emotional suffering. BPD is a severe mental disorder resulting from serious dysregulation of the affective system. Individuals with BPD show a characteristic pattern of instability in affect regulation, impulse control, interpersonal relationship, and self-image.
Emotion dysregulation has also been related to a variety of other mental health problems. Substance use disorders, eating disorders, and many other destructive behavioral patterns often function as escapes from unbearable emotions. Theorists have proposed that major depressive disorder should be conceptualized as an emotion dysregulation disorder, based partly on a deficit in up-regulating and maintaining positive emotions. Similarly, literature reviews have demonstrated that anxiety disorders, schizophrenia, and even bipolar disorders are directly linked to emotion dysregulation.
The DBT Model of Emotions
To understand emotion dysregulation, we have to first understand what emotions actually are. Proposing any definition of the construct "emotion," however, is fraught with difficulty, and there is rarely agreement even among emotion researchers on any one concrete definition. That being said, teaching clients about emotions and emotion regulation requires some attempt at a description of emotions, if not an exact definition. DBT in general, and DBT skills in particular, are based on the view that emotions are brief, involuntary, full-system, patterned responses to internal and external stimuli. Similar to others' views, DBT emphasizes the importance of the evolutionary adaptive value of emotions in understanding them. Although emotional responses are systemic responses, they can be viewed as consisting of the following interacting subsystems: (1) emotional vulnerability to cues; (2) internal and/ or external events that, when attended to, serve as emotional cues (e.g., prompting events); (3) appraisal and interpretations of the cues; (4) response tendencies, including neurochemical and physiological responses, experiential responses, and action urges; (5) nonverbal and verbal expressive responses and actions; and (6) aftereffects of the initial emotional "firing," including secondary emotions. It is useful to consider the patterned actions associated with emotional responses to be part and parcel of the emotional responses rather than consequences of the emotions. By combining all these elements into one interactional system, DBT emphasizes that modifying any component of the emotional system is likely to change the functioning of the entire system. In short, if one wants to change one's own emotions, including emotional actions, it can be done by modifying any part of the system.
Emotion dysregulation is the inability, even when one's best efforts are applied, to change or regulate emotional cues, experiences, actions, verbal responses, and/or nonverbal expressions under normative conditions. Pervasive emotion dysregulation is seen when the inability to regulate emotions occurs across a wide range of emotions, adaptation problems, and situational contexts. Pervasive emotion dysregulation is due to vulnerability to high emotionality, together with an inability to regulate intense emotion-linked responses. Characteristics of emotion dysregulation include an excess of painful emotional experiences; an inability to regulate intense arousal; problems turning attention away from emotional cues; cognitive distortions and failures in information processing; insufficient control of impulsive behaviors related to strong positive and negative affect; difficulties organizing and coordinating activities to achieve non-mood-dependent goals during emotional arousal; and a tendency to "freeze" or dissociate under very high stress. It can also present as emotion overcontrol and suppression, which leads to pervasive negative affect, low positive affect, an inability to up-regulate emotions, and difficulty with affective communication. Systemic dysregulation is produced by emotional vulnerability and by maladaptive and inadequate emotion modulation strategies. Emotional vulnerability is defined by these characteristics: (1) very high negative affectivity as a baseline, (2) sensitivity to emotional stimuli, (3) intense response to emotional stimuli, and (4) slow return to emotional baseline once emotional arousal has occurred.
Emotion regulation, in contrast, is the ability to (1) inhibit impulsive and inappropriate behavior related to strong negative or positive emotions; (2) organize oneself for coordinated action in the service of an external goal (i.e., act in a way that is not mood-dependent when necessary); (3) self-soothe any physiological arousal that the strong emotion has induced; and (4) refocus attention in the presence of strong emotion. Emotion regulation can be automatic as well as consciously controlled. In DBT, the focus is first on increasing conscious control, and second on eliciting sufficient practice to overlearn skills such that they ultimately become automatic.(Continues…)
Excerpted from "DBT Skills Training Manual"
Copyright © 2015 Marsha M. Linehan.
Excerpted by permission of The Guilford Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of ContentsI. An Introduction to DBT Skills Training
1. Rationale for Dialectical Behavior Therapy Skills Training
2. Planning to Conduct DBT Skills Training
3. Structuring Skills Training Sessions
4. Skills Training Treatment Targets and Procedures
5. Application of Fundamental DBT Strategies in Behavioral Skills Training
Part I Appendices
II. Teaching Notes for DBT Skills Modules
6. General Skills: Orientation and Analyzing Behavior
7. Mindfulness Skills
8. Interpersonal Effectiveness Skills
9. Emotion Regulation Skills
10. Distress Tolerance Skills
Clinical psychologists, psychiatrists, clinical social workers, mental health counselors, and psychiatric nurses. May serve as a supplemental text in graduate-level courses.