Table Of Contentebook
THE GUILFORD PRESS
DBT ® Skills
Training Manual
SeconD eDiTion
Marsha M. Linehan
THe GUiLFoRD PReSS
new York London
© 2015 Marsha M. Linehan
Published by The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com
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Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system,
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Last digit is print number: 9 8 7 6 5 4 3
LIMITED DUPLICATION LICENSE
The publisher grants to individual purchasers of this book nonassignable permission to photocopy
the diary card (p. 73) and Teaching Notes herein (pp. 123–490). The publisher additionally grants
purchasers of this book nonassignable permission to download and print the supplementary material
(handouts, worksheets, and teaching notes) posted to www.guilford.com/dbt-manual. See that
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These licenses are limited to you, the individual purchaser, for personal use, or for use with clients.
They do not extend to additional clinicians or practice settings, nor does purchase by an institution
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or medical sciences, neither the author, nor the editor and publisher, nor any other party who has been
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Library of Congress Cataloging-in- Publication Data
Linehan, Marsha, author.
[Skills training manual for treating borderline personality disorder]
DBT skills training manual / Marsha M. Linehan. — Second edition.
p. ; cm.
Dialectical behavior therapy skills training manual
Preceded by: Skills training manual for treating borderline personality disorder / Marsha M.
Linehan. c1993.
Includes bibliographical references and index.
ISBN 978-1-4625-1699-5 (paperback : alk. paper)
1. Dialectical behavior therapy. I. Title. II. Title: Dialectical behavior therapy skills
training manual.
[DNLM: 1. Borderline Personality Disorder— therapy. 2. Behavior Therapy—
methods. 3. Psychotherapeutic Processes. 4. Psychotherapy— methods. 5. Suicide— prevention
& control. WM 190.5.B5]
RC489.D48
616.89´142—dc23
2014026329
DBT is a registered trademark of Marsha M. Linehan.
When I teach my graduate students—who work with complex,
difficult-to-treat individuals at high risk for suicide—I always
remind them that they can choose whether to look out for themselves
or to look out for their clients, but they cannot always do both.
If they want to look out for themselves at a possible cost to their
clients, I remind them that they are in the wrong profession.
I dedicate this book to all those who have found the courage to
carry on this work at a possible cost to themselves.
I also dedicate it to my colleagues at the University of Washington
Behavioral Research and Therapy Clinics: Elaine Franks, who has
done everything possible to limit the costs to me; my students, who
have kept me going when I wanted to stop; Katie Korslund, my
second in command, who has given me such wise counsel; Melanie
Harned, who has backed me up so many times in so many ways;
and all those at the University of Washington Human Subjects
Division, who have never even once impeded my often “out-of-
the-box” research treating individuals at extremely high risk for
suicide. Their willingness to allow such high-risk research when
other universities likely would not sets an example for others—and
made this book possible.
Also from Marsha M. Linehan
Books
Cognitive- Behavioral Treatment of Borderline Personality Disorder
DBT Skills Training Handouts and Worksheets, Second Edition
Dialectical Behavior Therapy with Suicidal Adolescents
Alec L. Miller, Jill H. Rathus, and Marsha M. Linehan
Mindfulness and Acceptance: Expanding the Cognitive- Behavioral Tradition
Edited by Steven C. Hayes, Victoria M. Follette, and Marsha M. Linehan
DVDs
Crisis Survival Skills, Part One: Distracting and Self- Soothing
Crisis Survival Skills, Part Two: Improving the Moment and Pros and Cons
From Suffering to Freedom: Practicing Reality Acceptance
Getting a New Client Connected to DBT (Complete Series)
Opposite Action: Changing Emotions You Want to Change
This One Moment: Skills for Everyday Mindfulness
Treating Borderline Personality Disorder: The Dialectical Approach
Understanding Borderline Personality: The Dialectical Approach
For more information and for DBT skills updates from the author,
see her websites:
www.linehaninstitute.org, http://blogs.uw.edu/brtc,
and http://faculty.washington.edu/linehan/
About the Author
Marsha M. Linehan, PhD, ABPP, is the developer of dialectical behavior therapy (DBT)
and Professor of Psychology and of Psychiatry and Behavioral Sciences and Director of
the Behavioral Research and Therapy Clinics at the University of Washington. Her pri-
mary research interest is in the development and evaluation of evidence-based treatments
for populations with high suicide risk and multiple, severe mental disorders.
Dr. Linehan’s contributions to suicide research and clinical psychology research
have been recognized with numerous awards, including the Gold Medal Award for Life
Achievement in the Application of Psychology from the American Psychological Founda-
tion and the James McKeen Cattell Award from the Association for Psychological Sci-
ence. In her honor, the American Association of Suicidology created the Marsha Linehan
Award for Outstanding Research in the Treatment of Suicidal Behavior.
She is a Zen master and teaches mindfulness and contemplative practices via work-
shops and retreats for health care providers.
v
Acknowledgments
There is truly something magical about being a uni- the Linehan Institute Research Advisory Board) for
versity professor. Students arrive excited but often approval: Martin Bohus, Alan Fruzzetti, André Iva-
with threadbare knowledge, and before you know noff, Kathryn Korslund, and Shelley McMain.
it they have not only climbed on your shoulders No one with multiple jobs and never- ending de-
but have built a ladder from there reaching to the mands on their time can get much done without
sky. I have been enormously privileged to have had strong administrative help. I could not have gotten
many such students and postdoctoral fellows in my this book done without the help of Elaine Franks,
research clinic while I wrote this book. They have my fabulous administrative assistant. She canceled
read countless versions of the skills presented here phone calls and meetings, said no before I could say
and tried out new skills, correcting, improving, and yes, called me at all hours— morning, noon, and
throwing them out as they went. They have radical- night—to see what I was doing and how I was pro-
ly accepted canceled meetings and frantic requests gressing, and sent me repeated copies of things I had
to find missing references, rearrange entire refer- lost. Thao Truong, our office and financial manag-
ence lists, and find research I knew I had read but er, made sure that the whole place did not fall apart
could not locate to save my soul. They have helped while everyone was waiting on me to finish tasks
me early in the day, at night, and when I called on well beyond deadline.
weekends. They have stayed by my side even though Much of what is in this manual I learned from
my door said: “Do Not Disturb: Please Do Not Ig- the many clients who participated in skills train-
nore This Message!” Although I am sure that I have ing groups that I have conducted over the years. I
missed some names here (please let me know for the am grateful to all those who put up with the many
next printing), I want especially to thank the follow- versions that did not work or were not useful, and
ing students and former students, now colleagues: to those among them who gave enough feedback
Milton Brown, Linda Dimeff, Safia Jackson, Alis- for me to make needed revisions in the skills being
sa Jerud, Anita Lungu, Ashley Maliken, Lyndsey taught.
Moran, Andrada Neacsiu, Shireen Rizvi, Cory I want to thank Copyeditor Marie Sprayberry,
Secrist, Adrianne Stevens, Stephanie Thompson, Editorial Project Manager Anna Brackett, Senior
Chelsey Wilks, and Brianna Woods; and fellows Editor Barbara Watkins, Executive Editor Kitty
and former fellows, now colleagues: Alex Chap- Moore, and the staff at The Guilford Press. In get-
man, Eunice Chen, Melanie Harned, Erin Miga, ting this manual out in a timely fashion, they each
Marivi Navarro, and Nick Salman. Many others had occasion to practice all the distress tolerance
have jumped in when asked: colleagues Seth Axel- skills in this book. Their concern for the manuscript
rod, Kate Comtois and her entire DBT team, Sona and for this form of treatment was evident at every
Dimidjian, Anthony DuBose, Thomas Lynch, Helen step. Last, but certainly not least, I want to thank
McGowan, and Suzanne Witterholt. When I had my family: Nate and Geraldine, who supported me
something controversial to say, I sent it to the DBT at every step, and Catalina, who brought enough joy
strategic planning executive group (also known as to keep us all going.
vi
Preface
The original edition of this skills training manual my colleagues’ and my research, increases in use of
was published in 1993. At that time, the only re- skills mediates reductions in suicide attempts, non-
search conducted on Dialectical Behavior Therapy suicidal self- injury, difficulties regulating emotions,
(DBT) was a 1991 clinical trial comparing DBT to and interpersonal problems.6 A subset of skills was
treatment as usual for the treatment of chronically also added to a treatment for problem drinkers and
suicidal individuals meeting criteria for borderline improved outcomes compared to a treatment with-
personality disorder (BPD). Since then, an enor- out the skills.7 A subset of DBT skills is taught in
mous amount of research has been conducted on the evidence-based National Education Alliance for
“standard” DBT, which typically consists of DBT Borderline Personality Disorder’s Family Connec-
individual therapy, group skills training, telephone tions program for family members of individuals
coaching, and a therapist consultation team. Re- with BPD. The entire set of core skills is taught in
search has also been conducted on stand-alone DBT the friends and families skills groups at the Universi-
skills training, and on the behavioral practices that ty of Washington Behavioral Research and Therapy
together make up the DBT skills. The new skills in Clinics, which consist of individuals who want to
this edition are a product of my experience and re- learn skills for coping with and accepting individu-
search using the original skills; the wide- ranging re- als in their lives who are difficult. This could in-
search on emotions, emotion regulation, distress tol- clude friends or relatives with serious mental health
erance, and mindfulness, as well as new findings in problems, employees with problematic colleagues
the social sciences; and new treatment strategies de- and/or managers, managers with problematic em-
veloped within the cognitive- behavioral paradigm. ployees, and therapists treating very difficult client
The major changes in the revised skills package are populations. Corporate consultants are looking at
described below. DBT skills as a way to improve corporate morale
and productivity. New sets of specialized skills have
been developed for specific disorders, including a
Skills for Multiple Disorders
module targeting emotion overcontrol,8 middle path
and Nonclinical Populations
skills developed originally for parents and adoles-
The original skills training manual was focused en- cents but appropriate for many populations,9 skills
tirely on treating clients with high risk for suicide for attention- deficit/hyperactivity disorder, and a
and BPD. This was primarily because the research set of skills specifically designed for individuals with
on DBT, including DBT skills, had been conduct- addictions. DBT skills lesson plans are now being
ed with clients meeting criteria for BPD and for used in school systems to teach middle school and
high suicide risk. Since the first edition, however, high school students,10 are working their way into
a number of studies have been conducted focusing programs focused on resilience, and can be applied
on skills training with different populations. For across work settings. DBT skills are widely taught in
example, DBT skills training has been shown ef- general mental health programs in community men-
fective with eating disorders,1, 2 treatment- resistant tal health, inpatient, acute care, forensic, and many
depression,3, 4 and a variety of other disorders.5 In other settings. In sum, there are substantial data
vii
viii • Preface
and clinical experience suggesting that DBT skills have been expanded greatly and also reorganized.
are effective across a wide variety of both clinical The number of emotions described in detail has ex-
and nonclinical populations and across settings. panded from six to ten (adding disgust, envy, jeal-
Of course, it should not come as a surprise that ously, and guilt). A section on changing emotional
DBT skills are widely applicable. I developed many responses adds two new skills: check the facts and
of the skills by reading treatment manuals and treat- problem solving. Also in that section, the opposite
ment literature on evidence-based behavioral inter- action skill has been extensively updated and ex-
ventions. I then looked to see what therapists told panded. Skills for reducing emotional vulnerability
patients to do for each problem, repackaged those have been reorganized into a set of skills called the
instructions in skills handouts and worksheets, and ABC PLEASE skills. In the section on accumulat-
wrote teaching notes for therapists. For example, for ing positive emotions, I changed the Pleasant Events
the skill “opposite action” (see Chapter 9) for fear, Schedule (now called the Pleasant Events List) to be
I repackaged exposure-based treatments for anxi- appropriate for both adolescent and adult clients. I
ety disorders in simpler language. I also applied the also added a values and priorities handout that lists
same principles of change across other disordered a number of universal values and life priorities. An-
emotions. “Check the facts” is a core strategy in other new skill, cope ahead, focuses on practicing
cognitive therapy interventions. DBT skills are what coping strategies in advance of difficult situations.
behavior therapists tell clients to do across many ef- Optional nightmare and sleep hygiene protocols are
fective treatments. Some of the skills are entire treat- also included. Finally, a new section is added for rec-
ment programs formulated as a series of steps. The ognizing extreme emotions (“Identify Your Personal
new “nightmare protocol,” an emotion regulation Skills Breakdown Point”), including steps for using
skill, is an example of this. The mindfulness skills crisis survival skills to manage these emotions.
are a product of my 18 years in Catholic schools, my 4. The distress tolerance skills (Chapter 10) now
training in contemplative prayer practices through start with a new STOP skill—stop, take a step back,
the Shalem Institute’s spiritual guidance program, observe, and proceed mindfully— adapted from the
and my 34 years as a Zen student and now as a Zen skill developed by Francheska Perepletchikova, Seth
master. Other skills came from basic behavioral sci- Axelrod, and colleagues.12 The crisis survival sec-
ence and research in cognitive and social psycholo- tion now includes a new set of skills aimed at chang-
gy. Some came from colleagues developing new DBT ing body chemistry to rapidly regulate extreme
skills for new populations. emotions (the new TIP skills). A new set of skills fo-
cused on reducing addictive behaviors has also been
added: dialectical abstinence, clear mind, commu-
New Skills in This Edition nity reinforcement, burning bridges, building new
ones, alternate rebellion, and adaptive denial.
There are still four primary DBT skills training 5. Across modules I have also made a number of
modules: mindfulness skills, interpersonal effective- changes. Every module now starts with goals for
ness skills, emotion regulation skills, and distress that module along with a goals handout and a corre-
tolerance skills. Within these modules, I have added sponding pros and cons worksheet. The worksheet is
the following new skills. optional and can be used if the client is unwilling or
ambivalent about practicing the skills in the module.
1. In mindfulness skills (Chapter 7), I have added A mindfulness skill has been added to both the
a section on teaching mindfulness from alternative interpersonal module (mindfulness of others) and
perspectives, including a spiritual perspective. the distress tolerance module (mindfulness of cur-
2. In interpersonal effectiveness skills (Chapter 8), rent thoughts). Together with mindfulness of cur-
I have added two new sections. The first focuses on rent emotion (emotion regulation), these additions
skills for finding and building relationships you want are aimed at keeping the thread of mindfulness alive
and ending relationships you don’t want. The second across time.
focuses on balancing acceptance and change in inter-
personal interactions. It closely duplicates the skills
Alec Miller, Jill Rathus, and I developed for adoles- More Extensive Teaching Notes
cent multifamily skills training, in which parents of
adolescent clients also participate in skills training.11 Many people who have watched me teach DBT skills
3. The emotion regulation skills (Chapter 9) have commented that most of what I actually teach
