ebook 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 All rights reserved Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the publisher. Printed in the United States of America This book is printed on acid-free paper. 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). 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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