ebookTHE 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 PressA Division of Guilford Publications, Inc.370 Seventh Avenue, Suite 1200, New York, NY 10001www.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.

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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 website for more details.

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 constitute a site license. These licenses do not grant the right to reproduce these materials for resale, redistribution, electronic display, or any other purposes (including but not limited to books, pamphlets, articles, video- or audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures, workshops, or webinars, whether or not a fee is charged). Permission to reproduce these materials for these and any other purposes must be obtained in writing from the Permissions Department of Guilford Publications.

The author has checked with sources believed to be reliable in her efforts to provide information that is complete and generally in accord with the standards of practice that are accepted at the time of publication. However, in view of the possibility of human error or changes in behavioral, mental health, or medical sciences, neither the author, nor the editor and publisher, nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or the results obtained from the use of such information. Readers are encouraged to confirm the information contained in this book with other sources.

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 manualPreceded 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.D48616.89´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 AdolescentsAlec L. Miller, Jill H. Rathus, and Marsha M. Linehan

Mindfulness and Acceptance: Expanding the Cognitive- Behavioral TraditionEdited 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/

v

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.

vi

There is truly something magical about being a uni-versity professor. Students arrive excited but often with threadbare knowledge, and before you know it they have not only climbed on your shoulders but have built a ladder from there reaching to the sky. I have been enormously privileged to have had many such students and postdoctoral fellows in my research clinic while I wrote this book. They have read countless versions of the skills presented here and tried out new skills, correcting, improving, and throwing them out as they went. They have radical-ly accepted canceled meetings and frantic requests to find missing references, rearrange entire refer-ence lists, and find research I knew I had read but could not locate to save my soul. They have helped me early in the day, at night, and when I called on weekends. They have stayed by my side even though my door said: “Do Not Disturb: Please Do Not Ig-nore This Message!” Although I am sure that I have missed some names here (please let me know for the next printing), I want especially to thank the follow-ing students and former students, now colleagues: Milton Brown, Linda Dimeff, Safia Jackson, Alis-sa Jerud, Anita Lungu, Ashley Maliken, Lyndsey Moran, Andrada Neacsiu, Shireen Rizvi, Cory Secrist, Adrianne Stevens, Stephanie Thompson, Chelsey Wilks, and Brianna Woods; and fellows and former fellows, now colleagues: Alex Chap-man, Eunice Chen, Melanie Harned, Erin Miga, Marivi Navarro, and Nick Salman. Many others have jumped in when asked: colleagues Seth Axel-rod, Kate Comtois and her entire DBT team, Sona Dimidjian, Anthony DuBose, Thomas Lynch, Helen McGowan, and Suzanne Witterholt. When I had something controversial to say, I sent it to the DBT strategic planning executive group (also known as

the Linehan Institute Research Advisory Board) for approval: Martin Bohus, Alan Fruzzetti, André Iva-noff, Kathryn Korslund, and Shelley McMain.

No one with multiple jobs and never- ending de-mands on their time can get much done without strong administrative help. I could not have gotten this book done without the help of Elaine Franks, my fabulous administrative assistant. She canceled phone calls and meetings, said no before I could say yes, called me at all hours— morning, noon, and night—to see what I was doing and how I was pro-gressing, and sent me repeated copies of things I had lost. Thao Truong, our office and financial manag-er, made sure that the whole place did not fall apart while everyone was waiting on me to finish tasks well beyond deadline.

Much of what is in this manual I learned from the many clients who participated in skills train-ing groups that I have conducted over the years. I am grateful to all those who put up with the many versions that did not work or were not useful, and to those among them who gave enough feedback for me to make needed revisions in the skills being taught.

I want to thank Copyeditor Marie Sprayberry, Editorial Project Manager Anna Brackett, Senior Editor Barbara Watkins, Executive Editor Kitty Moore, and the staff at The Guilford Press. In get-ting this manual out in a timely fashion, they each had occasion to practice all the distress tolerance skills in this book. Their concern for the manuscript and for this form of treatment was evident at every step. Last, but certainly not least, I want to thank my family: Nate and Geraldine, who supported me at every step, and Catalina, who brought enough joy to keep us all going.

Acknowledgments

vii

The original edition of this skills training manual was published in 1993. At that time, the only re-search conducted on Dialectical Behavior Therapy (DBT) was a 1991 clinical trial comparing DBT to treatment as usual for the treatment of chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Since then, an enor-mous amount of research has been conducted on “standard” DBT, which typically consists of DBT individual therapy, group skills training, telephone coaching, and a therapist consultation team. Re-search has also been conducted on stand-alone DBT skills training, and on the behavioral practices that together make up the DBT skills. The new skills in this edition are a product of my experience and re-search using the original skills; the wide- ranging re-search on emotions, emotion regulation, distress tol-erance, and mindfulness, as well as new findings in the social sciences; and new treatment strategies de-veloped within the cognitive- behavioral paradigm. The major changes in the revised skills package are described below.

Skills for Multiple Disorders and Nonclinical PopulationsThe original skills training manual was focused en-tirely on treating clients with high risk for suicide and BPD. This was primarily because the research on DBT, including DBT skills, had been conduct-ed with clients meeting criteria for BPD and for high suicide risk. Since the first edition, however, a number of studies have been conducted focusing on skills training with different populations. For example, DBT skills training has been shown ef-fective with eating disorders,1, 2 treatment- resistant depression,3, 4 and a variety of other disorders.5 In

my colleagues’ and my research, increases in use of skills mediates reductions in suicide attempts, non-suicidal self- injury, difficulties regulating emotions, and interpersonal problems.6 A subset of skills was also added to a treatment for problem drinkers and improved outcomes compared to a treatment with-out the skills.7 A subset of DBT skills is taught in the evidence-based National Education Alliance for Borderline Personality Disorder’s Family Connec-tions program for family members of individuals with BPD. The entire set of core skills is taught in the friends and families skills groups at the Universi-ty of Washington Behavioral Research and Therapy Clinics, which consist of individuals who want to learn skills for coping with and accepting individu-als in their lives who are difficult. This could in-clude friends or relatives with serious mental health problems, employees with problematic colleagues and/or managers, managers with problematic em-ployees, and therapists treating very difficult client populations. Corporate consultants are looking at DBT skills as a way to improve corporate morale and productivity. New sets of specialized skills have been developed for specific disorders, including a module targeting emotion overcontrol,8 middle path skills developed originally for parents and adoles-cents but appropriate for many populations,9 skills for attention- deficit/hyperactivity disorder, and a set of skills specifically designed for individuals with addictions. DBT skills lesson plans are now being used in school systems to teach middle school and high school students,10 are working their way into programs focused on resilience, and can be applied across work settings. DBT skills are widely taught in general mental health programs in community men-tal health, inpatient, acute care, forensic, and many other settings. In sum, there are substantial data

Preface

viii  •  Preface

and clinical experience suggesting that DBT skills are effective across a wide variety of both clinical and nonclinical populations and across settings.

Of course, it should not come as a surprise that DBT skills are widely applicable. I developed many of the skills by reading treatment manuals and treat-ment literature on evidence-based behavioral inter-ventions. I then looked to see what therapists told patients to do for each problem, repackaged those instructions in skills handouts and worksheets, and wrote teaching notes for therapists. For example, for the skill “opposite action” (see Chapter 9) for fear, I repackaged exposure-based treatments for anxi-ety disorders in simpler language. I also applied the same principles of change across other disordered emotions. “Check the facts” is a core strategy in cognitive therapy interventions. DBT skills are what behavior therapists tell clients to do across many ef-fective treatments. Some of the skills are entire treat-ment programs formulated as a series of steps. The new “nightmare protocol,” an emotion regulation skill, is an example of this. The mindfulness skills are a product of my 18 years in Catholic schools, my training in contemplative prayer practices through the Shalem Institute’s spiritual guidance program, and my 34 years as a Zen student and now as a Zen master. Other skills came from basic behavioral sci-ence and research in cognitive and social psycholo-gy. Some came from colleagues developing new DBT skills for new populations.

New Skills in This Edition

There are still four primary DBT skills training modules: mindfulness skills, interpersonal effective-ness skills, emotion regulation skills, and distress tolerance skills. Within these modules, I have added the following new skills.

1. In mindfulness skills (Chapter 7), I have added a section on teaching mindfulness from alternative perspectives, including a spiritual perspective.

2. In interpersonal effectiveness skills (Chapter 8), I have added two new sections. The first focuses on skills for finding and building relationships you want and ending relationships you don’t want. The second focuses on balancing acceptance and change in inter-personal interactions. It closely duplicates the skills Alec Miller, Jill Rathus, and I developed for adoles-cent multifamily skills training, in which parents of adolescent clients also participate in skills training.11

3. The emotion regulation skills (Chapter 9)

have been expanded greatly and also reorganized. The number of emotions described in detail has ex-panded from six to ten (adding disgust, envy, jeal-ously, and guilt). A section on changing emotional responses adds two new skills: check the facts and problem solving. Also in that section, the opposite action skill has been extensively updated and ex-panded. Skills for reducing emotional vulnerability have been reorganized into a set of skills called the ABC PLEASE skills. In the section on accumulat-ing positive emotions, I changed the Pleasant Events Schedule (now called the Pleasant Events List) to be appropriate for both adolescent and adult clients. I also added a values and priorities handout that lists a number of universal values and life priorities. An-other new skill, cope ahead, focuses on practicing coping strategies in advance of difficult situations. Optional nightmare and sleep hygiene protocols are also included. Finally, a new section is added for rec-ognizing extreme emotions (“Identify Your Personal Skills Breakdown Point”), including steps for using crisis survival skills to manage these emotions.

4. The distress tolerance skills (Chapter 10) now start with a new STOP skill—stop, take a step back, observe, and proceed mindfully— adapted from the skill developed by Francheska Perepletchikova, Seth Axelrod, and colleagues.12 The crisis survival sec-tion now includes a new set of skills aimed at chang-ing body chemistry to rapidly regulate extreme 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-nity reinforcement, burning bridges, building new ones, alternate rebellion, and adaptive denial.

5. Across modules I have also made a number of changes. Every module now starts with goals for that module along with a goals handout and a corre-sponding pros and cons worksheet. The worksheet is optional and can be used if the client is unwilling or ambivalent about practicing the skills in the module.

A mindfulness skill has been added to both the interpersonal module (mindfulness of others) and the distress tolerance module (mindfulness of cur-rent thoughts). Together with mindfulness of cur-rent emotion (emotion regulation), these additions are aimed at keeping the thread of mindfulness alive across time.

More Extensive Teaching Notes

Many people who have watched me teach DBT skills have commented that most of what I actually teach

Preface  •  ix

was not included in the first edition of this book. In this second edition, I have added much more infor-mation than was in the previous one. First, as much as possible I have included the research underpin-nings for the skills included. Second, I have provided a very broad range of different teaching points that you can choose from in teaching, far more points than either you or I could possibly cover in a skills training class. The teaching notes may, at first, seem overwhelming. It is important to remember that this book is not to be read cover to cover at one sitting. Instead, teaching notes are organized by specific skills so that when teaching a specific skill you can find the notes just for that skill or set of skills. It will be important for you to read over the material for the skills you plan to teach and then highlight just those points that you wish to make when teach-ing. With practice over time, you will find that you expand your teaching to include different parts of the material. You will also find that some parts of the material fit some of your clients and other parts fit other clients. The material is meant to be used flexibly. With experience, you will no doubt start adding your own teaching points.

More Clinical ExamplesA larger number of clinical examples are also in-cluded in this second edition. Examples are essential for good teaching. However, you should feel free to modify the examples provided and to substitute new ones to meet the needs of your clients. In fact, this is the major difference in teaching skills for various populations; one set of examples may be needed for clients with high emotion dysregulation and impulse control difficulties, another for those with emotion overcontrol, and another for substance-dependent clients. Differences in culture, ethnicity, nationality, socioeconomic status, and age may each necessitate different sets of examples. In my experience, it is the examples but not the skills that need to be changed across populations.

More Interactive Handouts and Optional HandoutsMany of the handouts have been modified to allow greater interaction during skills training sessions. Most have check boxes so participants can check items of importance to them or skills they are will-ing to practice in the coming weeks. Each module also now includes a number of optional handouts.

These have the same number as the core handout with which they are associated plus a letter (e.g., 1a, 1b). These optional handouts can be given out and taught to participants, given out but not formally taught, used by the skills trainer to teach but not given out, or simply ignored if not viewed as useful. My experience is that these optional handouts are extremely useful for some groups and individuals but not for others.

Improved WorksheetsBy popular demand, homework sheets have been re labeled worksheets. Also, on each handout the corresponding worksheets are listed, and on each worksheet the corresponding handouts are listed.

There are now multiple alternative worksheets as-sociated with many of the handouts. The increase in worksheets is due to a number of factors. First, it became clear over the years that a worksheet that works very well for one person may not be good for another person. As a result, I have developed a range of worksheets for each handout. For most skills sec-tions, there is one set of worksheets that covers the skills in the entire section. This is for clients who are unlikely to complete much homework practice and can help those who have already completed skills training and are now working on maintaining their practice of skills.

Second, different clients like different types of practice. There are clients who want to check off what homework they have done, clients who prefer to describe their homework and rate its effective-ness, and those who like to write diaries describ-ing what they have done and how it affected them. I have found it most effective to let clients choose worksheets to fill out from a set.

Multiple Teaching Schedules OutlinedThe 1993 edition of the skills manual included the specific skills and worksheets that were used in the first randomized clinical trial of DBT. At that time, DBT had not spread very far, and there were not many examples of how to choose skills for situa-tions in which some but not all of the skills could be taught, nor were skills developed at that time for special populations such as adolescents or individu-als with addictions, eating disorders, and so forth. Given the many new skills in this edition, it is not possible to teach all the skills in a 24-week skills

x  •  Preface

group, even when the skills are repeated for a sec-ond 24 weeks, as in a 1-year DBT treatment pro-gram. This edition includes a number of schedules for teaching skills, including schedules for 1-year, 6-month, and briefer skills training in acute care units and nontraditional settings. Schedules for par-ticular populations (such as adolescents and sub-stance abusers) are also provided. As often as pos-sible, the teaching schedules are based on clinical trials that showed that the specific skills schedule was effective. With this in mind, there are now sev-eral sets of core DBT skills that are outlined in the appendices to Part I. My general strategy in teaching skills is to give participants all the DBT handouts and worksheets. I then follow a teaching schedule I determine based on the population, the number of weeks of treatment, and current research. Along the way, I tell participants that if we have time I will teach them other skills—if they talk me into it.

A Word about TermsThere are many terms for a person who teaches and coaches behavioral skills: therapist, psychothera-pist, individual therapist, marital therapist, family therapist, milieu therapist, group therapist, group leader, counselor, case manager, skills trainer, be-havioral coach, skills coach, crisis worker, mental health worker, mental health care provider, and so on. In this manual, the term “therapist” refers to a person who is providing psychotherapy or other mental health services. In standard DBT, this would be the person’s individual therapist. The terms “skills trainer,” “skills leader,” “skills co- leader,” and “leader” refer to individuals who are providing skills training either individually or in a group. In standard DBT, this refers to the group skills leaders. On occasion I use the term “provider” as a general reference to any person providing health care ser-vices.

For a quick guide on How to Use This Book, please refer to page xi.

References 1. Telch, C. F., Agras, W. S., Linehan, M. M. (2001).

Dialectical behavior therapy for binge eating disor-

der. Journal of Consulting and Clinical Psychology, 69(6), 1061–1065.

2. Safer, D. L., & Jo, B. (2010). Outcome from a ran-domized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior ther-apy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41(1), 106–120.

3. Lynch, T. R., Morse, J. Q., Mendelson, T., & Rob-ins, C. J. (2003). Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry, 11(1), 33–45.

4. Harley, R., Sprich, S., Safren, S., Jacobo, M., & Fava, M. (2008). Adaptation of dialectical behavior therapy skills training group for treatment- resistant depression. Journal of Nervous and Mental Disease, 196(2), 136–143.

5. Soler, J., Pascual, J. C., Tiana, T., Cebria, A., Bar-rachina, J., Campins, M. J., & Pérez, V. (2009). Dia-lectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy, 47, 353–358.

6. Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behaviour Research and Thera-py, 48(9), 832–8.

7. Whiteside, U. (2011). A brief personalized feedback intervention integrating a motivational interviewing therapeutic style and dialectical behavior therapy skills for depressed or anxious heavy drinking young adults. Unpublished doctoral dissertation, University of Washington.

8. Lynch, T. R. (in press). Radically open DBT: Treating the overcontrolled client. New York: Guilford Press.

9. Miller, A. L., Rathus, J. H., & Linehan, M. M. (2007). Dialectical behavior therapy with suicidal adolescents. New York: Guilford Press.

10. Mazza, J. J., Dexter-Mazza, E. T., Murphy, H. E., Miller, A. L., & Rathus, J. L. (in press). Dialectical behavior therapy in schools. New York: Guilford Press.

11. Miller, A. L., Rathus, J. H., Linehan, M. M., Wetz-ler, S., & Leigh, E. (1997). Dialectical behavior therapy adapted for suicidal adolescents. Journal of Psychiatric Practice, 3(2), 78–86.

12. Perepletchikova, F., Axelrod, S., Kaufman, J., Ro-unsaville, B. J., Douglas- Palumberi, H., & Miller, A. (2011). Adapting dialectical behavior therapy for children: Towards a new research agenda for paediat-ric suicidal and non- suicidal self- injurious behaviors. Child and Adolescent Mental Health, 16, 116–121.

  xi

This book has two parts, both of which are impor-tant. Part I describes DBT and gives instructions for how to set up a DBT skills program and how to manage various problems that arise in teaching the skills. Part II provides detailed teaching notes for each DBT skill included in the book. There is also a companion volume, DBT Skills Training Handouts and Worksheets, Second Edition. For some, the enormous amount of content in both volumes can feel overwhelming. If that happens to you, practice paced breathing before going further. As it turns out, it is not that hard to use the teaching notes and the handouts and worksheets effectively. People have found the following steps very helpful:

1. The first step is to decide which skills you want to teach. To get ideas about what to teach, go to the Part I appendices (p. 107) to see session-by session outlines of different DBT skills programs that have been used in clinical trials. Select a program, or, if you don’t find any that are compatible with what you want to teach, look through the list of skills under Part II in the Contents (p. xiii) and pick out the specific skills you want to teach. Within each module, teach the skills in the order in which they appear in the book. You do not have to teach every single skill.

2. Now that you have figured out what you want to teach, you will want to consult the teaching notes in Part II. Teaching notes are organized by skill and each skill has a roman numeral. Critical information is in a box at the beginning of the discussion about each skill. Do not skip reading this information. For each skill that you want to teach, read through all of the notes. Do not try to cover all the teaching points when teaching! Teaching points with check-

marks are most important. Nonetheless, many of the points provide information that will help you to answer questions from clients. Next, either copy the teaching notes pages or download and print them at the companion website for purchasers. Type www.guilford.com/dbt- manual into your browser’s address bar (do not type the URL into the search field; it will not show up in search results). We sug-gest bookmarking this address for future use. By printing out the teaching notes, you can highlight the points you want to make with particular clients or groups, and write additional points of your own.

3. The next step is to locate the corresponding handouts and worksheets that are referenced in each teaching note. The handouts and worksheets can be accessed in multiple ways. First, purchas-ers of this manual can download and print them at the website that contains the teaching notes (www.guilford.com/dbt- manual). You can then cre-ate a packet of handouts and worksheets for each skill you are teaching (no single client will need all of the handouts and worksheets). Second, you can pho-tocopy the handouts and worksheets you need from the companion volume, DBT Skills Training Hand-outs and Worksheets, Second Edition. With an 8½" × 11" format and spiral binding, the Handouts and Worksheets book contains all of the handouts and worksheets for easy reference and photocopying. It is a good companion to this manual for those times when you are away from your computer or simply prefer to look at a printed book rather than access-ing the handouts and worksheets online. You might also want to give the spiral-bound book to clients or have them purchase it. It contains brief introduc-tions to each module specifically written for clients. In addition, clients purchasing the spiral-bound

How to Use This Book

xii  •  How to Use This Book

Purchasers can download and print the teaching notes, handouts, and worksheets at www.guilford.com/dbt-manual

See page ii for information.

book get access to a separate website specifically designed for them, where they can download and print extra copies of the handouts and worksheets themselves. Whether you are using the print or on-line versions of the handouts and worksheets, cross- references help you easily find the specific materials you need. At the top of each handout, correspond-ing worksheets designed to be used in conjunction are identified by title and page number (or linked to, in the online versions), and vice versa.

My policy is to give all of the skills to my clients—

or invite them to look through the Handouts and Worksheets volume—and, after teaching the core skills and others I want to teach, I tell clients I will teach the skills they want, if they can talk me into it. (They almost always talk me into it.)

4. If you haven’t done so already, please read the Preface (p. vii), which allows you to get a grasp of what’s new in this book versus the first edition.

I wish you skillful means in your teaching.

  xiii

contents

List of Online Handouts and Worksheets xvii

PART I

An Introduction to DBT Skills Training

Chapter 1 Rationale for Dialectical Behavior Therapy Skills Training 3

Chapter 2 Planning to Conduct DBT Skills Training 25

Chapter 3 Structuring Skills Training Sessions 43

Chapter 4 Skills Training Treatment Targets and Procedures 61

Chapter 5 Application of Fundamental DBT Strategies in Behavioral Skills Training 81

Part I Appendices 107

PART II

Teaching Notes for DBT Skills Modules

Chapter 6 General Skills: Orientation and Analyzing Behavior 125

i. The Goals of Skills Training, 127 ii. overview: introduction to Skills Training, 131 iii. orientation to Skills Training, 131 iV. Biosocial Theory of emotion Dysregulation, 138 V. overview: Analyzing Behavior, 143 Vi. chain Analysis of Problem Behavior, 143