Skills

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 Populations

The 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

vii

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

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 Examples

A 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 Handouts

Many 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.

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