For years I worked in a state hospital and a community mental health center. One thing I noticed early on was that when staff found a client to be difficult or resistant — or even just hard to like — too often they gave a diagnosis of borderline.
Sometimes it would happen just because a client made a choice that her therapist didn’t like: Suddenly, the therapist would give a new, unjustified diagnosis.
I am grateful to psychologist Marsha Linehan for helping to change this dynamic when she developed a new form of psychotherapy called dialectical behavior therapy (DBT) in the late 1980s. Now, this researcher, Zen master, teacher, and therapist has published a new, compassionate book on DBT as well as an accompanying book of worksheets.
Some time ago, I visited an adolescent inpatient facility to look at a program for teenagers who had picked up the borderline tag along the way. The facility had incorporated DBT into its program — and even if the diagnosis may have been the same, the tone was markedly different. Instead of “borderline,” staff described the teens as “passionate personalities.” The teens seemed to prefer it.
Throughout Linehan’s DBT Skills Training Manual, Second Edition, she talks about using skills such as mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance not just for the clients but for yourself, the mental health practitioner, the teacher of these skills. She goes over the roles, boundaries, and responsibilities of the therapist, skills trainers, case managers, pharmacotherapists, nurses, line staff, and, of course, the client/participant. She gives some flexibility to allow for individual differences of participants. Training can be done individually, but Linehan emphasizes group work, and discusses the advantages of open versus closed groups and the need for two trainers (and the role of each). The service is truly wrap-around.
This second edition covers and implements the enormous amount of research on DBT since the original volume was published in 1993. Since then, DBT has moved beyond a focus only on borderline and high suicide risk to an effective evidence-based treatment for eating disorders, treatment-resistant depression, problem drinking, and many other issues.
The 2014 book is much more detailed than the earlier edition, and includes research on the effectiveness of the training. Skills training can also be incorporated into any therapy, whether or not the focus is DBT, and I have begun to use exercises and work from this book in my own practice.
Linehan gives a lot of credit to the individuals she has worked with over the years and all that they have taught her. I appreciate that she shares stories of those learning experiences and the choices and difficulties she has faced in continuing to improve this process. What really draws me to her work, though, is her respect for the participants. Linehan wants to help people build lives they actually want to live, she writes, and she treats participants as adults who can run their own lives.
Linehan also seeks the same commitment from all those in the treatment team — which includes the participant. But “in over 30 years of conducting DBT skills groups,” she writes, “I have never kicked out a group member.” That doesn’t mean there weren’t difficult members that she felt the group would be better off without, but that her ability to handle a difficult group member has improved. Specifically, she writes, “my ability to manage a difficult group participant with equanimity and a lightness of tone has allowed other group members not only to cope with disturbance, but also to find ways of appreciating the contributions that the difficult member often does manage to make.”
In addition to the second edition of the skills training manual, Guilford has published a second edition of Linehan’s DBT Skills Training Handouts and Worksheets as well. But as thorough and detailed as these two more recent books are, especially in tandem, therapists might still want to keep a copy of Linehan’s original Cognitive-Behavioral Treatment of Borderline Personality Disorder from 1993 on hand. (She refers to her earlier text throughout her newer handbook.) Still, the second-edition research, handouts, worksheets, and teaching notes are wonderful, and are available as printable PDFs at the Guilford Press website.
Over the years, Linehan has provided therapists and other mental health workers with an outstanding resource. She reminded us then, and reminds us now, that we can work with individuals in a respectful, effective way — and she gives us the tools to do so. Drawing from her own research, Zen practice, and experience, Linehan teaches us not to judge an action or an outcome as good or bad — and not to slap on labels for no reason.
DBT Skills Training Manual, Second Edition
The Guilford Press, October 2014
Paperback, 504 pages