DBT (dialectical behavior therapy) has been credited with revolutionizing cognitive behavioral therapies and pioneering and first describing concepts such as mindfulness and acceptance. Dr. Marsha Linehan introduces this comprehensive clinical manual by commenting the authors were her students in one of her first Dialectical Behavior Therapy DBT training courses. She was struck by their “passion and compassion” and how deeply they grasped the fundamentals of this treatment and how thoughtfully they applied it to adolescents. She acknowledged the importance of their work in developing DBT for teens in need.
This brief clinical manual is an original contribution now recognized to the field of DBT therapies. The authors have adapted the Linehan model creatively so that it now can be used in the struggles between teens and teens, parents and teens, and teens and their therapists. The manual teaches dialectics as a skill set not only for therapists but also as a skill set for teens and their parents. The authors have spelled out novel ways to teach biosocial theory to parents, to list its theoretical assumptions and underpinnings. They have also devised mindfulness exercises that have special appeal to a teenage population, while maintaining the essential elements of DBT, such as its dialectical underpinnings, its Biosocial Theory of Disorder, its assumptions, its change procedures, and its treatment strategies.
Their clinical work began in the 1990s when they began applying DBT to suicidal multi-problem adolescents and families in an inner city outpatient clinic. They recognized early that many of the youth and their parents had difficulty reading and comprehending the basic materials and exercises necessary for therapy. They began to adapt the original Linehan protocols to use with this special population and then to get feedback from teenagers and their parents. They have maintained the essential elements of DBT, but adapted it to this difficult and hard-to-reach population. They have also identified life’s problems which are peculiar to adolescent life (such as residing with parents, lack of independence, skipping school, and using drugs). They have modified both the language and look of the original skills manuals for adolescents. The modifications include:
1. slightly reducing the amount of content in a treatment session
2. limiting the amount of information presented to a single handout
3. simplifying language on handouts to patients and parents with reading levels at or below middle school level
4. adjusting teaching stories, exercises, and examples on handouts and in teaching techniques which are developmentally relevant for an adolescent population
5. adding graphics and different fonts to make the handouts more visually and emotionally accessible to distractible and dysregulated teens
6. added a new 5th module titled Walking the Middle Path (special skills to target the special issues that arise working with teens and families)
They have also devised some new handouts which teach important skills related to emotional regulation, sleep, and to pleasant activities which parents and teens can share.
They report that before publication of the book, many of the skills handouts were first used in the treatment, research, and clinical settings they worked in. They are hopeful that the manual makes their handouts more widely available. They also hope that treatment will become more standardized and replicable for the special under-treated population, and will enhance research in the area.
I was most impressed with the skills training handouts they have designed and pioneered, including the comic book characters created which are sure to catch the attention of distracted teenage patients and illustrate the points that the written handouts convey. For example, a Mindfulness Cheat Sheet is illustrated by a teenager sitting quietly with a stethoscope, listening to his own heartbeat. They also illustrate handouts with pictures using iPhones, TV screens, and iPads and other contemporary technology appealing to teenage audiences.
The authors understand that catching the attention of teenagers and developing programs to treat them effectively is different than lecturing to an adult population. They note that to be an effective skills trainer, it is critical to vary delivery and not be predictable. To be a successful skills trainer, one has to make ample use of movement, speed, and drama, and engage an audience. This manual was designed as another useful tool to first engage the reader/therapist and then teach by example. I was also engaged and impressed by the many anecdotes and examples taken from the authors’ wide and varied experience with an under-served teenage population and their caregivers. Needless to say, I can recommend this manual to both newcomers to DBT and therapists who are highly experienced in its methods but lack clinical experience in the joint treatment of adolescents and their caregivers.
Elissa P. Benedek, MD, FACPsych
Clinical Adjunct Professor
University of Michigan Medical Center and Private Practitioner
Ann Arbor, MI
The author declares no conflict of interest.