Dr. Linehan’s second edition of DBT Skills Training Manual is a valuable resource and the DBT Skills Training Handouts and Worksheets enhance the training manual. The work sheets volume contains hundreds of worksheets that patients can work through if they so choose. As Linehan observes and learns more, she adds additional worksheets and a range of worksheets for each handout. The worksheets are teaching devices but to the extent they are read and “work” they enhance memory building. They also serve as bridges to the next session and help maintain the continuity of the work, the connection to the therapist, and recognize that seriously ill patients feel connections are easily broken and unreliable. Linehan uses mindfulness skills deriving from her extensive Zen Buddhism experience as a subtle learning device which opens up the current moment without reserve or grudges including emotions (feeling states) and understandings of the inner world of being. This is critical if individuals with BPD are to effectively tame the affective storms that assail them, allowing them to feel more in control, more genuine, and less frightened and anxious. Mindfulness is entering the current moment, entering into the cosmic awareness that life is constantly changing (Linehan, 2015). Linehan reminds us that her original mindfulness was focused on individuals with BPD and high risk for suicide (Miller et al., 2006. Dialectical Behavior Therapy with Suicidal Adolescents. New York: Guilford Press).
Since the 2006 publication of Dialectical Behavior Therapy with Suicidal Adolescents, Linehan has learned a great deal, researched it, and included it in her skills training. This has been helpful in the treatment, “…of eating disorders, treatment-resistant depression and other conditions including the treatment of victims of domestic abuse.” (Linehan, 2015). In the second edition, Linehan utilizes the four primary DBT skills training modules: mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress tolerance skills. She has added teaching mindfulness from alternative perspectives including a spiritual perspective, and two new sections in interpersonal effectiveness skills, one focusing on wanted relationships and one focusing on unwanted relationships. The second focuses on balancing acceptance and change in interpersonal interactions. The section on emotional regulation skills has been expanded greatly. She also adds distress tolerance skills and across module skills with an added mindfulness module to keep the thread of mindfulness alive across time. Mindfulness as described above is a Buddhist concept referring to attentiveness to the present that promotes self-awareness, improves productivity, and is effective in relapse prevention (Allen et al., 2008. Mentalizing in Clinical Practice, p. 300). Her dialectical approach looking at both sides of issues, good-bad, happy-sad, growth-loss, is helpful in patients suffering from chronic unpredictable inner world of being storms to gain both understanding of themselves and others and developing better controls with improved relatedness. “…DBT emphasizes the role of difficulties in regulating emotions both under and over control…”. DBT skills addressed in the manual are designed to treat emotional dysregulation and its maladaptive consequences. Linehan stresses the importance of integrating positives and negatives as life moves along. Without this integration, she believes there can be no real recovery. For example, joy over an important promotion necessarily includes acknowledgment of grief as life is bittersweet. As patients improve, they have to deal with loss of their former states. Over the years, a number of BPD patients have said something like, “…now that I am better, I miss being sick…” or “There were things I could do when I was sicker that I can’t do now…”. Mindfulness is the control glue holding this treatment together supported by the other modules of this therapy. Linehan emphasizes and I agree that DBT is effective with BPD patients whereas CBT is not effective with these patients who are highly sensitive, emotionally reactive, and who have endured years of invalidating judgments and communications that they are flawed (Linehan, 2015). Linehan’s empathy shines through. She points out, “…these volumes are not to be read cover-to-cover at one setting, they are just too full of important information.” However, her caution is not meant for reviewers. Grappling with her teachings steadily over time and navigating the complexity of her work gave me to conclude that learning DBT is difficult, interesting, demanding, and consuming. It should take place over time with experienced teachers.
I have seen a number of patients in my current practice who describe DBT as “the best and most helpful therapy they have ever had.” Patients find that DBT builds hope and it does not leave them in glum, depleted, and depressed states. If there is a critique, it is that the treatment ends too quickly. Linehan describes a situation in which a person was hiding her progress out of fear she would have to leave the program. Linehan does make provision for patients with differing needs. Her system is not “sink or swim” nor does it dictate the number of sessions a patient requires. However, to the extent that the number of therapy sessions is arbitrarily fixed in advance without a sense of the needs of individual patients (e.g., some people learn more slowly in emotional contexts than others), it could be harmful even if sessions are added.
These two volumes should be read and studied by all those concerned about individuals suffering from BPD and other disorders.
Over the years, I have cobbled together an approach that has been helpful to patients suffering from Borderline Personality Disorder (BPD). A prevailing perspective with which Linehan and I both disagree is that patients with BPD are incurable and somehow bad. Though diminished, this perspective remains to this day. A number of years ago, a mother of a largely recovered daughter suffering from BPD invited me to speak at a discussion session with members of a BPD association which I helped her to form. It was like NAMI in type but focused primarily on BPD.
The mother spoke highly of Marsha Linehan and her very positively regarded dialectical behavior therapy in the BPD community because loved ones were benefiting from Linehan’s book and the approach she suggests. I used Linehan’s book, Dialectical Behavior Therapy with Suicidal Adolescents (Miller et al., 2006) in preparation for the meeting. Borderline Personality Disorder is of considerable interest to me. Patients with BPD present with difficult, challenging, and engaging clinical problems. I have clinically researched BPD and taught what I have learned to a host of clinicians, social workers, psychologists, and psychiatrists. The study of BPD and treatment of BPD patients has consumed a large percentage of my professional life. During the 5 years I was at Chestnut Lodge (1967–1972), we had frequent small group discussions about the therapy of BPD and the reactions that BPD patients stimulated in their therapists. For 25 years after leaving the Lodge, I regularly taught seminars and workshops on BPD.
All in all, Linehan’s approach to treating BPD patients works because it is respectful, empowering, and encourages mutuality of understanding in relationships. Importantly, it engages patients in partnerships and it builds hopefulness. Hopefulness is a potent antidote to depression. Linehan’s work is a must read because it is one of the best available resources for understanding BPD patients and their treatment. I strongly recommend these two volumes be carefully and slowly reviewed by those working with BPD patients.
Harold I. Eist,MD, DLFAPA, FRCP(C)
Clinical Professor of Psychiatry
George Washington University
School of Medicine
The author declares no conflict of interest.