ebookTHE GUILFORD PRESS

DBT® SkillS Manual for aDoleScenTS

Also from Jill H. Rathus and Alec L. Miller

Dialectical Behavior Therapy with Suicidal AdolescentsAlec L. Miller, Jill H. Rathus, and Marsha M. Linehan

DBT® Skills Manual for Adolescents

Jill H. Rathus Alec L. Miller

Foreword by Marsha M. Linehan

THE GUILFORD PRESS New York London

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Library of Congress Cataloging-in-Publication Data

Rathus, Jill H. DBT skills manual for adolescents / Jill H. Rathus, Alec L. Miller. pages cm Includes bibliographical references and index. ISBN 978-1-4625-1535-6 (pbk. : acid-free paper) 1. Dialectical behavior therapy. 2. Adolescent psychotherapy. 3. Adolescent psychology. I. Miller, Alec L. II. Title. III. Title: Dialectical behavior therapy skills manual for adolescents. RC489.B4R36 2015 616.89′142—dc23 2013043128

Illustrations by Sam Miller

DBT is a registered trademark of Marsha M. Linehan.

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Jill H. Rathus, PhD, is Professor of Psychology at Long Island University—C. W. Post Campus, where she directs the DBT scientist-practitioner training program within the clinical psychol-ogy doctoral program. She is also Co-Director and Co-Founder of Cognitive Behavioral Associ-ates, a group private practice in Great Neck, New York, specializing in dialectical behavior ther-apy (DBT) and cognitive-behavioral therapy (CBT). Her clinical and research interests include DBT, CBT, adolescent suicidality, marital distress, intimate partner violence, anxiety disorders, and assessment, and she publishes widely in these areas. Dr. Rathus is coauthor (with Alec L. Miller and Marsha M. Linehan) of Dialectical Behavior Therapy with Suicidal Adolescents, and she trains mental health professionals internationally.

Alec L. Miller, PsyD, is Professor of Clinical Psychiatry and Behavioral Sciences, Chief of Child and Adolescent Psychology, and Director of the Adolescent Depression and Suicide Program at Montefiore Medical Center of the Albert Einstein College of Medicine. He is also Co-Founder of Cognitive and Behavioral Consultants of Westchester and Manhattan. Dr. Miller has pub-lished widely on DBT, adolescent suicide, childhood maltreatment, and borderline personality disorder, and has trained thousands of mental health professionals in DBT. A Fellow of Divi-sions 12 (Clinical Psychology) and 53 (Clinical Child and Adolescent Psychology) of the Ameri-can Psychological Association, he is coauthor (with Jill H. Rathus and Marsha M. Linehan) of Dialectical Behavior Therapy with Suicidal Adolescents.

About the Authors

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Jill Rathus and Alec Miller attended one of my first dialectical behavior therapy (DBT®) inten-sive trainings. They were working on learning DBT and applying it to an urban, multiproblem, suicidal adolescent population at Montefiore Medical Center, Bronx, New York. When they returned for Part II of the intensive training, during which teams present their programs, I was struck by their passion and compassion, by how deeply they grasped the treatment, and by how thoughtfully they applied it to adolescents. I realized then how fabulous their work was for DBT and for teens in need of DBT.

Rathus and Miller infused their version of DBT with original, creative, and developmen-tally appropriate elements. They included family members in the treatment through skills train-ing, family sessions, and parent coaching modalities, to directly address adolescents’ environ-ments; this helps not only adolescents, but also their parents, who are often despondent and don’t know what to do. They identified new dialectical dilemmas that they observed in the struggles between parents and teens, parents and parents, and teens and therapists. They developed a new skills module that addresses family conflict by explicitly teaching dialectics as a skill set not only for DBT therapists, but also for teens and their parents; validation, which families desper-ately need; and behavior change, which families often attempt ineffectively and also desperately need. They devised a sensitive way to teach the biosocial theory to parents, developed teach-ing points for the DBT assumptions that address the negative attributions parents and teens often make for one another’s behavior, figured out how to handle matters of confidentiality, and devised mindfulness exercises that appeal to teens—to name just a few of their creative ideas. They thoughtfully explicated these innovations and more in an earlier book, Dialectical Behav-ior Therapy with Suicidal Adolescents. Rathus and Miller developed the teen-based treatment and wrote the 2007 book; I was simply a coauthor, serving as consultant and confidant on DBT when needed. That work has become the primary text on applying DBT with adolescents, and as such is a companion volume to the present book.

Throughout the nearly two decades I have known them, Jill Rathus and Alec Miller have also published research, expanded their clinical practices, and trained professionals around the world to conduct DBT with adolescents. They have been a driving force behind the international

Foreword

proliferation of adolescent DBT programs, and in disseminating this treatment to youth and families who in the past were often rejected from treatment settings and clinical research trials.

The current volume presents their latest contribution to adolescent DBT, and is certain to be as influential as their 2007 book. It is written for clinicians in various settings to use with adolescents coping with a broad array of emotional and behavioral difficulties. The book presents 10 chapters on conducting skills training with adolescents and their caregivers. The first four chapters contain everything practitioners need to know about setting up and structur-ing an adolescent DBT skills training program. This section includes solutions to problems and questions regarding such topics as whom to include in skills training; group management strate-gies; skills training challenges; variations on the basic skills training format; therapy-interfering behaviors of teens and parents; dialectical tensions that arise in skills training; and dialectical dilemmas and their related treatment targets, not only in the context of individual and family therapy with adolescents, but also within the modality of skills training. The next six chapters provide the teaching notes corresponding to each adolescent skills training module: Mindful-ness, Distress Tolerance, Walking the Middle Path, Emotion Regulation, and Interpersonal Effectiveness. These notes contain not only the basic “how-to” of teaching each skill group, but also the authors’ collective clinical wisdom regarding teen- and family-based teaching stories, examples, exercises, role plays, and possible responses to likely questions/challenges by parents or teens.

Finally, the volume contains a set of skills handouts and practice worksheets. Whereas we at the University of Washington have used the adult versions of handouts and worksheets with our adolescent clients at high risk for suicide (and teens seems to understand them better than their parents), many clinicians and treatment programs are more comfortable with skills designed specifically for adolescents. These skills handouts and worksheets are wonderfully done. While keeping to the essence of the skills content from standard DBT, Rathus and Miller have added several new versions of skills tailored to teen and family work, such as the Parent–Teen Shared Pleasant Activities List, a Pleasant Activities List for teens, and the Crisis Survival Kit for school.

Make no mistake: Jill Rathus and Alec Miller are the experts on adolescent DBT. No clini-cians in this rapidly expanding field better know the ins and outs of working with teens. This volume reveals in fine detail how to deliver this treatment to teens and their families in a way that will engage them, reach them, and offer them hope. This skills manual is an essential addi-tion to their body of work, likely to make clinicians’ jobs easier while enhancing outcomes, and sure to touch many lives.

Marsha M. Linehan, PhD, ABPP University of Washington

viii Foreword

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Marsha M. Linehan’s dialectical behavior therapy (DBT®; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, 1993a, 1993b) has revolutionized cognitive-behavioral therapies, with constructs such as mindfulness and acceptance now permeating behavioral approaches. Her technology for treating complex problems of emotional and behavioral dysregulation has brought compassionate treatment to clients who had been previously rejected by many therapists.

Linehan originally developed her treatment for clients with suicidal or self-injurious behav-iors who were at high risk of suicide. Her work evolved using an iterative approach, system-atically developing solutions for each problem that arose. To address the problem that patients receiving DBT lack certain capabilities, Linehan developed a set of standardized skills to teach clients how to regulate emotions, recognize internal states, focus attention, tolerate distress, and develop and sustain satisfying interpersonal relationships. To address the problem that thera-pists cannot teach new skillful behaviors while managing crises, Linehan determined that it is necessary to have skills training delivered as a separate modality. Linehan designed DBT as a comprehensive treatment package, including not only skills training, but also individual therapy, between-session telephone coaching, and therapist peer consultation (Linehan, 1993a, 1993b).

In the 1990s, we began applying DBT to suicidal multiproblem adolescents and families in an inner-city outpatient clinic and used the original Linehan (1993b) skills training manual. We recognized that many of the youth and their parents had difficulty reading and comprehend-ing the material. However, we were reluctant to adapt the protocol before we had used it in its entirety. We piloted the adult manual as written with cohorts of adolescent patients and their caregivers in order to gain clinical information before making any modifications.

AdApting the Adult SkillS trAining MAnuAl for AdoleScentS

Direct participant feedback coupled with our clinical observations informed our initial altera-tions to the adult manual (Miller, Rathus, Linehan, Wetzler, & Leigh, 1997), and we have con-tinued to make minor modifications as reflected in our 2007 book, Dialectical Behavior Ther-apy with Suicidal Adolescents (Miller, Rathus, & Linehan, 2007), and in the present manual.

Preface

We have modified only where necessary while maintaining the essential elements of DBT, such as its dialectical underpinnings; its biosocial theory of disorder; its functions; its assumptions; its targets; its change procedures; its treatment strategies (i.e., core, dialectical, stylistic, case man-agement); and its skills. We have retained virtually all of Linehan’s original DBT skills because (1) we have no basis for determining which, if any, are nonessential; (2) clients are idiosyncratic with regard to which skills they find most helpful, so we believe exposure to all skills is helpful; (3) while we do not expect clients to master the skills during skills training group, they have opportunities for mastery through the take-home practice exercises, practice exercise review, application in problem solving during individual therapy, and phone coaching; and (4) clients have an opportunity to relearn the skills by repeating the cycle through the skills modules or in a graduate group, described in Chapter 2.

This fidelity requires, of course, that clinicians conducting DBT with adolescents know DBT, and do not mistake DBT with adolescents for a treatment other than DBT. We based our 2007 book, written with Linehan (Miller et al., 2007), on our research and clinical work with this population and followed the treatment as it had been originally developed by Linehan.

We based modifications to the treatment on characteristics inherent to adolescents—they differ from adult clients with regard to emotional and cognitive developmental level—and con-text—they overwhelmingly attend school, and reside with their families and depend on them for daily functioning, including for getting to therapy. Thus, we considered developmentally rel-evant as well as family-based targets, cognitive processing and capability differences, distinct liability issues, and interventions with their environments, that is, their caregivers. We identified adolescent-quality-of-life treatment targets (e.g., skipping school) and adolescent–family secondary treatment targets, emphasized adolescent-appropriate therapeutic interactions, and increased the use of environmental intervention. The latter meant including parents in treatment by offering as-needed family or parenting sessions as well as including parents in skills training. With parents participating in skills training, we added a family-based module called Walking the Middle Path Skills. In addition, we modified the language and look of the original skills materials to enhance accessibility for adolescents, given their cognitive processing and capability differences. Additional changes included (1) slightly reducing the amount of content; (2) limiting the amount of information presented on a single handout; (3) simplifying language on handouts given that many patients and parents had reading levels at or below a middle school level, due to learning disabilities or speak-ing English as a second language; (4) adjusting the teaching stories, exercises, and examples on handouts and in the teaching notes to be developmentally relevant for an adolescent population (in both language and content); (5) adding graphics, pictures, and varied fonts to make handouts more visually and emotionally accessible to distractable and dysregulated teens; and (6) adding a fifth module, called Walking the Middle Path Skills, to target prominent issues that arose when working with teens and families, such as polarizing conflict, behavioral extremes, invalidation, and ineffec-tive behavior change strategies. To counter these problems, the module teaches (1) principles of dialectics and adolescent–family dialectical dilemmas to reduce extreme thinking and behavior and enhance perspective taking, (2) validation skills, and (3) behavior change/learning principles and strategies for obtaining changes in one’s own or others’ behaviors. We believed that through such modifications, we could more effectively deliver Linehan’s DBT skills to a teen population.

AdditionAl SkillS in thiS MAnuAl

Along with the original set of DBT skills (Linehan, 1993a) and those from the Walking the Middle Path Skills module introduced in our 2007 book (Miller et al., 2007), we have included

x Preface

several additional skills. The following handouts are based on Linehan’s recently revised skills manual (Linehan, 2015a; Linehan, 2015b): “Crisis Survival Skills: TIPP Skills for Managing Extreme Emotions” (Distress Tolerance Handout 11), “Building Mastery and Coping Ahead” (Emotion Regulation Handout 15), and “Check the Facts and Problem Solving” (Emotion Regu-lation Handout 19). The “Wise Mind Values and Priorities List” (Emotion Regulation Handout 13) is also based on Linehan’s revised skills manual. To date, with the exception of Cope Ahead, these skills have not been included in adolescent research trials.

Original to this manual is the “Parent–Teen Shared Pleasant Activities List” (Emotion Reg-ulation Handout 11). This handout expands the emotion regulation skill of Accumulating Posi-tives in the short term to address the deficit in positive interactions that we have noted within many families seeking DBT. We also include two supplemental handouts to the emotion regula-tion PLEASE skill, for those who need more in-depth information on managing eating (“FOOD and Your MOOD,” Emotion Regulation Handout 16a) and sleep (“BEST Ways to Get REST: 12 Tips for Better Sleep,” Emotion Regulation Handout 16b). We have also expanded the validation skill in the Walking the Middle Path Skills module to formally include self-validation (see “How Can We Validate Ourselves?,” Walking the Middle Path Handout 10). This is a secondary treat-ment target in DBT and a skill often lacking in teens. Finally, in the Interpersonal Effectiveness Skills module, we include the optional THINK skill. We developed this skill based on Crick and Dodge’s (1994) social information-processing model after noticing that teens and families often assumed the worst about others’ intentions and needed more help with perspective taking. THINK skills are not part of standard DBT and have not been used in any clinical trials to date.

Our skills adaptations for adolescents were designed as part of a comprehensive DBT treat-ment package, which is fully described in Dialectical Behavior Therapy with Suicidal Ado-lescents (Miller et al., 2007). This skills manual can serve as a companion to that 2007 book. Since then, however, clinicians and researchers have found DBT treatment and skills applicable to a much broader range of adolescents, many of whom have never been suicidal (see Groves, Backer, van den Bosch, & Miller, 2012, for review). Clinicians can, therefore, use this manual in the treatment of adolescents across diagnoses and behavioral problems who present with emotional and behavioral dysregulation.

Our adapted adolescent skills handouts are being used in multiple research settings; many clinical settings around the world employ some version of our materials. The publication of this manual makes them more widely available, along with group management strategies and skills teaching notes to assist the DBT skills trainer working with adolescents. We also believe in the importance of establishing a standardized and replicable set of materials to enhance research and clinical applications with materials faithful to DBT, and to reduce piecemeal application or continued reinvention of the adolescent materials.

Throughout this book, we use the terms “family member,” “parent,” or “caregiver” inter-changeably. Our adolescent clients come from various backgrounds and settings. Some youth live with their parents or stepparents, some with a grandparent or other relative, and others in foster care or group home settings. Thus, some youth will invite nontraditional caregivers to participate in their treatment.

We hope this in-depth presentation of skills training for teens and families will help clini-cians and researchers as they work toward improving the lives of adolescents who suffer from and struggle with emotional and behavioral dysregulation.

Preface xi

xii

Both of us are deeply indebted to Marsha Linehan for her friendship, collaboration, and mentor-ing over the past two decades. We thank her for supporting this work and sharing her insights and materials with us.

We especially want to acknowledge our illustrator, Sam Miller (MFA, Columbia Univer-sity), whose creativity, artistry, and sensitivity enhanced the communication of our words.

Our wonderful and talented team at The Guilford Press deserves so much credit for help-ing to usher this book through to completion: Bob Matloff, President; Seymour Weingarten, Editor-in-Chief; Kitty Moore, our acquisitions editor; Barbara Watkins, our developmental edi-tor; Laura Specht Patchkofsky, our production editor; Judith Grauman, Managing Editor; and many other Guilford staff. We are grateful for their influence in the shaping of this volume, their patient and thorough work, and their investment in this project.

We also wish to mention some of our current and former colleagues at Montefiore Medical Center who helped encourage us when we first endeavored to adapt DBT for teens and families. These colleagues include Scott Wetzler, Bill Sanderson, and especially the late Marcia Lands-man, who joined us during the first 4 years of our journey, helping us adapt these skills for teens.

Finally, we would like to thank so many of our DBT colleagues for their friendship, wisdom, and support of our work over the years. While we cannot recognize the entire DBT commu-nity by name, we want to extend a special thank you to Charlie Swenson, Larry Katz, Michael Hollander, Lizz Dexter-Mazza, Jim Mazza, Blaise Aguirre, Tony DuBose, Linda Dimeff, Helen Best, Alan Fruzzetti, Christine Foertsch, Kelly Koerner, Adam Payne, Lars Mehlum, Emily Cooney, Seth Axelrod, Gwen Abney-Cunningham, Perry Hoffman, Matthew Nock, and the late Cindy Sanderson.

I want to thank my dear coauthor, Alec Miller, for 20-plus years of friendship and collabora-tion. We’ve spent countless hours together discussing, researching, and writing. We’ve inspired

Acknowledgments

each other and remoralized each other when needed, and it never fails to be a delight to work together.

I’d like to thank my family for their love, encouragement, and unwavering support. Now that my children are solidly into their teen years, they keep me on my toes, teach me every day about my work, and keep me smiling.

In addition, I am extremely grateful to my colleagues and friends at Long Island University–C. W. Post Campus (LIU Post) for being a long-standing source of support, person-ally and professionally: Bob Keisner, Eva Feindler, David Roll, Camilo Ortiz, Danielle Knafo, Geoff Goodman, Hilary Vidair, Marc Deiner, Cathy Kudlak, and Katherine Hill Miller. I also want to thank my assistant program director, Pam Gustafson, for always looking out for me and anticipating program and faculty needs. I also want to acknowledge the wonderful graduate students at LIU Post for participating in my DBT Clinical Research Lab, filling my DBT elec-tives and workshops, sharing their enthusiasm with me, and keeping me fresh. For their help at various stages with research for this book and with running my DBT Lab, I would like to thank Erika Rooney, Melody Wysocki, Neal Bauer, Shannon York, Rivka Halpert, and Rebecca Kason.

I want to express special appreciation to my wonderful friend, co director, and cofounder of Cognitive Behavioral Associates, LLP (CBA), Ruth DeRosa. Ruth anchors our practice and our team, and infuses our work with thoughfulness, positivity, creativity, clarity, and clinical acu-men. I also want to extend a thank you to my other fabulous and talented DBT team members—Michelle Chung, Nira Nafisi, Shamshy Schlager, Hilary Vidair, and Vince Passarrelli—and our current and recent psychology externs—Gus Cutz, Kristin Wyatt, Lisa Shull Gettings, Avigail Margolis, Steve Mazza, and Esther Pearl. Hilary has been my longest-running skills group co-leader at CBA and brings great skill and precision to skills training.

My friend, colleague, and fellow Guilford author, Valerie Gaus, provided helpful tips for the book, and I am grateful to her. I also thank Martha Guerra for all of her help and dedication. In addition, I thank Rahsaan Robinson for being a well of optimism and encouragement.

I also thank those who provided mentoring and modeling at Stony Brook, particularly Daniel O’Leary. I also thank Dina Vivian, Marv Goldfried, Dan Klein, Everett Waters, and the late Ted Carr. And I’d like to acknowledge the late Stephen Parrish—a Romantic Poetry scholar and my caring and dedicated English mentor at Cornell. His voice remains with me as I write.

I am deeply grateful to my clients, the teens, adults, parents, and families who work so hard to accept—and change—their problems. They show tremendous courage, honesty, persever-ance, and good humor; they teach and inspire me each week. This work is for them.

—J. H. R.

I feel deep gratitude for my colleagues and trainees at Montefiore Medical Center’s Depart-ment of Psychiatry and Behavioral Sciences who have supported my DBT treatment and train-ing program for the past 20 years. Specifically, within Montefiore’s Adolescent Depression and Suicide Program (ADSP), many have helped contribute to the development and refinement of my thinking about skills training with adolescents and families. I want to give a special thanks to Heather Smith, who has served as my Associate Director over the past 10 years and is ceaselessly committed to teaching DBT skills to Bronx youth and their caregivers. My research director, Miguelina German, and dozens of research assistants have helped enhance our under-standing and application of DBT with Hispanic families. Jenny Seham and Michelle Lupkin are talented attending psychologists in the ADSP and continue to provide support to me at Mon-tefiore and within our DBT program. None of this would be possible without Madelyn Garcia,

Acknowledgments xiii