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Book Review   |    
Barent Walsh
Psychiatric Services 2008; doi: 10.1176/appi.ps.59.3.331

by Alec L. Miller, Psy.D., Jill H. Rathus, Ph.D., and Marsha M. Linehan, Ph.D.; New York, Guilford Press, 2006, 346 pages, $40

Dr. Walsh is affiliated with the Bridge of Central Massachusetts, Worcester.

This long-awaited volume is the first full-length publication from the dialectical behavior therapy (DBT) establishment since Marsha Linehan's seminal works in 1993 (1,2). The focus is the treatment of suicidal and self-injuring adolescents, using a considerably modified form of DBT. The book thereby formalizes what is already well known among DBT practitioners: that the treatment can be employed with diverse clientele—well beyond the original trials with adult suicidal women with borderline personality disorder—and that it can be modified, with due caution in regard to adherence.

For those not familiar with DBT, it is an empirically validated, cognitive-behavioral treatment informed by the mindfulness practices of Zen Buddhism. It has four major components: weekly highly structured individual therapy (using a hierarchy of behavioral targets and diary cards); weekly group skills training that focuses on four major skill areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness; as-needed coaching between sessions to assist clients with skill acquisition and generalization; and a weekly consultation meeting for the treatment team, designed to enhance learning of DBT and to provide peer support and supervision. These modes of treatment are designed to teach self-destructive and self-defeating clients to employ healthier emotional regulation and interpersonal skills and thereby achieve an improved "life worth living" (1,2). Via the consultation team, the treatment is also designed to "treat the treaters," a phenomenon that may be unique to DBT.

DBT is a complex, intensive, and comprehensive treatment that is not meant for everybody. As noted in the book's introduction. "This book is not intended for the prototypical teen exhibiting fairly benign mood lability…. Nor is DBT intended for an adolescent with a single episode of major depression who makes a first suicide attempt following an acute stressor…. We believe that DBT is most appropriate for those suicidal teens who exhibit a more chronic form of emotion dysregulation with numerous coexisting problems."

The treatment described in this book is for youths whom I have described elsewhere as "poly-self-destructive" (3), meaning individuals who present with recurrent suicidal behavior in combination with other forms of self-harm, such as nonsuicidal self-injury, eating disorders, substance abuse, and risk-taking behaviors. DBT emphasizes an approach that is supported by considerable research; namely, that treatment that targets self-harm behaviors directly rather than underlying mental disorders—such as depression or anxiety—is more effective.

The book begins with a discussion of the research on suicidal behavior among youths. It provides a very useful summary of the distal and proximal risk factors. The book then moves to a review of the literature regarding treatment of suicidal youth. The authors note with regret that no randomized controlled trials have been conducted that document effective treatment of suicidal behavior of teens. The authors indicate that DBT is the only treatment that has been replicated in demonstrating effectiveness in reducing suicidal and self-injurious behavior of adults. They add that a number of these DBT studies have included older adolescents—18- to 21-year-olds.

Therefore, the authors argue that it is quite reasonable to apply a version of DBT in the treatment of adolescents. They also cite several of their own studies of outpatient DBT that provide promising results about reducing suicidal behavior in youths, although they concede the studies have not been randomized controlled trials.

After the discussion of suicide treatment research, the authors provide a summary of the components of standard DBT. This is useful because it is relatively brief and is considerably more accessible to the naïve reader than the original DBT text (1).

The real contribution of the book is in the next eight chapters, as the authors describe their treatment in detail, citing both the consistencies with and the modifications to standard DBT. Some of the more important changes include the length of the treatment, which is reduced from one year to 16 weeks—with the possibility of 16-week "graduate group" extensions; the inclusion of at least one family member—most often a parent, but in other cases, a grandparent, guardian, or even a teen spouse—in group skills training; the creation of a fifth skills training module, named "Walking the Middle Path;" and modifications to skills training lectures, handouts, and diary cards based on the developmental characteristics and learning styles of adolescent clients.

Going from the 52 weeks of standard DBT to 16 weeks is a substantial reduction. It suggests that the treatment can be delivered in a more abbreviated fashion with similar results. However, this is not really the claim of the authors. Rather, they note the "extremely high rate of treatment drop out of suicidal adolescents" and recommend the shorter regimen as a strategy to engage adolescents, who notoriously avoid treatment. The authors recommend convincing adolescent clients to accept a relatively brief 16 weeks of treatment as a first step; then, once teens have experienced the benefits of firsthand treatment, they are far more likely to commit to an additional round. The authors note that in this manner some youths remain in DBT treatment for as long as two years.

The addition of the new fifth module, "Walking the Middle Path," is another significant contribution of this book. The terminology reflects the Zen Buddhist roots of DBT and refers to the need for adolescents and their families to make peace with certain fundamental "dialectical dilemmas." The three new dialectics featured in this new module are framed as transactional paradoxes that parents, therapists, and youths need to understand and balance. The dilemmas are choosing between excessive leniency and authoritarian control, normalizing pathological behaviors versus pathologizing normal behaviors, and forcing autonomy versus fostering dependence. Therapists working with teens, and parents living with them, will recognize these dilemmas as fundamentally important in facilitating growth in adolescents. DBT offers a framework for understanding these dilemmas and the skills to navigate them.

The middle-path module also teaches skills of self-validation and other forms of validation and principles of basic behavior change, including extinction, punishment, and reinforcement. Thus, parents and children learn together in multifamily groups how to validate and effect positive change in themselves and their significant others.

I was struck by the discussion of how to conduct therapy with teens on an interpersonal level. I've never read a better, concise description of what it takes to work with adolescents than the following: "A key strategy to working with adolescents involves conveying a down-to-earth, friendly, egalitarian, and open demeanor, while maintaining an understated degree of expertise and credibility."

Of course, any book review should include some criticisms. First, the title of the book is delimiting. The treatment described is likely to be useful for a broad range of persistently and emotionally dysregulated adolescents, not just those who are suicidal. I also found the list of mindfulness exercises provided in appendix A to be somewhat disappointing. Although the diverse list of activities is helpful, I regret that more examples of mindful breathing exercises weren't included. My own experience in running DBT programs is that breathing skills are especially useful in assisting clients to regulate their emotions more effectively. Plus, such skills are immensely portable; breathing techniques require no equipment, other persons, or special circumstances. I have found that mindful breathing is often helpful for adolescents in dealing with such challenges as tests and exams, athletic competitions, peer conflicts, dating anxiety, authority figures, and agitated parents (3).

These are modest criticisms regarding an important contribution to the literature on the treatment of self-destructive adolescents and their families. What remains, as duly noted by the authors, is for randomized clinical trials to be conducted that support the efficacy of the treatment.

Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
Linehan MM: Skills Training Manual for Treating Borderline Personality Disorder. New York, Guilford, 1993
Walsh BW: Treating Self-Injury: A Practical Guide. New York, Guilford, 2006


Linehan MM: Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York, Guilford, 1993
Linehan MM: Skills Training Manual for Treating Borderline Personality Disorder. New York, Guilford, 1993
Walsh BW: Treating Self-Injury: A Practical Guide. New York, Guilford, 2006

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