Rathus, J. H. & Miller, A. L. (2015). DBT Skills Manual for Adolescents.

New York: Guilford

Press, xvi +392 pp. $38.00. paperback.

I have previously reviewed many books on DBT, including Linehan’s workbook and many

others. This book, by Rathus and Miller is fresh off the press and is the first book with a 2015

copyright that I am able to review. Jill Rathus, Professor of Psychology and CoDirector of the

Family Violence Program at Long Island University – CW Post Campus, is also CoDirector of

Cognitive Behavioral Associates in Great Neck New York. She is joined by Alec Miller,

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 the CoFounder of Cognitive

and Behavioral Consultants of Westchester and Manhattan. Their book contains a forward by

Marshall Linehan the Director of Behavioral Research and Therapy Clinics at the University of

Washington. Linehan states that Rathus and Miller are the experts on adolescent Dialectical

Behavior Therapy (DBT), stating that they “adding original, creative and developmentally

appropriate elements” to the DBT protocols developed by Lynehan to make it more appropriate

insensitive for use with adolescents. Rathus and Miller expanded DBT to include parents and

family members in this skill-based training program. Rathus and Miller’s previous book,

Dialectical Behavior Therapy with Suicidal Adolescents has already been reviewed in this

Journal. Along with the standard DBT exercises, Rathus and Miller have added several skills

meant specifically for adolescents including crisis survival skills, skills to help in managing

extreme emotion, fact checking and problem-solving, to name but a few. Their book is organized

into three parts, Part I contains four chapters on DBT skill training, structure and strategies. Part
II contains six chapters reviewing the 5 core skill training module of Rathus and Miller’s DBT

adaptation plus a detailed presentation of the initial orientation to the program. Part III consists

of six chapters which present all the skills training handouts used in Part II of the book.

Rathus and Miller target audience is mental health practitioners working with adolescents who

have difficulty controlling emotions and behavior. They note that adolescents who exhibit

emotional and behavioral dysregulation have difficulty establishing a sense of self and forming

stable relationships with both peers and family members. Impulsive and avoidant behaviors often

result from emotional dysregulation and create their own set of cascading problems. The five sets

of skills presented match the five major problems are associated with emotional dysregulation,

those being mindfulness skills, distress tolerance skills, emotion regulation skills, interpersonal

effectiveness skills, and what is termed “walking the middle path” which involves skills to

reduce conflict and to avoid polarized, all or none thinking. Negatively mirroring the skills

taught, lack of emotional control produces emotion dysregulation which manifests itself in

emotional vulnerability, excessive reactivity and lability, angry outbursts and negative emotional

states such as depression, anxiety and guilt. Positive emotions suffer because of this

dysregulation. Interpersonal dysregulation leads to unstable relationships, heightened

interpersonal conflict, family disturbance, social isolation difficulty maintaining one’s self-

respect and can also lead to dramatically unsuccessful efforts to avoid abandonment. Behavioral

dysregulation leads to impulsivity and, often self-injurious behaviors including cutting, skin

burning, binging, risky sexual behavior, risky online behaviors, binging, drug and alcohol abuse,

aggressive behaviors and poor management of money. Heightened probability of suicide

attempts also exists. Cognitive dysregulation is often characterized by polarized, black/white

thinking, poor conflict resolution skills, difficulty taking perspective, invalidation of self and
others, difficulty with self-control and influencing self and others in a positive way. Self

dysregulation is characterized by poor emotional awareness, poor attentional control, limited

ability to reduce negative feelings and difficulty accessing pleasure. Dissociation, identity

confusion and a sense of emptiness is often found. In order to address these many challenges,

DBT tries to increase both the teens’ and families’ capabilities through skill building, structuring

the environment to improve motivation, reinforcement and support of appropriate skills. DBT

also seeks to enhance motivation to increase the use of new skills while at the same time

reducing the use of nonfunctional behaviors. DBT seeks to identify the thoughts, feelings,

behaviors and contextual variables that often maintaining problematic behavioral patterns and

therefore inhibit more skillful ways of responding. DBT works to generalize new skills learned

in therapy into real-life situations where there are most needed and, DBT also provides support

for therapists who treat multi-problemed teens.

DBT contains a number of different treatment modes which include multifamily skills training

groups, individual DBT therapy sessions, telephone coaching, family sessions, parenting

sessions, therapist consultation meetings and ancillary treatments such as pharmacotherapy and

therapeutic or residential training programs. DBT takes individuals through a pretreatment and

then a four stage program. In the pretreatment phase adolescents and their families are informed

about DBT and a commitment to treatment is secured from not only the teen but the teens family

and the therapist. Stage 1 focuses on attaining basic capacities, increasing safety and reducing

behavioral dyscontrol. In stage 2, individuals are taught to decrease avoidance of negative

emotional experiences so that traumatic stress can be experienced and extinguished or at least

reduced. Stage 3 focuses on increasing self-respect, achieving individual goals and being able to
cope with the normal problems of living. Stage 4 focuses on connection, self-actualization,

making meaning of life and being able to experience happiness.

Rathus and Miller note that individuals with significant emotional dysregulation alternate

between overcontrol and under control, creating “dialectical dilemmas”. These polarities reflect

high emotional arousal on one hand versus self-invalidation and ignoring one’s own feelings on

the other. In parallel with this is a sense of unrelenting crisis versus a style of numb

experiencing. Chronic emotional dysregulation also leads people to vacillate between presenting

themselves as helpless are overconfident. Other dialectical dilemmas include vacillating between

excessive leniency and being overly demanding and using authoritarian control, presenting

pathological behaviors as normal and on the other pole, seeing many normal behaviors as

pathological. Many other polarized styles of reactivity are presented.

DBT is an empirically validated procedure which is remarkable given the significant challenge

inherent in working with such dysregulated individuals. DBT does appear to reduce suicidal

behavior, depression and many features of Borderline Personality Disorder (BPD).

It takes approximately 24 weeks to complete one round of all the training modules of DBT. The

number of weeks devoted to these various modules is explained together with group composition

with consideration of age, gender and homogeneity of diagnosis. Factors such as ethnicity and

culture as well as how flexible one might be in accepting individuals into the program when

parents are not available. By converse, in rare circumstances, parents are allowed through the

training program without the teen being present.

Rathus and Miller present a protocol for DBT therapist to use if they receive a call on the day of

the session saying that the participant will be absent. Occasionally such cancellations are
impulsive or mood dependent and it has been found that both coaching and being encouraging

and supportive can assist in motivating people to decide to attend their treatment. Their book

reviews many strategies that can be used to obtain commitment for therapy from both caretakers

and from the teen. Such strategies can include evaluating the pros and cons of engaging in

therapy, playing devil’s advocate by making argument against participation that the adolescent

would need to two argue against. Other strategies including shaping, “cheerleading”,

highlighting that engaging in DBT treatment is a choice and focusing on the reality that there are

often few alternative positive actions. These and others are discussed. Many treatment sessions

are initiated with a review of homework given the previous week. Therapists are encouraged to

engage the entire group during homework review and also to deal with incomplete homework

and with not doing homework at all, especially if the individual finds it to be unpleasant. DBT

therapists are often coached to engage the participants by utilizing an entertaining teaching style

and a genuine, warm and inviting manner so that participants will listen. It is hard but necessary

work to maintain participant’s interest. Therapists perform a balancing act when providing DBT

training in that validation of feelings needs to be juxtaposed with problem-solving strategies.

Therapists must somehow communicate to their clients that their responses are understandable

given the current life context the person is managing. Therapists are trained to actively accept the

client and communicate acceptance. DBT identifies six levels of validation which includes

listening without judgment and attending with interest. Reflection that shows that the therapist

understands through paraphrasing the of communications, “mind reading” by reading facial

expressions and body language and trying to articulate the presumed thoughts or feelings that

have not been openly expressed in words, acknowledging that the others experience and

behaviors make sense given their past learning history and what is termed “radical genuineness”
which is communicating in a way that conveys equality between the therapist and client and aims

to accept reality even if it is unpleasant. Problem-solving, using dialectic strategies and

managing dialectical dilemmas need to be presented so that clients do not feel invalidated given

the heightened probability that participants in the program can become highly distressed or

aroused with what might appear to be little provocation. While the skills training portion can be

broken down into key modules, many therapist skills such as knowing when to utilize many of

the motivational and validating tools available and when to shift from one strategy to the next

can take a good deal of supervision and training.

DBT programming begins with an orientation module in which the group participants and their

skill trainers are introduced. DBT is explained and what a dialectical means is presented.

Dialectical means that two opposing ideas can be true at the same time. When both perspectives

are viewed together it often lead to new understanding. Participants are explained that they were

chosen to be involved in a DBT program because they may have some or all of the problems the

group seeks to address. They may have difficulty staying focused and participating in the here

and now, they may be unsure of their goals, they may have rapid and intense mood changes that

they seem to have little control over, they may find themselves chronically in a negative

emotional state and they may act without thinking things through. They may have difficulty

keeping and maintaining relationships and getting what they want from others. They may have

difficulty maintaining their own self-respect and they may be lonely. In orientation, the five sets

of DBT skills are reviewed together with helping people understand that a biosocial theory is

utilized which help explain why things are as they are. Participants may be genetically

vulnerable and have high emotional sensitivity coupled with high emotional reactivity. They may

be quick to arouse but slow to return to calm state.

treatment assumptions. Some of these assumptions state that everyone is doing the best that they

can and, at the same time, everyone does wish to improve. Even though there is a basic

acceptance of everyone’s current status, it is also assumed that everyone can try harder and be

more motivated to change. DBT assumes that individuals may not have caused all of their own

problems but they are responsible to try to solve them. To that end, participants are assisted in

learning and practicing new behaviors in all the varied situations in their lives. Given the fact

that participants are in a DBT group in the first place, everyone acknowledges that the lives of all

in the group are painful as they are currently being lived in that pain is being maintained by the

repeated by faulty habits that have developed. DBT assumes that there is no absolute truth and

also believes that no one can fail in DBT. Participants must agree to not come to sessions under

the influence of drugs or alcohol and everyone must agree to group confidentiality. Rathus and

Miller carefully outline other agreements that participants must agree to in order to be in the

program.

After orientation, mindfulness skills are the first set of tool introduced. Mindfulness is described

as being aware of the present moment without judgment and without trying to change anything.

It is about having an open mind and trying to live in the here and now. Exercises to practice

maintaining a focused mind are introduced and participants are taught that mindfulness enables

increased control over behavior and can reduce suffering, therefore increasing the possibility of

having pleasure. Mindfulness can help with the making of important decisions and can make

people more effective and productive. Three states of mind are introduced, those being the

emotional mind, reasonable mind and wise mind. When our emotional mind is engaged, it is hard

to think rationally about consequences and emotions can be all-consuming. The opposite of
emotional mind is the reasonable mind. When using our reasonable mind we are trying to act or

think about something without emotions present and without taking feelings into account. When

we are using our wise mind we are trying to tap into what we believe to be true. Wise mind

neither ignores nor over focuses on emotion and emerges from the philosophy that there is

wisdom within everyone, we simply need to learn how to find it. Participants are given exercises

to “watch without words” and to observe pictures, people, objects and nature using all of the

senses available. Exercises are presented to observe thoughts and feelings as they come and go

which is coupled with “Teflon mind” where thoughts, feelings and experiences come into our

mind but slip right out. Exercises are presented to simply let feelings happen even when they are

painful and to tolerate them without pushing them away. Participants are taught to be

nonjudgmental and to do what works. In the mindfulness module at least 30 exercises are

presented and carefully explained.

Distress tolerance is the next module presented and is coupled with an explanation as to why it is

important to tolerate painful feelings and urges. Avoiding painful feelings and urges often leads

individuals to act impulsively and often avoiding pain can lead to more problems than it solves.

Self soothing exercises are presented and coupled with distraction and tapping into the wise

mind. Doing something nice for someone else is an excellent distractor as is working to create

different emotions. At times, intensifying alternative sensations can serve as an effective crisis

avoiding technique. Use of imagery, prayer, relaxation and finding meaning or purpose in the

pain being experienced can be helpful. One exercise involves developing pros and cons for old

behaviors and comparing that to the pros and cons of new ways to respond, which does include

tolerating distress. Skills which rapidly alter the activity in our autonomic nervous system are

presented as a way to work out of situations in which distress is so high that the conscious use of
newly developed skills is impaired. These activities are called TIPP skills and involve Tipping

facial temperature by splashing the face with very cold water, Intense aerobic exercise, Paced

breathing and the utilization of Progressive muscle relaxation.

The third skills module is called “walking the middle path” which was specifically designed for

adolescents due to their frequent polarized, non-dialectical thinking. Walking the middle path is

about balancing acceptance and change and working on both simultaneously. The concept of

dialectics is again reviewed and exercises follow to help individuals be able to see more than one

side of any problem. The concept of validation is revisited and participants come to understand

the validation can improve relationships and can assist in de-escalating conflict and intense

emotions. Validation skills show that individuals can listen and understand, be nonjudgmental,

care about relationships and can disagree without having significant conflict. Skills to improve

validation include active listening, being mindful of verbal and nonverbal reactions, reflecting

back feelings without judgment and demonstrating tolerance. Participants are also taught to

respond in ways that lets the other person know that they are being taken seriously and are being

heard. It is even possible to validate without agreeing. After the skills to validate others are

presented self validation skills are then introduced. Paradoxically, many believe that we are able

to promote change only after acceptance has first been established. In DBT, validation skills

precede the discussion of change skills. Reinforcement as a tool to increase behavior is presented

and the difference between positive and negative reinforcement is explained. Extinction as a tool

to reduce behavior is introduced together with the caveat and need to aware of intermittent

reinforcement and its effect. Punishment skills are introduced to parents only after reinforcement

skills are first understood and utilized. Parents are taught to communicate clear rules and

expectations and to always pair punishment with reinforcement of desired behaviors. Parents are
encouraged to have a menu of possible consequences prepared in advance. When parents “shoot

from the hip” punishments tend to be based on anger and not judicious thought. When angry, the

aim of punishment is corrupted to hurt rather than to teach. Parents are taught to use specific,

time-limited consequences that have some rational relationship to the error committed.

Punishment consequences are to be applied immediately and parents are taught to allow natural

consequences to do their job.

Emotion regulation skills are next taught with the goals of reducing emotional vulnerability,

decreasing the frequency of unwanted emotions and decreasing what is termed “emotional

suffering”. Emotions, even painful ones can serve a useful purpose such as providing

information or to communicate and influence others. Emotions can also motivate individuals and

prepare us for actions. Participants are taught to be mindful of positive experiences and to use the

“Teflon mind” when it comes to worries. Lists of pleasant activities, high-energy activities, low

energy activities and activities that can be shared with parents are compiled. One skill presented

is called “opposite action”. Participants are taught that when they are aware that their emotion is

not helping they are coached to do exactly the opposite of what the emotion would lead them

towards. Individuals are taught to use this strategy when emotion does not fit the facts or when

emotions are too intense or last too long or when the individual knows that acting on the emotion

will not be effective. Ways to act in opposition to fear, anger, shame and guilt are all discussed

and skills to do so are presented.

The last skill module taught involves interpersonal effectiveness. Each skill module takes a

number of sessions to complete and Rathus and Miller take us step by step through the skills to

be presented and in every module they identify which skills are taught during each weekly

meeting. Interpersonal effectiveness skills have as their goals keeping and maintaining healthy
relationships, increasing the probability that others will say yes or that we can comfortably say

no to other’s request and to maintain self-respect. DBT uses many acronyms such as GIVE,

DEAR MAN AND FAST all of which are carefully presented and explained. Participants are

asked to clarify their priorities by asking pointed questions such as: how do I want the other

person to feel about me when we complete our discussion, what is it that I would like from this

person, how do I effectively say no, and, most importantly, how I wish to feel about myself after

this interaction.

GIVE skills involve being Gentle, acting Interested, being Validating, and behaving using an

Easy manner. These skills are felt to help attain and maintain positive relationships. Role-play is

used as a training exercise and is combined with the concept is important to practice, even when

it is difficult.

FAST skills involved being Fair to yourself and others, and teaches participants to neither over

or under Apologize. Individuals are encouraged to Stick to their values and be Truthful.

Participants are taught to take other perspectives and to think about others’ motivations. Sample

role-playing scenarios are presented.

Throughout the presentation of modules there is a significant use of handouts all of which are

provided in this comprehensive book. Handouts for the orientation (7), the mindfullness module

(8), for distress tolerance (18), for walking the middle path (16) for the emotional regulations

module (21) and lastly the interpersonal effectiveness module (14) are all included. These

handouts have appropriate graphics and facilitate presenting the challenging concepts of DBT

and also highlight the meaning of many of the acronyms used throughout training. Rathus and

Miller’s book contains much information not mentioned in this review as many of the concepts
have just been skimmed over and only briefly noted. One will be required to read the book to see

its full breadth and depth.

DBT has developed over the years and this current book by Rathus and Miller provides us with a

very up-to-date iteration of DBT skills as they have been developed for adolescents and their

parents. The book is comprehensive, very inclusive and carefully detailed. As noted above,

reading a book will not make one a competent DBT therapist, however it is a good place to start.

When coupled with attendance of training seminars and workshops, involvement with other DBT

therapists and ensuring that one is provided DBT supervision, one can grow into a competent

DBT therapist.

This text could clearly be used in any graduate psychology training program, social work

training program or psychiatric residency where DBT skills are taught and where students can

participate in an ongoing DBT treatment program. Given the challenges of the population DBT

has been developed for and the clear, full, step-by-step manner in which DBT training, concepts

and philosophies are presented, this book is a value at its $45.00 cost.

Howard A Paul, Ph.D., A.B.P.P.

JCFBT Book Review Editor