The Dialectical Behavior Therapy Primer: How DBT can inform clinical practice By Brodsky Beth S. & Stanley Barbara West Sussex, UK: Wiley-Blackwell, 2012. $59.95. ISBN 978-1-119-96893-1
Article first published online: 6 JAN 2014
© 2014 The British Psychological Society
British Journal of Psychology
Volume 105, Issue 1, pages 145–146, February 2014
How to Cite
Sheppard, M. (2014), The Dialectical Behavior Therapy Primer: How DBT can inform clinical practice By Brodsky Beth S. & Stanley Barbara West Sussex, UK: Wiley-Blackwell, 2012. $59.95. ISBN 978-1-119-96893-1 . British Journal of Psychology, 105: 145–146. doi: 10.1111/bjop.12061
- Issue published online: 6 JAN 2014
- Article first published online: 6 JAN 2014
According to its authors, The Dialectical Behavior Therapy Primer is intended for clinicians who want to incorporate some or all aspects of Dialectical Behavior Therapy (DBT) into their clinical work, as well as to non-therapists who want a better understanding of what DBT is about. The former is a somewhat controversial undertaking. In the forward, Allen Frances notes that Marsha Linehan, the original developer of DBT, has always opposed practising ‘DBT light.’ The conflict of whether a therapy must be fully DBT or not at all DBT is a dialectic this book tries to address by offering a middle path.
In terms of layout, this book is highly accessible. It is organized into an introduction and two parts that address theory (Part 1; six chapters) and practice (Part 2; eleven chapters). The introduction proposes a ‘top ten list’ of questions that will accompany the book. Chapters open with brief paragraphs introducing the goals of each chapter, including which ones of the ‘top ten questions’ the respective chapter will address. Case examples in shaded boxes are used to illustrate either patient problems or clinical strategies. The authors make their points clearly and quickly (the book is only 250 pages), and chapters close with concise summaries of their contents.
Opening with theoretical considerations, ‘Part I: Theoretical, research, and clinical foundations’ describes the pathology DBT was designed to help treat, Borderline Personality Disorder (BPD). A discussion of the stigma of the BPD diagnosis, as well as biosocial theory of BPD, balances the experience of carers and patients. A chapter discussing self-harm provides clear definitions of suicidal behaviour and non-suicidal self-injury (NSSI), as well as the sometimes confusing motivations for self-destructive behaviour among emotionally dysregulated individuals. For clinicians who do not routinely work with patients who engage in NSSI or suicidal behaviour patients, this chapter likely includes a wealth of information. Chapter six, ‘The ABC's of DBT – the theoretical perspective,’ essentially focuses on the dialectical process of validation and change that is central to DBT, while chapter seven, ‘The ABC's of DBT – overview of treatment’ describes the four stages of DBT treatment. To me Part I read like a ‘Coles notes’ of DBT; it included the most relevant parts in a quick, easily accessible format, but it was less informative than Linehan's (1993a) original technical manual.
Next, ‘Part II: Using DBT in clinical practice’ describes the main ingredients of DBT as a therapy. These include individual psychotherapy, group skills training, telephone consultation, and the clinicians’ peer consultation. It should be emphasized that without all four ingredients, therapy is not DBT. It might be ‘partial DBT,’ ‘DBT-informed,’ or as Frances notes in the foreword, ‘DBT light,’ but it is not DBT. I suspect that Linehan would be less adverse to DBT ‘light’ if it were clearly labelled as such. Hopefully, clinicians using The Dialectical Behavior Therapy Primer as their main source of DBT training will not advertise themselves as practising DBT. This primer orients the reader to what DBT is, and possibly how to add some of the ideas from DBT to one's clinical practice. However, it is not a training manual for practising DBT and should not be read as such.
In Part II, the authors describe DBT strategies for committing to treatment, goal setting, and the structure of individual psychotherapy. They lay out the four skills domains in DBT (emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness) and how these are addressed in individual therapy and the skills training group. The individual skills are described very briefly and the reader is referred to Linehan's (1993b) skills training manual for further information. The discussion of telephone consultation includes the DBT practice of observing therapists’ limits (e.g., are midnight calls problematic) as they emerge rather than setting arbitrary limits, which is likely a relief to non-DBT practitioners who are considering adding telephone consultation to their practice. The take-home message is that clinicians are not expected to be immediately available by telephone, but they are expected to respond to calls from clients. Two chapters in this section focus on treating NSSI and suicidal behaviour. I found the chapter on ‘The Safety Planning Intervention’ to be a new and informative addition. This specific suicide prevention strategy is not described in Linehan's (1993a) text; it was developed by Barbara Stanley and is considered ‘best practice’ by the Suicide Prevention Resource Center/American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention. Consultation is described in three contexts, the peer supervision team, consultation to the client, and consultation with other clinicians. Consultation to the client is a practice unique to DBT in which the client is helped to advocate on his or her own behalf with other treatment providers. In DBT, this practice helps reduce ‘splitting’ between staff members and the authors describe it clearly. The chapter on DBT case formulation integrates the preceding chapters into how one can conceptualize a case from a DBT framework including treatment planning, by ways of a sample case. It is unlikely that one would use the case formulation as laid out in this chapter; it is too long. The book closes with a succinct discussion of the different types of treatment termination and the circumstances under which they occur (e.g., therapy ‘vacations,’ patients dropping out of therapy, goals being achieved).
I found this text to contain essential information of DBT. The book is not simply a primer on Linehan's (1993a,b) texts because it includes subsequent research findings and an important innovation by one of the authors. As the authors state at the outset, it is likely most useful for clinicians wondering what DBT is and what it includes, as well as for non-clinicians wondering what DBT is about. Some of the concepts are good therapy (e.g., the emphasis on validation), whereas some are unique to DBT (e.g., the consult team). Because some of the elements of DBT are good practice and can be incorporated into other treatment modalities, the authors succeed in finding a middle path between ignorance of DBT and trained practice of all elements of DBT. The caution is to note that good therapy and DBT are overlapping but not identical concepts, and adding useful elements from fully implemented DBT to an eclectic practice does not make such practice DBT.