DBT Skills Training Manual

The Manual's spine is Linehan's claim that skills training is a distinct therapeutic task requiring its own structure, not an incidental byproduct of individual therapy. It rejects the assumption that clients will acquire emotion regulation, distress tolerance, and interpersonal skills implicitly through the therapeutic relationship or through insight alone. The Manual instead specifies that skills must be taught explicitly, modeled, practiced in session, and assigned for homework, with the trainer using precise teaching notes and clinical examples. This operationalizes the biosocial theory from Linehan's 1993 treatment manual: if emotional dysregulation emerges from an invalidating environment, then the therapeutic environment must be deliberately, structurally validating and skills-focused. The Manual is thus the practical instrument for translating a theoretical claim about how skills develop into a teachable curriculum.

The second edition is a substantial expansion, not a cosmetic revision. Linehan notes in the preface that much of what she actually taught in skills groups was absent from the first edition[citation:2]. The new edition adds research underpinnings for each skill, a far broader range of teaching points than any trainer could cover, more clinical examples, and optional handouts marked with letter suffixes (1a, 1b) for flexible use[citation:2]. Every module now opens with goals handouts and a pros-and-cons worksheet for ambivalent clients. A mindfulness skill was added to the interpersonal and distress tolerance modules to thread mindfulness across the curriculum. The 1993 edition's specific skills and worksheets were tied to the first randomized clinical trial; the second edition offers multiple teaching schedules and curricula for different populations[citation:2][citation:4].

The two volumes divide trainer-facing and client-facing material. The Manual contains the teaching notes, session structures, and rationale; the Handouts and Worksheets volume contains the actual materials clients receive. Purchasers of the Manual get online access to download and print all handouts and worksheets, so the companion volume is not strictly necessary for trainers who prefer printing from the web[citation:4]. The division is practical for publishers and for trainers who want a clean separation between what they read in preparation and what they distribute in session. Some clinicians find the two-book requirement cumbersome, but the alternative—embedding 225+ reproducible handouts in a 504-page manual—would have made the teaching notes difficult to navigate during session preparation.

The most substantive critique comes from qualitative research with DBT clients, which found that the behavioral focus of skills training can feel reductive to some participants. One client described it as "in DBT they just extinguish behaviour – they don’t think about why it’s there"[citation:11]. Clients reported feeling that the distress tolerance skills, particularly distraction-based techniques, functioned as avoidance rather than processing, and that the sequencing rule—stabilize before addressing trauma—left their trauma unaddressed for extended periods[citation:11]. These are not critiques of the Manual's accuracy as a skills curriculum but of the treatment model's priorities. Linehan's own position, consistent with the 1993 treatment manual, is that life-threatening behaviors must be addressed first; the Manual reflects that hierarchy rather than contradicting it.

The 1993 treatment manual is the theoretical statement of DBT as a whole; the Skills Training Manual is the operationalization of one component—the skills group—within that treatment. Linehan's 1993 text presents the biosocial theory, the dialectical philosophy, and the treatment hierarchy for individual therapy. The Skills Training Manual takes the four-module skills curriculum that was embedded in the 1993 text and expands it into a standalone practitioner resource. The relationship is one of application: the treatment manual explains why DBT includes skills training and where it fits in the overall treatment, while the Skills Training Manual explains how to teach the skills. A clinician using the Skills Training Manual without familiarity with the 1993 treatment manual would be teaching skills without the dialectical and biosocial framework that gives them their clinical rationale.

The first edition was tied to borderline personality disorder and the specific skills used in the initial randomized trial. The second edition explicitly provides curricula for populations beyond BPD, including adolescents and clients with substance use problems[citation:4]. This reflects the broader research trajectory: a 2025 systematic review by the Swedish agency SBU found that DBT skills training alone (without full DBT) has positive effects in adults with emotionally unstable personality disorder and in adults with binge-eating disorder or bulimia[citation:13]. The Manual's shift from a BPD-specific skills protocol to a flexible, multi-population curriculum mirrors this evidence base. Linehan notes that across populations, the skills themselves remain stable—it is the clinical examples that require adaptation[citation:2].