Dialectical Behavior Therapy

Dialec­ti­cal Behav­ior Ther­apy in a Nutshell

Dialec­ti­cal Behav­ior Ther­apy (DBT) is a com­pre­hen­sive cognitive-behavioral treat­ment devel­oped by Dr. Mar­sha Line­han over the last 25 years.  DBT was orig­i­nally devel­oped to treat sui­ci­dal patients, evolved into a treat­ment for sui­ci­dal BPD patients, and has since been adapted for the treat­ment of BPD patients with pre­sent­ing prob­lems other than sui­ci­dal behav­iors. DBT is designed to treat BPD patients at all lev­els of sever­ity and com­plex­ity of dis­or­der and is con­cep­tu­al­ized as occur­ring in stages.  In Stage I, the pri­mary focus is on sta­bi­liz­ing the patient and achiev­ing behav­ioral con­trol.  Stage I treat­ment tar­gets are addressed in the fol­low­ing hier­ar­chi­cal order: 1) life-threatening behav­iors (pri­mar­ily sui­ci­dal and self-injurious behav­ior), 2) therapy-interfering behav­iors (e.g., poor atten­dance), and 3) severe qual­ity of life-interfering behav­iors (e.g., fre­quent use of cri­sis ser­vices, sub­stance abuse).  Stage I DBT con­sists of sev­eral modes of treat­ment, each designed to achieve spe­cific func­tions: indi­vid­ual ther­apy focuses on increas­ing client moti­va­tion (i.e., iden­ti­fy­ing spe­cific fac­tors main­tain­ing prob­lem behav­ior and pro­vid­ing inter­ven­tions); group skills train­ing teaches basic capa­bil­i­ties (i.e., behav­ioral skills includ­ing dis­tress tol­er­ance, emo­tion reg­u­la­tion, inter­per­sonal effec­tive­ness, and mind­ful­ness); phone coach­ing pro­vides the basis for gen­er­al­iza­tion of skills to the nat­ural envi­ron­ment; and the ther­a­pist con­sul­ta­tion team func­tions to increase ther­a­pist capa­bil­i­ties and moti­va­tion.  Presently, DBT is by far the best stud­ied treat­ment for BPD, and DBT treat­ment out­come stud­ies have focused pri­mar­ily on Stage I targets.

Dialec­ti­cal Behav­ior Ther­apy: Research Findings

To date, there have been nine pub­lished ran­dom­ized con­trolled tri­als and five con­trolled tri­als of DBT (click here to see tri­als).  Two of these tri­als (car­ried out in our research clinic) specif­i­cally tar­geted highly sui­ci­dal women with BPD, and we are in the midst of a third trial tar­get­ing the same pop­u­la­tion. In our first study, results favor­ing DBT were found in each DBT tar­get area. Com­pared to treatment-as-usual (TAU), DBT sub­jects were sig­nif­i­cantly less likely to attempt sui­cide or to self-injure, reported fewer inten­tional self-injury episodes at each assess­ment point, had less med­ically severe inten­tional self-injury episodes and lower treat­ment drop-out, tended to enter psy­chi­atric units less often, had fewer inpa­tient psy­chi­atric days, reported less anger, and improved more on scores of global as well as social adjust­ment.  In our sec­ond study, we com­pared DBT to a much stronger con­trol con­di­tion, treat­ment by non-behavioral com­mu­nity experts (TBE).  In com­par­i­son to TBE, DBT reduced sui­cide attempts by half, had less med­ically severe self-injurious episodes, lower rates of treat­ment drop-out, and fewer admis­sions to both emer­gency depart­ments and inpa­tient units due to sui­ci­dal­ity.  In stud­ies of DBT for BPD patients that have been con­ducted out­side of our research clinic, DBT has out­per­formed con­trol treat­ments in reduc­ing inten­tional self-injury, sui­ci­dal ideation, inpa­tient hos­pi­tal­iza­tions, hope­less­ness, depres­sion, dis­so­ci­a­tion, anger, and impul­siv­ity.  In stud­ies of sub­stance depen­dent BPD patients con­ducted at our research clinic as well as at other sites, DBT has been found to be supe­rior to con­trol treat­ments in reduc­ing sub­stance use.  In sum, DBT is an extremely effec­tive treat­ment for keep­ing sui­ci­dal BPD patients alive by help­ing them to gain con­trol over life-threatening and other severe behaviors.

For more infor­ma­tion on DBT

Inter­ested read­ers are referred to the DBT treat­ment man­u­als:

  • Line­han, M. M. (1993). Cog­ni­tive Behav­ioral Treat­ment of Bor­der­line Per­son­al­ity Dis­or­der. New York: Guil­ford Press.
  • Line­han, M. M. (1993). Skills train­ing man­ual for treat­ing bor­der­line per­son­al­ity dis­or­der. New York: Guil­ford Press.