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 (see Figure 1 below for a summary of these results). 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.