Research Studies on Dialectical Behavior Therapy (DBT)

Elec­tronic ver­sions of papers are pro­vided as a pro­fes­sional cour­tesy to ensure timely dis­sem­i­na­tion of aca­d­e­mic work for indi­vid­ual, non­com­mer­cial pur­poses. Copy­right resides with the respec­tive copy­right hold­ers, as stated within each paper. These files may not be reposted with­out permission.

For sum­maries of recently pub­lished DBT and BPD arti­cles on research con­ducted out­side of the BRTC click here.

Eleven Ran­dom­ized Con­trolled Tri­als of DBT

1a) ‚M.M., Armstrong,H.E., Suarez,A., Allmon,D., Heard,H.L. (1991). Cognitive-behavioral treat­ment of chron­i­cally para­sui­ci­dal bor­der­line patients. Archives of Gen­eral Psy­chi­a­try, 48, 1060–1064.
Com­pared 2 groups: 22 females (aged 18–45 yrs) with para­sui­ci­dal bor­der­line per­son­al­ity dis­or­der (PBPD) who under­went DBT for 1 yr and 22 matched females with PBPD who under­went treat­ment as usual in the com­mu­nity. Ss were assessed at pre­treat­ment and at 4, 8, and 12 mo post­treat­ment. There was a sig­nif­i­cant reduc­tion in the fre­quency and med­ical risk of para­sui­ci­dal behav­ior among Ss who received DBT com­pared with Ss who received treat­ment as usual. DBT effec­tively retained patients in ther­apy. The num­ber of days of inpa­tient psy­chi­atric hos­pi­tal­iza­tion was fewer for Ss who received DBT than for con­trols. These effects occurred despite the fact that DBT was not dif­fer­en­tially effec­tive in improv­ing patients’ depres­sion, hope­less­ness, sui­cide ideation, or rea­sons for living.
1b) Linehan,M.M., Heard,H.L. (1993) “Impact of treat­ment acces­si­bil­ity on clin­i­cal course of para­sui­ci­dal patients”: Reply. Archives of General-Psychiatry, 50(2): 157–158.
Replies to a com­ment by R. E. Hoff­man on an arti­cle by M. M. Line­han et al on the treat­ment of para­sui­ci­dal patients with bor­der­line per­son­al­ity dis­or­der. In con­trast to Hoff­man, the authors believe that they have pro­vided evi­dence that dialec­ti­cal behav­ioral ther­apy per se, as opposed to eco­nomic and other com­pli­cat­ing fac­tors, pro­duces clin­i­cal out­comes supe­rior to treat­ment as usual.
1c) Linehan,M.M., Heard,H.L., Armstrong,H.E. (1993). Nat­u­ral­is­tic follow-up of a behav­ioral treat­ment for chron­i­cally para­sui­ci­dal bor­der­line patients. Archives of Gen­eral Psy­chi­a­try, 50, 971–974.
Eval­u­ated whether the supe­rior per­for­mance of DBT for bor­der­line per­son­al­ity dis­or­der (BPD) was main­tained dur­ing a 1-yr post­treat­ment follow-up of Ss from a pre­vi­ous study (see record 1992–13734-001). 39 women with BPD who had a his­tory of para­sui­ci­dal behav­ior par­tic­i­pated. Ss were assigned to DBT, a cog­ni­tive behav­ioral ther­apy that com­bines psy­chother­apy with group behav­ioral skills train­ing, or to treatment-as-usual, which may or may not have included indi­vid­ual psy­chother­apy. Effi­cacy was mea­sured on para­sui­ci­dal behav­ior, psy­chi­atric inpa­tient days, anger, global func­tion­ing, and social adjust­ment. Through­out the follow-up, DBT Ss had sig­nif­i­cantly higher global func­tion­ing. Dur­ing the ini­tial 6 mo, DBT Ss had sig­nif­i­cantly less para­sui­ci­dal behav­ior, less anger, and bet­ter self-rated social adjust­ment. Dur­ing the final 6 mo, Ss had fewer inpa­tient days and bet­ter interviewer-rated social adjustment.

1d)     Linehan.M.M., Heard,H.L., Armstrong,H.E. (1994). “Nat­u­ral­is­tic follow-up of a behav­ioral treat­ment for chron­i­cally para­sui­ci­dal bor­der­line patients”: Erra­tum. Archives of Gen­eral Psy­chi­a­try, 51, 422.                                      Reports an error in the orig­i­nal arti­cle by M. Line­han et al. (Archives of Gen­eral Psy­chi­a­try, 1993, Vol 50[12], 971–974). A cor­rec­tion is made to the 2nd sen­tence of the “Results” sec­tion on page 973.

1e) Linehan,M.M., Tutek,D.A., Heard,H.L., Armstrong,H.E. (1994). Inter­per­sonal out­come of cog­ni­tive behav­ioral treat­ment for chron­i­cally sui­ci­dal bor­der­line patients. Amer­i­can Jour­nal of Psy­chi­a­try, 151, 1771–1776. Exam­ined the effi­cacy of a cog­ni­tive behav­ioral out­pa­tient treat­ment on inter­per­sonal out­come vari­ables for patients diag­nosed with bor­der­line per­son­al­ity dis­or­der. 26 female patients with bor­der­line per­son­al­ity dis­or­der were ran­domly assigned to either DBT or a treatment-as-usual com­par­i­son con­di­tion. In both the intent-to-treat and treat­ment com­ple­tion groups, Ss com­plet­ing DBT had sig­nif­i­cantly bet­ter scores on mea­sures of anger, interviewer-rated global social adjust­ment, and the Global Assess­ment Scale and tended to rate them­selves bet­ter on over­all social adjust­ment than did treatment-as-usual Ss. Results sug­gest that DBT is a promis­ing psy­choso­cial inter­ven­tion for improv­ing inter­per­sonal func­tion­ing among severely dys­func­tional patients with bor­der­line per­son­al­ity disorder.

2) Linehan,M.M., Schmidt,H., Dimeff,L.A., Craft,J.C., Kanter,J., Comtois,K.A. (1999). Dialec­ti­cal behav­ior ther­apy for patients with bor­der­line per­son­al­ity dis­or­der and drug-dependence. Amer­i­can Jour­nal on Addic­tion, 8(4), 279–292.
Com­pared results obtained from DBT and a treatment-as-usual (TAU) reg­i­men for drug-dependent sui­ci­dal women dis­play­ing bor­der­line per­son­al­ity dis­or­der. 28 women (aged 18–45 yrs) were ran­domly assigned to DBT or TAU groups. The 12 Ss receiv­ing DBT, which com­prises strate­gies from cog­ni­tive and behav­ioral ther­a­pies and accep­tance strate­gies adapted from Zen teach­ing, par­tic­i­pated in indi­vid­ual psy­chother­apy, group skills train­ing ses­sions, and skills coach­ing phone calls when needed. Those receiv­ing TAU were referred to alter­na­tive sub­stance abuse or men­tal health coun­selors and com­mu­nity pro­grams, or con­tin­ued with their own psy­chother­a­pists. Results show a drop-out rate of 36% from DBT com­pared with a rate of 73% from TAU. Uri­nal­y­sis showed a sig­nif­i­cant reduc­tion in sub­stance abuse among the DBT Ss, and sig­nif­i­cant improve­ments in social and global adjust­ment in DBT Ss at 16-mo follow-up. Find­ings sug­gest that DBT is an effec­tive treat­ment for severely dys­func­tional drug-dependent patients.
3) Line­han, M.M., Dim­eff, L.A., Reynolds, S.K., Com­tois, K.A., Welch, S.S., Hea­gerty, P., Kivla­han, D.R. (2002). Dialec­ti­cal behav­ior ther­apy ver­sus com­pre­hen­sive val­i­da­tion plus 12-step for the treat­ment of opi­oid depen­dent women meet­ing cri­te­ria for bor­der­line per­son­al­ity dis­or­der. Drug and Alco­hol Depen­dence, 67(1), 13–26.
Com­pared the effects of the use of DBT and com­pre­hen­sive val­i­da­tion ther­apy in con­junc­tion with a 12-step pro­gram (CVT + 12S) on the drug usage of heroin-dependent females. Dur­ing a 12-mo period, 23 heroin-dependent females (mean age 36.1 yrs) diag­nosed with bor­der­line per­son­al­ity dis­or­der received either DBT, a treat­ment that syn­the­sizes behav­ioral change with rad­i­cal accep­tance strate­gies, or CVT + 12S, a man­u­al­ized approach that pro­vides DBT in com­bi­na­tion with par­tic­i­pa­tion in a 12-step pro­gram. In addi­tion, Ss received con­cur­rent opi­ate ago­nist ther­apy with lev­omethadyl acetate hydrochlo­ride oral solu­tion. Sub­jects (Ss) were assessed for drug use through uri­nal­y­ses, inter­views, and self-reports. Results show that both treat­ment con­di­tions were effec­tive in reduc­ing opi­ate use rel­a­tive to base­line. At 4 mo fol­low­ing treat­ment ter­mi­na­tion, all Ss exhib­ited a low pro­por­tion of opiate-positive uri­nal­y­ses. Ss assigned to DBT main­tained reduc­tions in mean opi­ate use through 12 mo of active treat­ment, while those assigned to CVT + 12S treat­ment sig­nif­i­cantly increased opi­ate use dur­ing the last 4 mo of treat­ment. Pos­si­bly con­found­ing these results was that all 12 CVT + 12S Ss com­pleted the 12 mo of treat­ment, while only 64% of Ss com­pleted DBT.
4) Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gon­za­lez, A.M., Morse, J.Q., Bishop, G.K., But­ter­field, M.I., Bas­t­ian, L.A. (2001). Effi­cacy of dialec­ti­cal behav­ior ther­apy in women vet­er­ans with bor­der­line per­son­al­ity dis­or­der. Behav­ior Ther­apy, 32(2), 371–390.
Twenty women vet­er­ans (aged 21–46 yrs) who met cri­te­ria for bor­der­line per­son­al­ity dis­or­der (BPD) were ran­domly assigned to DBT or to treat­ment as usual (TAU) for 6 months. Com­pared with patients in TAU, those in DBT reported sig­nif­i­cantly greater decreases in sui­ci­dal ideation, hope­less­ness, depres­sion, and anger expres­sion. In addi­tion, only patients in DBT demon­strated sig­nif­i­cant decreases in num­ber of para­sui­ci­dal acts, anger expe­ri­enced but not expressed, and dis­so­ci­a­tion, and a strong trend on num­ber of hos­pi­tal­iza­tions, although treat­ment group dif­fer­ences were not sta­tis­ti­cally sig­nif­i­cant on these vari­ables. Patients in both con­di­tions reported sig­nif­i­cant decreases in depres­sive symp­toms and in num­ber of BPD cri­te­rion behav­ior pat­terns, but no decrease in anx­i­ety. Results of this pilot study sug­gest that DBT can be pro­vided effec­tively inde­pen­dent of the treatment’s devel­oper, and that larger effi­cacy and effec­tive­ness stud­ies are warranted.
5a) van den Bosch, L.M.C., Ver­heul, R., Schip­pers, G.M., van den Brink, W. (2002). Dialec­ti­cal Behav­ior Ther­apy of bor­der­line patients with and with­out sub­stance use prob­lems: Imple­men­ta­tion and long-term effects. Addic­tive Behav­iors, 27(6), 911–923.
Exam­ined whether stan­dard DBT (1) can be suc­cess­fully imple­mented in a mixed pop­u­la­tion of bor­der­line patients with or with­out comor­bid sub­stance abuse (SA), (2) is equally effi­ca­cious in reduc­ing bor­der­line symp­to­ma­tol­ogy among those with and those with­out comor­bid SA, and (3) is effi­ca­cious in reduc­ing the sever­ity of the sub­stance use prob­lems. The imple­men­ta­tion of DBT was exam­ined qual­i­ta­tively. The impact of comor­bid SA on its effi­cacy, as well as on its effi­cacy in terms of reduc­ing SA, is inves­ti­gated in a ran­dom­ized clin­i­cal trial com­par­ing DBT with treatment-as-usual (TAU) in 58 18–70 yr old female bor­der­line patients with (n=31) and with­out (n= 27) SA. Results show that stan­dard DBT can be applied in a group of bor­der­line patients with and with­out comor­bid SA. DBT resulted in greater reduc­tions of severe bor­der­line symp­toms than TAU, and this effect was not mod­i­fied by the pres­ence of comor­bid SA. It is con­cluded that Stan­dard DBT can be effec­tively applied with bor­der­line patients with comor­bid SA prob­lems, as well as those with­out. Stan­dard DBT, how­ever, is not more effi­ca­cious than TAU in reduc­ing sub­stance use problems.
5b) Ver­heul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Rid­der, M.A.J., Sti­j­nen, T., van den Brink, W. (2003). Dialec­ti­cal behav­iour ther­apy for women with bor­der­line per­soal­ity dis­or­der: 12-month, ran­domised clin­i­cal trial in the Nether­lands. British Jour­nal of Psy­chi­a­try, 182, 135–140.

Dialec­ti­cal behav­ior ther­apy (DBT) is widely con­sid­ered to be a promis­ing treat­ment for bor­der­line per­son­al­ity dis­or­der (BPD). How­ever, the evi­dence for its effi­cacy pub­lished thus far should be regarded as pre­lim­i­nary. This study com­pared the effec­tive­ness of DBT with treat­ment as usual for patients with BPD and exam­ined the impact of base­line sever­ity on effec­tive­ness. 58 women (mean age 34.9 yrs)with BPD were ran­domly assigned to either 12 mo of DBT or usual treat­ment in a ran­dom­ized con­trolled study. Ss were recruited through clin­i­cal refer­rals from both addic­tion treat­ment and psy­chi­atric ser­vices. Out­come mea­sures included treat­ment reten­tion and the course of sui­ci­dal, self-mutilating, and self-damaging impul­sive behav­iors. DBT resulted in bet­ter reten­tion rates and greater reduc­tions of self-mutilating and self-damaging impul­sive behav­iors com­pared with usual treat­ment, espe­cially among those with a his­tory of fre­quent self-mutilation. Find­ings show that DBT is supe­rior to usual treat­ment in reduc­ing high-risk behav­iors in patients with BPD.

6) Telch, C.F., Agras, W.S., Line­han, M.M. (2001). Dialec­ti­cal behav­ior ther­apy for binge eat­ing dis­or­der. Jour­nal of Con­sult­ing and Clin­i­cal Psy­chol­ogy, 69(6), 1061–1065.
This study eval­u­ated the use of DBT adapted for binge eat­ing dis­or­der (BED). Women with BED (N=44) were ran­domly assigned to group DBT or to a wait-list con­trol con­di­tion and were admin­is­tered the Eat­ing Dis­or­der Exam­i­na­tion in addi­tion to mea­sures of weight, mood, and affect reg­u­la­tion at base­line and post­treat­ment. Treated women evi­denced sig­nif­i­cant improve­ment on mea­sures of binge eat­ing and eat­ing pathol­ogy com­pared with con­trols, and 89% of the women receiv­ing DBT had stopped binge eat­ing by the end of treat­ment. Absti­nence rates were reduced to 56% at the 6-month follow-up. Over­all, the find­ings on the mea­sures of weight, mood, and affect reg­u­la­tion were not sig­nif­i­cant. These results sup­port fur­ther research into DBT as a treat­ment for BED.
7) Safer, D.L., Telch, C.F., Agras, W.S. (2001). Dialec­ti­cal behav­ior ther­apy for bulimia ner­vosa. Amer­i­can Jour­nal of Psy­chi­a­try, 158(4), 632–634.
The effects of DBT adapted for the treat­ment of binge/purge behav­iors were exam­ined. 31 (aged 18–65 yrs) were ran­domly assigned to 20 weeks of DBT or 20 weeks of a waiting-list com­par­i­son con­di­tion. The manual-based dialec­ti­cal behav­ior ther­apy focused on train­ing in emo­tion reg­u­la­tion skills. An intent-to-treat analy­sis showed highly sig­nif­i­cant decreases in binge/purge behav­ior with dialec­ti­cal behav­ior ther­apy com­pared to the waiting-list con­di­tion. No sig­nif­i­cant group dif­fer­ences were found on any of the sec­ondary mea­sures. The use of dialec­ti­cal behav­ior ther­apy adapted for treat­ment of bulimia ner­vosa was asso­ci­ated with a promis­ing decrease in binge/purge behaviors.
8) Lynch, T.R., Morse, J.Q., Mendel­son, T., Robins, C.J. (2003). Dialec­ti­cal behav­ior ther­apy for depressed older adults: A ran­dom­ized pilot study. Amer­i­can Jour­nal of Geri­atric Psy­chi­a­try, 11(1), 33–45.
Assessed the ben­e­fits of aug­ment­ing med­ica­tion with group psy­chother­apy in depressed older adults. The authors ran­domly assigned 34 (largely chron­i­cally) depressed indi­vid­u­als age 60 yrs and older to receive 28 wks of anti­de­pres­sant med­ica­tion plus clin­i­cal man­age­ment, either alone (MED) or with the addi­tion of dialec­ti­cal behav­ior ther­apy skills-training and sched­uled tele­phone coach­ing ses­sions (MED+DBT). Only MED+DBT showed sig­nif­i­cant decreases on mean self-rated depres­sion scores, and both treat­ment groups demon­strated sig­nif­i­cant and roughly equiv­a­lent decreases on interviewer-rated depres­sion scores. How­ever, on interviewer-rated depres­sion, 71% of MED+DBT patients were in remis­sion at post-treatment, in con­trast to 47% of MED patients. At a 6 mo fol­lowup, 75% of MED+DBT patients were in remis­sion, com­pared with only 31% of MED patients, a sig­nif­i­cant dif­fer­ence. Only patients receiv­ing MED+DBT showed sig­nif­i­cant improve­ments from pre– to post-treatment on depen­dency and adap­tive cop­ing that are pro­posed to cre­ate vul­ner­a­bil­ity to depres­sion. Results sug­gest that DBT skills train­ing and tele­phone coach­ing may offer promise to effec­tively aug­ment the effects of anti­de­pres­sant med­ica­tion in depressed older adults.
9) Line­han et al (2006) NIMH 3 Two-Year Ran­dom­ized Con­trol Trial and Fol­low up of DBT
Dialec­ti­cal behav­ior ther­apy (DBT) is a treat­ment for sui­ci­dal behav­ior and bor­der­line per­son­al­ity dis­or­der with well-documented effi­cacy. OBJECTIVE: To eval­u­ate the hypoth­e­sis that unique aspects of DBT are more effi­ca­cious com­pared with treat­ment offered by non-behavioral psy­chother­apy experts. DESIGN: One-year ran­dom­ized con­trolled trial, plus 1 year of post­treat­ment follow-up. SETTING: Uni­ver­sity out­pa­tient clinic and com­mu­nity prac­tice. PARTICIPANTS: One hun­dred one clin­i­cally referred women with recent sui­ci­dal and self-injurious behav­iors meet­ing DSM-IV cri­te­ria, matched to con­di­tion on age, sui­cide attempt his­tory, neg­a­tive prog­nos­tic indi­ca­tion, and num­ber of life­time inten­tional self-injuries and psy­chi­atric hos­pi­tal­iza­tions. INTERVENTION: One year of DBT or 1 year of com­mu­nity treat­ment by experts (devel­oped to max­i­mize inter­nal valid­ity by con­trol­ling for ther­a­pist sex, avail­abil­ity, exper­tise, alle­giance, train­ing and expe­ri­ence, con­sul­ta­tion avail­abil­ity, and insti­tu­tional pres­tige). MAIN OUTCOME MEASURES: Trimester assess­ments of sui­ci­dal behav­iors, emer­gency ser­vices use, and gen­eral psy­cho­log­i­cal func­tion­ing. Mea­sures were selected based on pre­vi­ous out­come stud­ies of DBT. Out­come vari­ables were eval­u­ated by blinded asses­sors. RESULTS: Dialec­ti­cal behav­ior ther­apy was asso­ci­ated with bet­ter out­comes in the intent-to-treat analy­sis than com­mu­nity treat­ment by experts in most tar­get areas dur­ing the 2-year treat­ment and follow-up period. Sub­jects receiv­ing DBT were half as likely to make a sui­cide attempt (haz­ard ratio, 2.66; P = .005), required less hos­pi­tal­iza­tion for sui­cide ideation (F(1,92) = 7.3; P = .004), and had lower med­ical risk (F(1,50) = 3.2; P = .04) across all sui­cide attempts and self-injurious acts com­bined. Sub­jects receiv­ing DBT were less likely to drop out of treat­ment (haz­ard ratio, 3.2; P < .001) and had fewer psy­chi­atric hos­pi­tal­iza­tions (F(1,92) = 6.0; P = .007) and psy­chi­atric emer­gency depart­ment vis­its (F(1,92) = 2.9; P = .04). CONCLUSIONS: Our find­ings repli­cate those of pre­vi­ous stud­ies of DBT and sug­gest that the effec­tive­ness of DBT can­not rea­son­ably be attrib­uted to gen­eral fac­tors asso­ci­ated with expert psy­chother­apy. Dialec­ti­cal behav­ior ther­apy appears to be uniquely effec­tive in reduc­ing sui­cide attempts.

10) pdf fileLine­han, M.,M. et al (2008) Olan­za­p­ine Plus DBT for Women with High Irritability.pdf                                                                                                         This double-blind study exam­ined whether olan­za­p­ine aug­ments the effi­cacy of dialec­ti­cal behav­ior ther­apy (DBT) in reduc­ing anger and hos­til­ity in bor­der­line per­son­al­ity dis­or­der patients. Twenty-four women with bor­der­line per­son­al­ity dis­or­der (DSM-IV cri­te­ria) and high lev­els of irri­tabil­ity and anger received 6 months of DBT. Sub­jects were ran­domly assigned to receive either low-dose olan­za­p­ine or placebo and were assessed with stan­dard­ized mea­sures in a double-blind man­ner. It was found that Olan­za­p­ine may pro­mote more rapid reduc­tion of irri­tabil­ity and aggres­sion than placebo for highly irri­ta­ble women with bor­der­line per­son­al­ity dis­or­der. Effect sizes were mod­er­ate to large, with the small sam­ple size likely lim­it­ing the abil­ity to detect sig­nif­i­cant results. Over­all, there were large and con­sis­tent reduc­tions in irri­tabil­ity, aggres­sion, depres­sion, and self-injury for both groups of sub­jects receiv­ing DBT.

11)   Dialec­ti­cal Behav­ior Ther­apy for High Sui­cide Risk in Indi­vid­u­als With Bor­der­line Per­son­al­ity Dis­or­der: A Ran­dom­ized Clin­i­cal Trial and Com­po­nent Analy­sis.
MM Line­han, KE Korslund, MS Harned, RJ Gal­lop… — JAMA psy­chi­a­try, 2015
Impor­tance: Dialec­ti­cal behav­ior ther­apy (DBT) is an empir­i­cally sup­ported treat­ment for sui­ci­dal indi­vid­u­als. How­ever, DBT con­sists of mul­ti­ple com­po­nents, includ­ing indi­vid­ual ther­apy, skills train­ing, tele­phone coach­ing, and a ther­a­pist con­sul­ta­tion team, and lit­tle is known about which com­po­nents are needed to achieve pos­i­tive out­comes.
Objec­tive: To eval­u­ate the impor­tance of the skills train­ing com­po­nent of DBT by com­par­ing skills train­ing plus case man­age­ment (DBT-S), DBT indi­vid­ual ther­apy plus activ­i­ties group (DBT-I), and stan­dard DBT which includes skills train­ing and indi­vid­ual ther­apy.
Design, Set­ting, and Par­tic­i­pants: We per­formed a single-blind ran­dom­ized clin­i­cal trial from April 24, 2004, through Jan­u­ary 26, 2010, involv­ing 1 year of treat­ment and 1 year of follow-up. Par­tic­i­pants included 99 women (mean age, 30.3 years; 69 [71%] white) with bor­der­line per­son­al­ity dis­or­der who had at least 2 sui­cide attempts and/or non­sui­ci­dal self-injury (NSSI) acts in the last 5 years, an NSSI act or sui­cide attempt in the 8weeks before screen­ing, and a sui­cide attempt in the past year. We used an adap­tive ran­dom­iza­tion pro­ce­dure to assign par­tic­i­pants to each con­di­tion. Treat­ment was deliv­ered from June 3, 2004, through Sep­tem­ber 29, 2008, in a university-affiliated clinic and com­mu­nity set­tings by ther­a­pists or case man­agers. Out­comes were eval­u­ated quar­terly by blinded asses­sors. We hypoth­e­sized that stan­dard DBT­would out­per­form DBT-S and DBT-I.
Inter­ven­tions: The study com­pared stan­dard DBT, DBT-S, and DBT-I. Treat­ment dose was con­trolled across con­di­tions, and all treat­ment providers used the DBT sui­cide risk assess­ment and man­age­ment pro­to­col.
Main Out­comes and Mea­sures: Fre­quency and sever­ity of sui­cide attempts and NSSI episodes.
Results: All treat­ment con­di­tions resulted in sim­i­lar improve­ments in the fre­quency and sever­ity of sui­cide attempts, sui­cide ideation, use of cri­sis ser­vices due to sui­ci­dal­ity, and rea­sons for liv­ing. Com­pared with the DBT-I group, inter­ven­tions that included skills train­ing resulted in greater improve­ments in the fre­quency of NSSI acts (F1,85 = 59.1 [P < .001] for stan­dard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depres­sion (t 399 = 1.8[P = .03] for stan­dard DBT and t399 = 2.9[P = .004] for DBT-S) dur­ing the treat­ment year. In addi­tion, anx­i­ety sig­nif­i­cantly improved dur­ing the treat­ment year in stan­dard DBT (t94 = −3.5 [P < .001]) and DBT-S (t94 = −2.6[P = .01]), but not in DBT-I. Com­pared with the DBT-I group, the stan­dard DBT group had lower dropout rates from treat­ment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use cri­sis ser­vices in follow-up (ED vis­its, 1 [3%] vs 3 [13%] [P = .02]; psy­chi­atric hos­pi­tal­iza­tions, 1 [3%] vs 3 [13%] [P = .03]).
Con­clu­sions and Rel­e­vance: A vari­ety of DBT inter­ven­tions with ther­a­pists trained in the DBT sui­cide risk assess­ment and man­age­ment pro­to­col are effec­tive for reduc­ing sui­cide attempts and NSSI episodes. Inter­ven­tions that include DBT skills train­ing are more effec­tive than DBT with­out skills train­ing, and stan­dard DBT may be supe­rior in some areas.

Six Non-Randomized Tri­als of DBT

1) Rathus, J.H., Miller, A.L. (2002). Dialec­ti­cal Behav­ior Ther­apy adapted for sui­ci­dal ado­les­cents. Sui­cide and Life-Threatening Behav­ior, 32(2), 146–157.                                                                                                                   Reports a quasi-experimental inves­ti­ga­tion of an adap­ta­tion of Dialec­ti­cal Behav­ior Ther­apy (DBT) with a group of sui­ci­dal ado­les­cents with bor­der­line per­son­al­ity fea­tures. The DBT group (n=29) received 12 wks of twice weekly ther­apy con­sist­ing of indi­vid­ual ther­apy and a mul­ti­fam­ily skills train­ing group. The treat­ment as usual (TAU) group (n=82) received 12 wks of twice weekly supportive-psychodynamic indi­vid­ual ther­apy plus weekly fam­ily ther­apy. Despite more severe pre­treat­ment symp­to­ma­tol­ogy in the DBT group, at post­treat­ment this group had sig­nif­i­cantly fewer psy­chi­atric hos­pi­tal­iza­tions dur­ing treat­ment, and a sig­nif­i­cantly higher rate of treat­ment com­ple­tion than the TAU group. There were no sig­nif­i­cant dif­fer­ences in the num­ber of sui­cide attempts made dur­ing treat­ment. Exam­in­ing pre-post change within the DBT group, there were sig­nif­i­cant reduc­tions in sui­ci­dal ideation, gen­eral psy­chi­atric symp­toms, and symp­toms of bor­der­line per­son­al­ity. DBT appears to be a promis­ing treat­ment for sui­ci­dal ado­les­cents with bor­der­line per­son­al­ity characteristics.

2) Trupin, E.W., Stew­art, D.G., Beach, B, Boesky, L. (2002). Effec­tive­ness of a dialec­ti­cal behav­iour ther­apy pro­gram for incar­cer­ated female juve­nile offend­ers. Child and Ado­les­cent Men­tal Health, 7, 121–127.
The State of Wash­ing­ton Governor’s Juve­nile Jus­tice Advi­sory Com­mit­tee spon­sored a col­lab­o­ra­tive project con­ducted by a research team from the Uni­ver­sity of Wash­ing­ton and the staff at a juve­nile reha­bil­i­ta­tive cen­ter to eval­u­ate the effec­tive­ness of a DBT inter­ven­tion. Pre-post inter­ven­tion records were com­pared for female offend­ers from a men­tal health and a gen­eral pop­u­la­tion unit where DBT was imple­mented. Youth on a third unit served as a com­par­i­son group. Youth behav­ior prob­lems, staff puni­tive responses were com­pared before and after the inter­ven­tion period. Youth behav­ior prob­lems and use of puni­tive responses by staff decreased com­pared to the year prior on one cot­tage (unit) while no behav­ior or staff changes were noted on another. The eval­u­a­tion demon­strated the effi­cacy of pro­vid­ing DBT to female offend­ers in a res­i­den­tial set­ting and yielded mixed results on behav­ior change dur­ing the study period that may relate to qual­ity of train­ing and prior youth behav­ior problems.
3) Bohus, M., Haaf, B., Stiglmayr, C., Pohl, U., Boehme, R., Line­han, M. (2000). Eval­u­a­tion of inpa­tient Dialectical-Behavioral Ther­apy for Bor­der­line Per­son­al­ity Disorder–A prospec­tive study. Behav­iour Research and Ther­apy, 38(9): 875–887.
Devel­oped and eval­u­ated a treat­ment pro­gram of inpa­tient ther­apy for chron­i­cally sui­ci­dal patients with bor­der­line per­son­al­ity dis­or­der (BPD) that was based on M. Linehan’s (see record 1993–97864-000) Dialectical-Behavioral Ther­apy for Bor­der­line Per­son­al­ity Dis­or­der (DBT). Ss were 24 female patients (aged 17.4 to 44.4 yrs) with BPD who had com­mit­ted at least 2 para­sui­cide acts (PAs; con­sciously intended, resul­tant phys­i­cal injury) and/or 1 sui­cide attempt within the past 2 yrs. The pro­gram con­sisted of a 3-mo inpa­tient treat­ment prior to long-term out­pa­tient ther­apy. Ss were com­pared at admis­sion to the hos­pi­tal, and at 1 mo after dis­charge on a vari­ety of instru­ments. Specif­i­cally, the authors wanted to deter­mine if there was a reduc­tion of the num­ber of PAs and an improve­ment in emo­tion reg­u­la­tion and gen­eral indices of psy­chopathol­ogy pre– ver­sus post­treat­ment. The results indi­cate sig­nif­i­cant improve­ments in rat­ings of depres­sion, dis­so­ci­a­tion, anx­i­ety and global stress between assess­ments. Fur­ther, a highly sig­nif­i­cant decrease in the num­ber of PAs is also reported. The authors state that inpa­tient DBT focuses upon self-injuries as high-ranking prob­lem areas and works con­tin­u­ously towards devel­op­ing skills for dis­tress tol­er­ance and emo­tion regulation.
4) Bar­ley, W.D., Buie, S.E., Peter­son, E.W., Hollingsworth, A.S., Griva, M., Hick­er­son, S.C., Law­son, J.E., Bai­ley, B.J. (1993). The devel­op­ment of an inpa­tient cognitive-behavioral treat­ment pro­gram for bor­der­line per­son­al­ity dis­or­der. Jour­nal of Per­son­al­ity Dis­or­ders, 7(3), 232–240.
Describes an inpa­tient treat­ment pro­gram for bor­der­line per­son­al­ity dis­or­der that evolved from a purely psy­cho­dy­namic to a more cognitive-behavioral treat­ment approach empha­siz­ing M. M. Linehan’s (1993) dialec­ti­cal behav­ior ther­apy (DBT). Inpa­tient DBT immerses bor­der­line patients in a cul­ture of sup­port for their attempts to skill­fully solve prob­lems with emo­tion reg­u­la­tion and related dys­func­tions. Data are pre­sented that sug­gest that this approach is asso­ci­ated with decreased rates of para­sui­cide on the inpa­tient unit.
5) Stan­ley, B., Ivanoff, A., Brod­sky, B, Oppen­heim, S. (Novem­ber, 1998). Com­par­i­son of DBT and “treat­ment as usual” in sui­ci­dal and self-mutilating behavior.
Paper pre­sented at the 32nd annual con­ven­tion of the Asso­ci­a­tion for the Advance­ment of Behav­ior Ther­apy. Wash­ing­ton, D.C.
6a) McCann, R.A., Ball, E.M., Ivanoff, A. (2000). DBT with an Inpa­tient Foren­sic Pop­u­la­tion: The CMHIP Foren­sic model. Cog­ni­tive and Behav­ioral Prac­tice, 7, 447–456. 
Imple­men­ta­tion of DBT in a foren­sic or crim­i­nal jus­tice set­ting dif­fers dra­mat­i­cally from stan­dard out­pa­tient DBT. Foren­sic patients are mul­ti­prob­lem patients with vio­lent his­to­ries and mul­ti­ple diag­noses includ­ing bor­der­line per­son­al­ity, anti­so­cial per­son­al­ity dis­or­der, and con­comi­tant Axis I psy­chotic or mood dis­or­ders. DBT was selected for this pop­u­la­tion because of its empha­sis on treat­ing life-threatening behav­iors of patients and therapy-interfering behav­iors of both patients and staff. The foren­sic inpa­tient DBT model described here includes mod­i­fi­ca­tion of agree­ments, tar­gets, skills train­ing groups, and dialec­ti­cal dilem­mas. An addi­tional skills mod­ule, the Crime Review, was devel­oped to sup­ple­ment stan­dard DBT. Con­clu­sions and rec­om­men­da­tions for apply­ing DBT in a foren­sic set­ting are presented.
6b) McCann, R.A., Ball E.M. (2000). The effec­tive­ness of DBT with Foren­sic Inpa­tients. Insti­tute for Foren­sic Psychiatry.
The objec­tive of the study was to deter­mine the effec­tive­ness of DBT with 21 pri­mar­ily male foren­sic inpa­tients. The 21 DBT patients wre com­pared with 14 Treat­ment as Usual patients over a 20 month period. Pre­lim­i­nary analy­ses sug­gested that DBT patients’ depressed or hos­tile mood, para­noia, and psy­chotic symp­toms sig­nif­i­cantly decreased between Novem­ber 1994 and July 1996. Sim­i­larly DBT patients sig­nif­i­cantly decreased sev­eral mal­adap­tive inter­per­sonal cop­ing styles and increased an adap­tive cop­ing strat­egy. TAU patients did not change sig­nif­i­cantly on these measures.
7) Beck­stead, J., Lam­bert, M.J., DuBose, Anthony P., and Line­han, M. (2015). DBT with Amer­i­can Indian/Alaska Native ado­les­cents diag­nosed with sub­stance use dis­or­ders: Com­bin­ing an evi­dence based treat­ment with cul­tural, tra­di­tional, and spir­i­tual beliefs
This pilot study exam­ined pre to post-change of patients in a sub­stance use res­i­den­tial treat­ment cen­ter that incor­po­rated Dialec­ti­cal Behav­ior Ther­apy with spe­cific cul­tural, tra­di­tional and spir­i­tual prac­tices for Amer­i­can Indian/Alaska Native ado­les­cents. Specif­i­cally, the incor­po­ra­tion of cul­tural, spir­i­tual and tra­di­tional prac­tices was done while still main­tain­ing fidelity to the evi­dence based treat­ment (DBT). 229 ado­les­cents par­tic­i­pated in the study and were given the Youth Out­come Questionnaire-Self-Report ver­sion at pre-treatment and post-treatment and the total scores were com­pared. The results of the research study showed that 96% of ado­les­cents were either “recov­ered” or “improved” using clin­i­cal sig­nif­i­cant change cri­te­ria. Addi­tion­ally, dif­fer­ences between the group’s pre-test scores and post-test scores were sta­tis­ti­cally sig­nif­i­cant using a matched stan­dard T-test com­par­i­son. Finally, the effect size that was cal­cu­lated using Cohen’s cri­te­ria was found to be large. The results are dis­cussed in terms of the impli­ca­tion for inte­grat­ing west­ern and tra­di­tional based meth­ods of care in address­ing sub­stance use dis­or­ders and other men­tal health dis­or­ders with Amer­i­can Indian/Alaska Native adolescents.

Other Arti­cles on Dialec­ti­cal Behav­ior Ther­apy and Bor­der­line Per­son­al­ity Disorder

Lieb, K., Zanarini, M., Schmahl, C., Line­han, M., Bohus, M Bor­der­line Pers. Dis.pdf
Swen­son, C.R., Sander­son, C., Dulit, R.A., Line­han, M.M. (2001). The appli­ca­tion of dialec­ti­cal behav­ior ther­apy for patients with bor­der­line per­son­al­ity dis­or­der on inpa­tient units. Psy­chi­atric Quar­terly, 72(4), 307–324.
Notes that inpa­tient treat­ment of indi­vid­u­als with bor­der­line per­son­al­ity dis­or­der (BPD) is typ­i­cally fraught with dif­fi­culty and fail­ure. Patients and staff often become entan­gled in intense neg­a­tive ther­a­peu­tic spi­rals that oblit­er­ate the poten­tial for focused, real­is­tic, and effec­tive treat­ment inter­ven­tions. The authors describe an inpa­tient treat­ment approach to BPD patients which is an appli­ca­tion of Dialec­ti­cal Behav­ior Ther­apy (DBT), a cognitive-behavioral ther­apy for patients with BPD which has been shown to be effec­tive in reduc­ing sui­ci­dal behav­ior, hos­pi­tal­iza­tion, and treat­ment dropout and improv­ing inter­per­sonal func­tion­ing and anger man­age­ment. The inpa­tient DBT staff cre­ates a val­i­dat­ing treat­ment milieu and focuses on ori­ent­ing and edu­cat­ing new patients and iden­ti­fy­ing and pri­or­i­tiz­ing their treat­ment tar­gets. Inpa­tient DBT treat­ment tech­niques include con­tin­gency man­age­ment pro­ce­dures, skills train­ing and coach­ing, behav­ioral analy­sis, struc­tured response pro­to­cols to sui­ci­dal and egre­gious behav­iors on the unit, and con­sul­ta­tion team meet­ings for DBT staff.

Dim­eff, L.A., Line­han, M.M. (2008) Dialec­ti­cal Behav­ior Ther­apy for Sub­stance Abusers. Addic­tion Sci­ence & Clin­i­cal Prac­tice. 40, 39–47.          DBT is a well-established treat­ment for indi­vid­u­als with mul­ti­ple and severe psy­choso­cial dis­or­ders, includ­ing those who are chron­i­cally sui­ci­dal. Because many such patients have sub­stance use dis­or­ders, the authors devel­oped DBT for Sub­stance Abusers, which incor­po­rates con­cepts and modal­i­ties designed to pro­mote absti­nence and to reduce the length and adverse impact of relapses. Among these are dialec­ti­cal absti­nence, clear mind, and attach­ment strate­gies that include off-site coun­sel­ing as well as active attempts to find patients who miss ses­sions. Sev­eral ran­dom­ized clin­i­cal tri­als have found that DBT for Sub­stance Abusers decreased sub­stance abuse in patients with bor­der­line per­son­al­ity dis­or­der. The treat­ment also may be help­ful for patients who have other sever dis­or­ders co-occurring with SUDs or who have not responded to other evidence-based SUD therapies.

4). Granato, Hol­lie F., Wilks, C.R., Miga, Erin M., Korslund, K.E., and Line­han M.M. (2015) The Use of Dialec­ti­cal Behav­ior Ther­apy and Pro­longed Expo­sure to Treat Comor­bid Dis­so­ci­a­tion and Self-Harm: The Case of a Client With Bor­der­line Per­son­al­ity Dis­or­der and Post­trau­matic Stress Dis­or­der.
There is a high rate of comor­bid­ity between bor­der­line per­son­al­ity dis­or­der (BPD) and post­trau­matic stress dis­or­der (PTSD; Pagura et al., 2010). Pre­lim­i­nary stud­ies have eval­u­ated the treat­ment of PTSD in a BPD pop­u­la­tion and found pos­i­tive out­comes for the inte­gra­tion of dialec­ti­cal behav­ior ther­apy (DBT) and pro­longed expo­sure (PE). This case study illus­trates the imple­men­ta­tion of a PE pro­to­col into stan­dard DBT treat­ment, specif­i­cally focus­ing on the man­age­ment of self-harm and severe dis­so­ci­a­tion for a client with co-occurring PTSD and BPD. The client entered into treat­ment with severe and per­sis­tent dis­so­ci­a­tion and a recent his­tory of self-harm, and the case includes con­sid­er­a­tion of two sep­a­rate pauses in PTSD treat­ment related to ele­vated dis­so­ci­a­tion and self-harm behav­iors. The client suc­cess­fully com­pleted the DBT PE pro­to­col and results indi­cate sig­nif­i­cant improve­ments in PTSD symp­toms as well as out­comes related to self-harm and dis­so­ci­a­tion. These find­ings demon­strate the effi­cacy of com­bin­ing DBT with PE for clients with comor­bid BPD and PTSD and exem­plify how com­plex clients with BPD who present with severe dis­so­ci­a­tion and self-harm behav­ior can safely and suc­cess­fully receive treat­ment for PTSD

Other Research Topics

The Video Cod­ing Sys­tem by James Long Com­pany is the obser­va­tional cod­ing method used in our research