Introduction to a Special Issue Dialectical Behavior Therapy: Evolution and Adaptations in the 21^st Century

Dialectical behavior therapy (DBT) was born in 1991 when Linehan and her colleagues published the results of their first randomized controlled trial demonstrating the treatment’s efficacy in reducing suicidal behaviors and improving other outcomes among adult women diagnosed with borderline personality disorder (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). This was the first empirically supported treatment for this population. In 1993, Linehan published her DBT treatment manual and skills-training manuals, which were used in her 1991 outcome study (1993a; 1993b). The immediate impact of these works was profound, and led to the development of numerous adaptations, which were first highlighted in a special section that I co-edited with Jill Rathus 15 years ago (Miller & Rathus, 2000). The adaptations described at the time included DBT for use with adolescents, domestic violence, forensic settings, substance abuse, and the treatment of elderly individuals with depression and personality disorders (Miller & Rathus, 2000).

During the past 25 years and after the publication of in excess of 20 randomized trials conducted by more than 12 independent investigators, DBT has become the gold-standard treatment for individuals who are suicidal and diagnosed with borderline personality disorder. This treatment continues to capture the attention of researchers, clinicians, and consumers alike, largely due to backing by sound research, and because it is a multimodal, principle-based treatment that conceptualizes emotional dysregulation based upon the biosocial theory (Linehan, 1993a) that engenders compassion among clinicians and others in the clients’ environments.

In this current special issue, we begin with a historical review of DBT provided by the treatment developer herself, and we introduce readers to new adaptations developed in the 21^st century. In the first article entitled “The Course and Evolution of DBT,” the authors describe how DBT was developed through trial and error to apply standard behavior therapy to highly suicidal individuals. They go on to further recount how the treatment modularity and hierarchical structure has allowed for easy adaptation and application to novel populations and settings. Linehan’s new skills manual (Linehan, 2015) was developed in large part due to the varied clinical needs of existing and novel clinical populations receiving DBT. Linehan and Wilks highlight some future directions where DBT may continue to evolve, including for use in schools (Mazza, Mazza, Miller, Rathus, & Murphy, in press).

One of the major areas of adaptation within the field of DBT has been with adolescents who are suicidal (Miller, Rathus, & Linehan, 2007; Rathus & Miller, 2002; Rathus & Miller, 2015). After 20 years of promising research by numerous investigators, Mehlum and colleagues (2014) recently published the first randomized, controlled trial of DBT with suicidal and self-harming adolescents. This special section contains three articles highlighting clinical adaptations of DBT for youth. In their article, “Treatment acceptability study of walking the middle path, a new DBT skills module for adolescents and their families,” Rathus, Campbell, Miller & Smith provide a description and empirical evaluation of this uniquely developed skills module for teens. Teens and families genuinely find these new skills helpful.

In a related paper evaluating dialectical dilemmas, otherwise known as polarizing behavioral patterns that can arise in family systems, German, Smith, Rivera-Morales, Gonzalez, Haaz and Miller employ a mixed-methods analysis to study these patterns among suicidal Latina adolescents and their mothers. Corollaries of previously identified adolescent–family dilemmas are created that appear useful when working with Hispanic families. Culturally informed secondary treatment targets are presented to help treat the identified problematic behavioral patterns of “old school vs. new school parenting” as well as “over-controlling vs. under-controlling parenting.”

Fasulo, Ball, Jerkovic, and Miller, apply and adapt a DBT-informed, trauma-focused treatment for male adolescents who are incarcerated in juvenile justice settings. Not surprisingly, while the DBT principles are the same regardless of gender, age, ethnicity, and diagnosis, the emphasis on acceptance-oriented strategies, including rapport, radical genuiness, and validation, is critical to the engagement of these young men. This paper includes clinical vignettes that bring to life the exciting work conducted by the first two authors.

Ritschel, Lim and Stewart (2015) present their paper describing the transdiagnostic applications of DBT for adolescents and adults. They highlight that beyond the treatment of borderline personality disorder and suicidal behavior, DBT has been shown to be effective for those with substance use disorders, eating disorders, PTSD, as well as adolescents (as highlighted in the earlier papers). Clinicians will find this paper useful in considering how the adaptations work across diagnostic groups, ages, and settings.

Some of the leading experts in the treatment of eating disorders, Wisniewski and Ben-Porath, present a paper not only reviewing the application of DBT to eating disorders but also suggesting a novel use of contingency management procedures to manage dialectical dilemmas in this population. Specifically, the authors describe the highly problematic dilemma of apparent compliance vs. active defiance and how to treat it effectively.

Lynch, Hempel, and Dunkley present a unique application of DBT to those with disorders of over control named “Radically Open DBT”. Such disorders include anorexia nervosa, chronic depression, and obsessive compulsive personality disorder. Persons who suffer from over control often experience social isolation, cognitive rigidity, risk aversion, and inhibited emotional expression. In contrast to targeting emotional dysregulation, this treatment targets over control. The paper highlights the commonalities and differences from standard DBT.

Finally, Swenson and Choi-Kahn compare aspects of DBT with another evidence-based treatment for BPD, called mentalization-based treatment (MBT; Bateman and Fonagy, 1999; 2001). MBT treatment developers suggest mentalizing is the crucial ingredient in secure attachment and is thus the focus of their treatment since individuals with BPD are thought to be poor at mentalizing their own states, others’ states, and the relational state. The authors, a DBT and an MBT expert, examine whether or not mentalizing is already present in DBT practice, whether it would be compatible with DBT conceptually and practically, and whether a focus on mentalizing would be of use to DBT therapists and their patients.

I hope this special issue informs the AJP readership about the evolution and adaptations of DBT in the 21^st century and further stimulates clinical research and practice of this treatment.