Overview of dialectical behavior therapy
Dialectical behavior therapy combines change strategies from cognitive and behavioral therapies with acceptance strategies adapted from Zen teaching and practice; it is a synthesis of both validation and acceptance of the patient, on the one hand, with persistent attention to behavioral change on the other. The change procedures consist of systematic and repeated behavioral analyses of dysfunctional response chains, training in behavioral skills, contingency management to weaken or suppress disordered responses and strengthen skillful responses, cognitive restructuring, and exposure-based strategies aimed at blocking avoidance and reducing maladaptive emotions. The acceptance procedures consist of mindfulness (
eg, attention to the present moment, assuming a nonjudgmental stance, and focusing on effectiveness) and a variety of validation and stylistic strategies [
6]. In its standard form, the treatment is provided in once-weekly individual psychotherapy and group skills training sessions, skills coaching phone calls with the primary therapist (when needed), and weekly team meetings of all DBT therapists aimed at reducing therapist burn-out and increasing therapists’ adherence to the treatment model and competence in treating these patients. Individual sessions are based on clearly prioritized targets and focus on reducing maladaptive response patterns (life threatening behaviors, behavioral patterns that interfere with or threaten therapy, severe Axis I disorders, and patterns that preclude a reasonable quality of life) and enhancing motivation for skillful behaviors. The foci of specific sessions are determined by the patient’s behavior and problems since the previous session. Skills training is psychoeducational and teaches mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self-management skills.
Data on this standard model indicate that DBT is more effective than treatment-as-usual (TAU) in the community in terms of reductions in parasuicidal behavior, completion of treatment, and fewer inpatient hospital days [
7]. Since this first controlled trial, recent replication studies of standard DBT to treat BPD, as well as research with adaptations of the standard model, have been conducted. These are summarized below and outlined in Table 1.
Treatment of antisocial behaviors
Dialectical behavior therapy has also been applied in forensic settings. The appeal of DBT for this population can be attributed to its focus on life-threatening behaviors (both suicidal and homicidal), its focus on behaviors that interfere with a treatment program, or with a therapist’s motivation and willingness to treat a patient, and the high prevalence of personality disorders, especially antisocial personality disorder and BPD, within this population [
13,
14]. McCann
et al. [
14] adapted DBT for forensic inpatient units with a violent and severely mentally ill population. Their modifications to the standard DBT protocol include the following: expansion of the category of life-threatening behaviors to include those specifically related to homicide and interpersonal violence, specific attention to the reinforcement of honest recording of maladaptive behaviors, testing skills acquisition with exams and role-play quizzes, targeting emotional insensitivity of antisocial patients, and inclusion of a “graduate” level skills group following a standard completion of DBT skills training. This graduate level group entitled
DBT Graduates’ Crime Group is designed to increase empathy for victims and prevent relapse of violent behavior. What is perhaps most unusual about these modifications is that the inpatients with antisocial personality disorder themselves contributed most to the modifications.
A 20-month nonrandomized pilot study was conducted with 35 patients comparing the modified DBT with TAU within the forensic inpatient ward. Approximately 50% of the patients met full criteria for BPD, the other 50% each had at least three BPD symptoms. In addition, one third of the participants met criteria for antisocial personality disorder. Twenty-one of the patients received DBT and 14 received TAU. As compared with TAU, the DBT group had significantly decreased levels of maladaptive coping and significantly increased levels of adaptive coping over the 20-month period. Moreover, the DBT group showed a trend toward significant decreases in depression, hostility, paranoia, and psychotic behaviors. This study highlights the potential utility of the use of DBT with a broader spectrum of personality-disordered individuals as well as its utility in more diverse settings, such as a forensic inpatient ward.
Similarly, Trupin
et al. [
15] have used DBT in the treatment of incarcerated female juvenile offenders. Participants had an average of six prior offenses. Information on the prevalence of personality disorders was not reported. DBT was implemented in two mental health cottages at a juvenile detention center. The staff on one DBT mental health cottage (DBT1) received extensive DBT training (80 hours), whereas staff in the other mental health cottage (DBT2) received an abbreviated training of 16 hours. The two cottages were also significantly different at the beginning of the study; residents of the DBT1 cottage exhibited more severe mood and thought disturbances as well as a higher frequency of parasuicide episodes. Key modifications to standard DBT included the addition of a self-management module to skills training, specifying “unit-destructive behaviors” and targeting them after life-threatening behaviors, and focusing special attention on offense related behaviors. Over the 10-month study duration, juveniles in the DBT1 cottage had a significant reduction in problem behaviors whereas no significant changes were found in the DBT2 cottage. In addition, staff in the DBT2 cottage actually showed a significant increase in punitive actions toward the adolescent girls over the course of the study, a result not found in the DBT1 cottage. Although the mixed results of this quasi-experimental study are difficult to interpret unambiguously, they highlight the need for further research on the issue of training in DBT.
Is the use of dialectical behavior therapy in the community ahead of its time?
Both Scheel [
16•] and Westen [
17] have suggested that DBT has been disseminated into the community more widely and faster than empiric support warrants. The rapid spread of DBT certainly cannot be accounted for solely by the few studies showing treatment efficacy. Swenson [
18•] articulates reasons why this may have occurred. For one, DBT is used to treat a population of individuals with severe pain and dyscontrol. Thus, any treatment that appears effective, as well as cost-effective, is accepted wholeheartedly. Second, Swenson [
18•] argues that DBT addresses the issue of therapist support. Clinicians who deal with BPD patients experience significant stress and a therapy that includes a therapist consultation group as a mandatory component is incredibly appealing. Third, quite simply, there is a lack of other options available to practitioners dealing with BPD patients. Since the first controlled trial of DBT [
7], only one other randomized trial of a psychosocial treatment for BPD has been published [
19]. Bateman
et al. [
19] have developed an 18-month, partial hospitalization treatment program, based on object-relations theory, and demonstrated efficacy in a randomized trial comparing it to a community control condition consisting of a community treatment that prohibited individual therapy but provided all other community supports. The widespread attention to DBT is due in part to the scarcity of other cost-effective, efficacious treatments available to clinicians dealing with highly difficult-to-treat populations.
Any new treatment shown efficacious in clinical trials must stand up to rigorous examination of grounds for empiric support. With respect to DBT, it is particularly important to ask whether findings to date demonstrating DBTs efficacy might be due to several non-DBT specific factors such as allegiance factors, the provision of stable individual therapy, rather than DBT per se, the high amount of structure provided, and the training involved in behavioral treatment, in general, and DBT, in particular. Each of these will be addressed in turn.
Is DBT only effective implemented at the University of Washington or by Linehan [
1–3]? Replication by other investigators is, of course, of the essence in science. As illustrated in this paper as well as other reviews [
4,
5], Linehan’s findings have been replicated by other research groups. The high risk of the patient population and length of treatment that must be offered together with the time needed for researchers to be trained in a new treatment technique has limited the speed of replications. Interestingly, an argument against Linehan’s results being due simply to allegiance can be found in her own research. In an earlier study described in the DBT treatment manual [
2], Linehan
et al. tested their hypothesis that adding DBT skills training to stable, individual therapy in the community would greatly enhance the outcomes of those treatments. Linehan was one of the principle skills trainers in the study. Results did not support the hypothesis, at least as tested by Linehan, suggesting that allegiance may not be sufficient by itself to produce positive outcomes with highly suicidal BPD patients.
If DBT is efficacious, why is it so? Is it simply that DBT is particularly good at insuring that patients receive stable, individual therapy of any sort? Although stability in the treatment of BPD is not to be underrated, a few studies have tentatively discounted this claim. Koons
et al. [
8] provided individual therapy to all participants in their study and still found favorable results for DBT. In the Linehan
et al. [
7] study, not only did patients assigned to DBT and TAU have equivalent number of therapeutic hours, but the number of treatment hours received did not predict outcome. Similarly, one could argue that DBT is effective because it provides a highly structured and stable environment for disordered individuals. This is a reasonable hypothesis; however, even inpatient settings such as described in the Trupin
et al. [
15] and McCann
et al. [
13,
14] studies, which theoretically have a lot of structure for all individuals, found some support for DBT. More research is needed to test this hypothesis further by comparing DBT with a more tightly controlled alternative treatment with a similar amount of structure and stability.
Finally, it can be argued that positive results have been found for DBT because, as opposed to TAU in the community, DBT clinicians have had superior training and supervision. Again, this is a reasonable hypothesis that cannot be discounted. In fact, one major feature that distinguishes between treatment research conducted within academia and TAU in nonacademic settings is training of therapists and monitoring of the treatment delivered. However, to discount DBT for this reason is to discount most psychosocial treatments that have been shown to be effective for a whole host of mental disorders. Perhaps what needs to occur is not the “naturalizing” of DBT but the improvement of training, supervision and monitoring in community therapeutic settings.
Conclusions
Interest in DBT has peaked in recent years despite only relatively few studies providing empiric support for its superiority to other forms of treatment. In this paper, we have provided information on seven research studies. Although the level of empiric support for DBT is still inadequate, each of these studies offers some further support for DBT as a efficacious treatment for personality disorders, specifically BPD and antisocial characteristics. Many of these treatments used adaptations of DBT, which further illustrates its generalizability across settings and populations. Although these studies all provide support for the idea that DBT is effective, we have yet to learn why DBT works. The next generation of research studies must address this question. DBT is a compilation of current behavioral treatments combined with extensive validation and acceptance of the patient packaged within a format that provides clear guidelines and expectations, structure and support for both patients and treatment providers. Although the guiding premise has been that both explicit behavioral change strategies and equally explicit acceptance strategies are both equally important in the treatment, this is an empirical question yet to be answered. It is also unclear whether the DBT skills training component is essential to efficacy. DBT is defined as a community of therapists treating a community of patients. The guidelines for how the treatment team members are to interact with each other forms a part of the treatment itself. Is the focus on the community of therapists and the requirement of team application of the treatment really essential? Are the proscribed guidelines an important component of treatment effectiveness? Common sense suggests that a treatment program that reduces the sense of burnout of therapists, provides emotional support and consultation to increase competence, and rigorously requires a compassionate and nonjudgmental attitude among the treatment providers would enhance efficacy. Treatment providers regularly report that this is the case. As is always the case with new treatments and new lines of research, many more studies are needed.