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DBT

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This page contains information and summaries of published research that are intended for people with professional training in mental health. We urge caution since it may be difficult to know how to interpret the information without advanced training in psychology or psychiatry.

We recommend that readers interested in information intended for the general public check other areas of this web site (such as Info for Adults or Info for Children). They contain similar information, but in a more readable form. Also, elsewhere we have provided links to other websites that we feel may be helpful.

The following outline on DBT and BPD is from a presentation by Dr. Lilly in 2001. The contents of the outline draw a great deal from Linehan's book on DBT and from an excellent article by Scheel in Clinical Psychology: Science and Practice. We highly recommend these resources for information on DBT, including an outline of the treatment and a scholarly summary of the limited empirical base that supports it. We have omitted the section of the outline that summarizes the treatment priorities and process for DBT since we feel Linehan's book provides a much better resource.

	Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York : The Guilford Press.
	Scheel, K.R. (2000). “The empirical basis of dialectical behavior therapy: Summary, critique, and implications. Clinical Psychology: Science and Practice, 7, 68-86.

Please note that Sonnet Psychological, LLC does not accept referrals for DBT. We have a small, two psychologist practice that specializes in treatment for anxiety and autism. Since DBT requires considerable resources, availability, and consultation we recommend people seeking this treatment contact other practitioners belonging to agencies, hospitals, or larger practices who are able to better accommodate the systemic requirements of this treatment approach.

A LOOK AT DIALECTICAL BEHAVIOR THERAPY (DBT):

RESEARCH, THEORY, AND ALTERNATIVES IN THE TREATMENT OF BORDERLINE PERSONALITY DISORDER

September 27, 2001

Central Maine Psychological Society

David C. Lilly, Psy.D.

DIAGNOSTIC CRITERIA FOR BORDERLINE PERSONALITY DISORDER (BPD)

DSM-IV diagnostic criteria are based on an “eclectic-descriptive” approach, derived from characteristics defined by consensus (Linehan, 1993):

BORDERLINE PERSONALITY DISORDER (American Psychiatric Association, 1994)

(Inclusion: At least 5 criteria)

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by at least five of the following:

(1) Frantic efforts to avoid real or imagined abandonment. (Do not include suicidal or self-mutilating behavior covered in criterion 5).

(2) A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

(3) Identity disturbance: markedly and persistently unstable self-image or sense of self.

(4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) Note: Do not include self-mutilating or suicidal behavior listed in (5).

(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

(6) Affective instability due to a marked reactivity of mood (e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

(7) Chronic feelings of emptiness.

(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

(9) Transient, stress-related paranoid ideation or severe dissociative symptoms.

BPD: PREVELANCE AND ASSOCIATED FEATURES

Prevalence of BPD is estimated at 0.2 – 1.8% in the general population, 8-11% of mental health outpatients, and 14-20% of inpatients (Linehan, 2000)

q BPD characteristics decrease in severity and prevalence into middle age (Linehan, 1993)

People who meet criteria for BPD comprise 40% of the very highest utilizers of psychiatric hospitals. 50% of patients report misusing their medications, and high drop out rate from therapy are considered to be common (Linehan, 2000)

One of the most significant features associated with the BPD diagnosis is suicide risk:

q from 7-38% of all individuals who commit suicide meet BPD criteria, and approximately 9% of BPD patients eventually commit suicide. The rates double when only those with a history of parasuicide are included (Linehan, 2000).

q One study followed BPD inpatients from 10-23 years after discharge. Patients exhibiting all eight DSM-III criteria for BPD at the index admission had a suicide rate of 36%, compared to a rate of 7% for individuals who met five to seven criteria. The study also showed that participants with a history of parasuicide had suicide rates that were double the rates of individuals without previous parasuicide (Stone, 1989 cited in Linehan, 1993).

No therapeutic approach, including hospitalization, has been proven to reduce suicide rates (Linehan, 1997a cited in Scheel, 2000)

60-80% of people given a diagnosis of BPD engage in parasuicidal behavior (Linehan, 2000)

q Approximately 75% of instances of self-injurious behavior involve people between the ages of 18 and 45 (Greer & Lee, 1967; Paerregaard, 1975; Tuckman & Youngman, 1968. Cited in Linehan, 1993)

q “Self-mutilative behaviors (usually wrist cutting and burning), especially in the absence of a history of suicidal acts, predict very low suicide risk. In fact, in Stone’s study, there were no suicides in this category. McGlashan (1986), too, found that self-mutilative behaviors correlate negatively with suicide.” (Kroll, 1993. p. 27)

q A recent study ( Stanley , 2001 cited in Clinician’s Research Digest, Aug. 2001) found that people with Cluster B disorders who self mutilate may not make more attempts or more lethal attempts, but also noted that they may tend to underestimate the lethality of their attempts and have more persistent suicidal urges.

q However, there is also research indicating that self-mutilation correlates with a significantly higher rate of suicide.

Over the past few years some excellent information on categorizing and managing suicide risk has been published by Rudd and Joiner. Although the information has not focused on suicide risk in BPD, the topic seemed important enough to warrant mention of the following resources:

Joiner, T.E., Walker, R.L., Rudd, M.D., Joves, D.A. (1999). “Scientizing and routinizing the assessment of suicidality in outpatient practice.” Professional Psychology: Research and Practice, 30, 447-453.

Rudd, M.D. & Joiner, T. (1998). “The assessment, management, and treatment of suicidality: Toward clinically informed and balanced standards of care.” Clinical Psychology: Science and Practice, 5, 135-150.

Rudd, D.R., Joiner, T., Rajab, M.H. (2001). Treating Suicidal Behavior: An Effective, Time-Limited Approach. New York : The Guilford Press.

OUTCOME RESEARCH ON TREATMENTS FOR

BORDERLINE PERSONALITY DISORDER

“The high prevalence of [borderline personality disorder], together with poor outcomes in traditional treatments, low compliance with treatment, high hospitalization rates, and serious suicide risk, suggests that any new treatment with even marginal data on empirical validity would be greeted with enthusiasm by the clinical community. Dialectical behavior therapy (DBT) is such a treatment. . . [T]he extent of the treatment’s efficacy, the mechanisms of efficacy, and the degree to which the treatment should be adopted in community mental health are not clear” (Linehan, 2000).

“[T]he treatment is first and foremost a variation of standard, clinical behavior therapy.” The incorporation of Zen and mindfulness along with Western dialectical methods “was necessitated by my own failure to get DBT patients to stay in therapy and to collaborate with the therapist” (Linehan, 2000).

(Scheel’s (2000) article “The empirical basis of dialectical behavior therapy: Summary, critique, and implications” in Clinical Psychology: Science and Practice is highly recommended as a thorough and scholarly overview of DBT research.)

What’s Available in Terms of Empirical Research on BPD?

q The Division 12 Taskforce on Psychological Interventions cites DBT as the only treatment for Borderline Personality Disorder that it considered “probably efficacious.” It categorized no treatments as “well-established” (Chamberless et al., 1998.)

q There is only one adequately controlled outcome study (with a one year follow up) that has been published since the treatment was introduced over a decade ago. There have been a multitude of articles published discussing DBT, as well as Linehan’s book and companion workbook. The Behavioral Technology Transfer Group also provides a number of workshops each year. (Scheel, 2000)

o Weston (2000) notes that there is approximately a 20:1 ratio of theoretical and clinical papers to empirical studies that have been published on DBT

q There are two other controlled studies of inpatient adaptations of DBT, as well as one small process-based study. A dismantling study of DBT has been conducted but has not been published (Scheel, 2000). These studies will be briefly summarized towards the end of this section.

LINEHAN’S 1991 STUDY:

The conditions being compared in the only RCT on DBT (Linehan’s 1991 study) were clients receiving DBT at the University of Washington vs. clients who were referred out to seek treatment in the community. The following chart summarizes Scheel’s (2000) review of the groups being compared:

	DBT	“Treatment as Usual” Control Condition
Treatment Offered	DBT individual and group therapy	A mix. 27% received no treatment at all. Only 9 of 22 received stable therapy during the year the study took place. They received significantly fewer hours of individual and group therapy and significantly more day treatment.
Providers	Doctoral level providers, most of whom were on the research team.	Varying. Of the nine who received individual therapy practitioners included five psychiatrists, eight masters level professionals, and two people of no or unknown training
Charged for Therapy?	No charge	Required to pay for therapy; Reported that most were able to seek treatment only at settings accepting “low-fee clients.”

Based on this information, it appears that there were a number of significant variables that were not controlled. While the results for DBT (described below) look promising, it is important to note that the only available study begs the question of whether some of DBT’s effects may have been due to differences aside from treatments being compared, such as (Scheel, 2000):

	highly skilled, trained, motivated, and supervised doctoral-level therapists at a leading training site being compared to non-selected therapists in the community
	free therapy compared to paying for therapy
	therapy at a prominent research hospital compared therapy at low fee facilities
	Linehan’s involvement as trainer, therapist, and direct supervisor in practically all the research to date raises the possibility of inadvertent experimenter bias or of Linehan’s capabilities as a therapist/supervisor being the variable that accounts for outcomes, rather than the DBT protocol.

Sheel also cautions: “With the exception of reduced parasuicide, all positive published findings are from a single study, and as Linehan (1993a) has stated, ‘one study is a very slim basis for deciding that a treatment is effective’ (p.24).”

	all positive published findings except parasuicide are based on no more than 23 DBT subjects, including dropouts
	client retention and first year hospitalization findings aside, all other remaining positive findings are based on 13 or few subjects, and in some cases on 7 or fewer subjects

There are other characteristics about DBT that also may contribute to non-equivalence between the DBT therapists in this study and the therapists in the community. An important element of DBT is the regular use of consultation and peer supervision for therapists to maintain motivation and avoid engaging in iatrogenic behaviors in therapy. While some have argued that supervision and consultation could be considered a confound, Linehan’s descriptions of DBT have been explicit that this resource for therapists is a central part of DBT.

Outcomes at the End of the One-Year Trial (Scheel, 2000):

	DBT Results
Stayed in Therapy	More likely to begin therapy and maintain therapy with same therapist over the course of a year
# of Inpatient Days	Fewer, even in comparison to TAU clients who received stable inpatient therapy
Parasuicidal Behavior	o Less frequent even when DBT Ss were compared to TAU Ss that stayed in Tx o No difference in medical risk when DBT Ss compared with TAU Ss o After controlling for therapy hours, indication that DBT approach to phone contacts reduces parasuicidal behavior frequency
Suicidal Ideation	DBT not superior to TAU
Depression	DBT not superior to TAU
Hopelessness	DBT not superior to TAU
Survival and Coping based Reasons for Living	DBT not superior to TAU
# receiving Rx	DBT not superior to TAU
Therapist rated Global Functioning	DBT superior
Therapist rated Social Adjustment	DBT superior
Client Rated Trait Anger	DBT superior

As noted above, the strongest finding from the available research is that DBT is associated with reduced incidence of parasuicidal behavior in women with BPD.

To date, studies have not been published comparing DBT to another organized therapy protocol. However, one such study is being undertaken at present (see below).

Another potential methodological issue is that the large number of independent variables may result in a high risk of Type I errors (Scheel, 2000)

Follow Up at 6 Months and 12 Months After the 1 Year Treatment Trial (Scheel, 2000)

	DBT
Parasuicidal Behavior	6 months: DBT superior 12 months: no difference (low for both DBT and TAU groups)
Inpatient Days	6 months: No difference 12 months: DBT superior (low number for both groups)
Global Functioning	6 months: DBT superior 12 months: DBT superior
Anger	6 months: DBT superior 12 months: No difference
Social Adjustment	6 months: No difference 12 months: DBT superior
Work Performance	6 months: No difference 12 months: No difference
Anxious Rumination	6 months: No difference 12 months: No difference

Researchers also compared outcome for DBT subjects who had continued with DBT with those who did not. Scheel (2000) reports that “Little evidence was found for the superiority of continued DBT, however, the small sample size greatly limited these analyses.” It is possible that a follow up study with greater statistical power might find significant effects.

At present, there are no follow up data available beyond the one year mark (Weston, 2000).

Other Studies on DBT

Unpublished Dismantling Study: (Scheel, 2000)

	Psychotherapy in the community vs. DBT skills training group (with no individual DBT component)
	Participants and community therapists thought that skills training was helpful, but there was no evidence of beneficial effect on any of the outcome variables
	Therefore, DBT skills training alone may not be an effective treatment (Linehan, 2000)

Study underway comparing DBT to treatment by peer-nominated experts in the community, who are provided with clinical supervision and provided treatment through an institution associated with excellence. Controlled for therapist pay and subjects fee for Tx (Koerner & Dimeff, 2000)

This study may be helpful in addressing one of the confounds in Linehan’s original study, that clients were referred out into the community rather than getting treatment from highly trained and supervised therapists at an institution with an impressive reputation

Adaptations of DBT

Inpatient Adaptations of DBT: (Scheel, 2000)

	some findings of reduced rates of parasuicidal behavior on an inpatient unit when modified DBT was introduced, compared with prior treatment on the same unit based on a psychodynamic model (Barley et al., 1993 cited in Scheel, 2000). Unfortunately, study is essentially uncontrolled.
	modified DBT (called “Creative Coping”) compared to “Wellness and Lifestyles” control treatment. Treatment duration was very brief, averaging only about six sessions. Important to note that experimental group was more depressed before starting treatment (Springer et al, 1996 cited in Scheel, 2000)

	No difference in depression, hopelessness, or suicidal ideation at the end of the study.
	Surprisingly, no difference in knowledge or attitudes taught in the modified DBT group, no reductions in anger, and no increases in internal locus of control.
	Positive trends favored the control group doing better than the modified DBT group.
	A significantly higher percentage of people in the DBT group engaged in parasuicidal behavior, indicating that this modification of DBT for short term use might not be appropriate

Linehan notes that the “Creative Coping” group was different from standard group skills training in DBT since discussion of self-mutilation and suicidality was allowed in a group setting. There is evidence that such discussions can result in a “contagion” of suicidal ideation (see Kay Redfield Jamison’s book, Night Falls Fast)

Modifications of DBT have also been tested on a preliminary basis for substance use reduction in women who meet criteria for BPD. Initial results have been encouraging, although the study appears to have suffered from many of the possible confounds present in Linehan’s 1991 research (Koerner & Dimeff, 2000)

As uncontrolled pilot study was completed for treatment of women meeting the DSM proposed criteria for Binge Eating Disorder. (Telch et al., 2000). Results were positive, indicating that better controlled research on this issue would be welcomed. The study that was completed consisted of:

	11 women, no control group
	20 two hour group sessions adapted from Linehan’s manuals for DBT
	Hypothesis that binge eating is an attempt at regulating negative affect

Other Treatments for BPD Being Studied in Controlled Trials

A psychoanalytic intervention based on an 18 month partial hospitalization program has been tested in England . Findings indicated that people who participated in the psychoanalytic treatment experienced greater improvement than treatment as usual in the community. (Bateman & Fonagy, 1999 & 2001)

	18 month follow up showed fewer incidence of self-mutilation, fewer suicide attempts, fewer days of inpatient treatment, lower anxiety and depression levels, higher proportion below clinical cutoff for depression, improved social and interpersonal functioning
	The treatment group got ongoing group Tx during follow-up, which was not offered to the control group. However, the control group actually consumed more professional mental health staff time through consultations and hospitalizations
	This study suffers from many of the same confounds as Linehan’s 1991 research, however.

The psychoanalytic treatment being used was abased on once weekly individual psychoanalytic treatment, 3x/wk groups, 1x/wk expressive therapy oriented towards psychodrama, and a weekly community meeting. All therapy was provided by psychiatric nurses. Participants in the control group received no formal psychotherapy beyond psychiatric review about 2x/month, medication, and inpatient admission when necessary.

A large randomized clinical trial comparing DBT with treatment based on Kernberg’s formulation for BPD is reportedly underway in Sweden (Linehan, 2000)

REFERENCES

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. (4^th ed.). Washington D.C. : Author.

American Psychological Association (2001). “Clinicians may underestimate the lethality of individuals who self-mutilate.” Clinician’s Research Digest, 19, 1.

Bateman, A.B. & Fonagy, P. (1999). “Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized control trial.” American Journal of Psychiatry, 156, 1563-1569.

Bateman, A.B. & Fonagy, P. (2001). “Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. American Journal of Psychiatry, 158, 36-42.

Chamberless, D.L., Baker, M.J., Baucom, D.H., Beutler, L.E., Calhoun, K.S., Crits-Christoph, P., Daiuto, A., DeRubeis, R., Detweiler, J., Haaga, D.A.F., Bennett Johnson, S., McCurry, S., Mueser, K.T., Pope, K.S., Sanderson, W.C., Shoham, V., Stickle, T., Williams, D.A., & Woody, S.R. (1998). “Update on empirically validated therapies II.” The Clinical Psychologist, 51, 3-21.

Koerner, K. & Dimeff, L.A. (2000). “Further data on dialectical behavior therapy.” Clinical Psychology: Science and Practice, 7: 102-112.

Kroll, J. (1993). PTSD/Borderlines in Therapy: Finding the Balance. New York : W.W. Norton & Company, Inc.

Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York : The Guilford Press.

Linehan, M.M. (2000). “The empirical basis of dialectical behavior therapy: Development of new treatments versus evaluation of existing treatments.” Clinical Psychology: Science and Practice, 7: 113-119.

Redfield Jamison, K. (1999). Night Falls Fast: Understanding suicide. New York : Alfred A. Knopf.

Rudd, D.R., Joiner, T., Rajab, M.H. (2001). Treating Suicidal Behavior: An Effective, Time-Limited Approach. New York : The Guilford Press.

Scheel, K.R. (2000). “The empirical basis of dialectical behavior therapy: Summary, critique, and implications. Clinical Psychology: Science and Practice, 7, 68-86.

Telch, C.F., Agras, W.S., & Linehan, M.M. (2000). “Group dialectical behavior therapy for binge-eating disorder: A preliminary, uncontrolled trial.” Behavior Therapy, 31, 569-582.

Weston, D. (2000). “The efficacy of dialectical behavior therapy for borderline personality disorder.” Clinical Psychology: Science and Practice, 7, 92-94.

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The information posted on this site reflects our understanding of peer-reviewed research and generally accepted principles in psychology. It is not intended to be used for self-treatment or as a substitute for individualized assessment and treatment by a licensed professional, and should not be construed as professional advice.