annual review of clinical psychology volume 3 issue 1 2007 [doi...

8/12/2019 Annual Review of Clinical Psychology Volume 3 Issue 1 2007 [Doi 10.1146%2Fannurev.clinpsy.2.022305.095229] Lynch, Thomas R.; Trost, William T.; Salsm

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Dialectical BehaviorTherapy for BorderlinePersonality Disorder

Thomas R. Lynch,1 William T. Trost,2

Nicholas Salsman,3 and Marsha M. Linehan4

1Departments of Psychology & Neurosciences and Psychiatry & Behavioral Sciences,Duke University and Duke University Medical Center, Durham, North Carolina

27710; email: [email protected] and Psychological Associates, Durham, North Carolina 27704;email: [email protected]

3Department of Psychology, University of Washington, Seattle, Washington 98195;email: [email protected]

4Department of Psychology, University of Washington, Seattle, Washington 98195;email: [email protected]

Annu. Rev. Clin. Psychol. 2007. 3:181205

First published online as a Review inAdvance on December 8, 2006

TheAnnual Review of Clinical Psychologyis onlineat http://clinpsy.annualreviews.org

This articles doi:10.1146/annurev.clinpsy.2.022305.095229

Copyright c2007 by Annual Reviews.All rights reserved

1548-5943/07/0427-0181$20.00

Key Words

intentional self-injury, suicide, DBT, emotion regulation,

mindfulness

Abstract

Since the introduction of Linehans treatment manuals in 1993,

dialectical behavior therapy (DBT) has been widely disseminatedthroughout multiple therapeutic settings and applied to a variety of

diagnoses. The enthusiasm with which it was embraced by clini-

cians early on led some to question whether DBTs popularity wasoutstripping its empirical foundation. Most of the specific concernsraised regarding DBTs early empirical base have been meaningfully

addressed in subsequent randomized controlled trials. This review

provides a brief introduction to DBT, followed by a critical appraisaof empirical support for the treatment and a discussion of current

research trends.

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Contents

INTRODUCTION... . . . . . . . . . . . . . . 182

OVERVIEW OF DIALECTICALBEHAVIOR THERAPY

TREATMENT APPROACHES. . 183Functions and Modes of

Dialectical BehaviorTherapy . . . . . . . . . . . . . . . . . . . . . . 184

Four Stages of Dialectical BehaviorTherapy . . . . . . . . . . . . . . . . . . . . . . 185

Therapy Adherence in DialecticalBehavior Therapy . . . . . . . . . . . . . 186

RANDOMIZED CONTROLLED

TRIALS OF DIALECTICALBEHAVIOR THERAPY FOR

BORDERLINE PERSONALITYDISORDER . . . . . . . . . . . . . . . . . . . . . 187

Linehan et al. 1991, 1993, 1994 . . . 187Koons et al. 2001. . . . . . . . . . . . . . . . . 187

Turner 2000a. . . . . . . . . . . . . . . . . . . . . 189Van den Bosch et al. 2002, 2005;

Verheul et al. 2003 . . . . . . . . . . . . 190Linehan et al. 1999 . . . . . . . . . . . . . . . 192

Linehan et al. 2002 . . . . . . . . . . . . . . . 192

Linehan et al. 2006b . . . . . . . . . . . . . . 193

RANDOMIZED CONTROLLEDTRIALS OF DIALECTICAL

BEHAVIOR THERAPY FORCLIENTS WITH OTHER

DIAGNOSES . . . . . . . . . . . . . . . . . . . 195Dialectical Behavior Therapy for

Depression and OtherPersonality Disorders. . . . . . . . . . 195

Dialectical Behavior Therapy forEating Disorders . . . . . . . . . . . . . . 196

Quasi-Experimental Studies. . . . . . . 196

GENERAL ISSUES . . . . . . . . . . . . . . . . 197CURRENT DEVELOPMENTS

AND FUTURE DIRECTIONS . . 198Are Direct Comparisons with

Other Borderline PersonalityDisorder Treatments

N e e d e d ? . . . . . . . . . . . . . . . . . . . . . . 1 9 8Dismantling Studies and Testing

Mechanisms of Change . . . . . . . . 199CONCLUSION . . . . . . . . . . . . . . . . . . . . 200

DBT: dialecticalbehavior therapy

BPD: borderlinepersonality disorder

Dialectic: thedevelopment of twoopposing positions(the thesis andantithesis) that areresolved through

formation of asynthesis

INTRODUCTION

Following the publication of Linehans(1993a,b) treatment manuals and the first in-

tensive training for therapists outside of theUniversity of Washington in 1992, dialecti-

cal behavior therapy (DBT) for the treatmentof borderline personality disorder (BPD) has

grown increasingly popular among clinicians,patients, and mental health advocate groups.

However, excitement generated by new treat-

ments should correspond with the empiricaldata supporting the efficacy of the new ap-

proach. In an attempt to align enthusiasmwith empiricism, several reviewers compre-

hensively critiqued the body of existent DBTresearch in a special section ofClinical Psy-chology: Science and Practice(Levendusky 2000,Scheel 2000, Swenson 2000, Turner 2000b,

Westen 2000, Widiger 2000). The goals of

this review are to continue with this approach

by conservatively scrutinizing the status ofDBT research and evaluating the rigor with

which criticisms of prior research have been

addressed to date.Prior to any careful review of an existing

treatment literature, it is useful to define thenecessary elements required for an interven-

tion to be classified as representative of thetreatment. These issues are particularly im-

portant considering the growing number ofadaptations developed based on DBT. For our

review, we focused primarily on randomizedcontrolled trials (RCTs), and we used crite-

ria for study inclusion based in part on a cur-rently ongoing meta-analytic study of DBT

(S. McMain, personal communication). Con-

sequently, we included studies if they metthe following criteria: (a) At least one of the

182 Lynch et al.


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treatment arms was DBT or described as

cognitive behavior therapy and based ontreatment protocols specified in Linehans

(1993a,b) books.(b)TheDBTtreatmentmusthave included individual therapy sessions, a

formal skills-training group, a therapist con-sultation team, and some form of coach-

ing (typically telephone for outpatient care),and/or the function associated with each ofthese modes was addressed in some fashion

(e.g., individual therapy conducted over thetelephone). (c) DBT treatment length must

have been at least six months for outpatientprograms and at least two months for inpa-

tient treatments. (d) Outcome measures musthave included at least one scaled measure of

self-injury. (e) The study specifically statesthat it is an RCT, or a review of methodology

revealsthatthestudymeetsRCTcriteria(ran-dom assignment of subjects to two or more

treatment groups). We also report whether

thestudy included measures of adherence. ForRCT studies using DBT in non-BPD popu-

lations, we used the same criteria with the ex-ception that a measure of self-harm was not

required.Using this as our definitional criteria, we

note that DBT has garnered considerablygreater empirical evidence for its efficacy in

treating BPD since the critiques in 2000, war-ranting designation as well-established when

utilizing criteria outlined by the Division12 Task Force (Chambless & Hollon 1998).

To be considered well-established accord-

ing to this criteria, a treatment must havedemonstrated efficacy in at least two rigor-

ous RCTs with superiority over placebo con-trol conditions or another bona fide treatment

(Chambless & Ollendick 2001). At this time,DBT has been evaluated and found to be ef-

ficacious for the treatment of BPD in sevenwell-designed RCTs conducted across four in-

dependent research teams (Koons et al. 2001;Linehan et al. 1991, 1993, 1994, 1999, 2002,

2006b; Turner 2000a; Verheul et al. 2003).In addition, it has demonstrated efficacy in

RCTs for chronically depressed older adults

(Lynch et al. 2003), older depressed adults

Randomizedcontrolled trial(RCT): controls forfactors thatjeopardize internalvalidity (history,maturation ofparticipants, testing,instrumentation,statistical regression,selection, andexperimentalmortality)

Biosocial theory:the transactionbetween aninvalidating rearingenvironment and abiological tendencytoward emotionalvulnerability producea dysregulation inthe clients emotionalsystem

with comorbid personality disorder (Lynch

et al. 2006b), and eating-disordered individu-als (Safer et al. 2001, Telch et al. 2001).

In this chapter, we first briefly review theprinciples and strategies associated with DBT

treatment and adherence measures used intreatment studies. Next, we critically review

findings from RCTs for BPD and other DBTadaptations that have been published. Wethen mention published DBT studies that

were not RCTs (e.g., quasi-experimental de-sign, open trial). Finally, we outline future di-

rections for research.

OVERVIEW OF DIALECTICALBEHAVIOR THERAPY

TREATMENT APPROACHES

DBT was originally developed as a treatmentfor people who meet criteria for BPD, par-ticularly those who are highly suicidal. Since

then, DBT has been reformulated and con-ceptualized as a treatment for multidiagnostic

treatment-resistant populations. DBT drawsits principles from behavioral science, dialec-

tical philosophy, and Zen practice. The ther-apy balances acceptance and change, with the

overall goal of helping patients not only tosurvive, but also to build a life worth living.

In addition, DBT explicitly helps therapistsavoid becoming burned out, as often happens

in the treatment of behaviors associated with

BPD or multidiagnostic cases.A guiding principle of DBT is summarized

in the biosocial theory elucidated by Linehan.Briefly, the biosocial theory of BPD asserts

that the clients emotional and behavioraldysregulation are elicited and reinforced by

the transaction between an invalidating rear-ing environment and a biological tendency

toward emotional vulnerability (Linehan1993a). Practically speaking, this theory en-

courages DBT therapists to view client be-haviors as natural reactions to environmental

reinforcers. This theory also informs treat-

ment, which focuses on shaping and reinforc-ing more adaptive behaviors while also pro-

viding clients with a validating environment.

www.annualreviews.org Dialectical Behavior Therapy 183


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Table 1 Interventions that serve the five functions of dialectical

behavior therapy

Function Example interventions

1. Enhance capabilities Behavioral skills training, modeling,

behavioral rehearsal, psychoeducation,

coaching and feedback, homework

2. Increase motivation Behavioral assessment, chain analysis,

contingency management,exposure-based strategies, cognitive

modification

3. Enhance generalization

to the natural environment

Phone and email consultation, homework,

in vivo interventions, client review of

therapy tapes

4. Structure the

environment

Case management, family or marital

interventions

5. Enhance therapist

capabilities and motivation

to treat effectively

Weekly consultation team meeting,

treatment manuals, supervision,

continuing education

Intentionalself-injury:nonfatal, intentionalself-harm resultingin tissue damage,illness, or risk ofdeath or ingestion ofdrugs or othersubstances with clear

intent to causebodily harm or death

In DBT, therapists pay particularly close at-tention to the factors that maintain dys-

functional behaviors, such as reinforcers ofself-injurious behavior and aversive conse-

quences of more effective behavior. Whereasbehavioral principles focus on changing inef-

fective behavior, a great challenge in treatingindividuals with BPD is to balance the efforts

to change with acceptance and validation. Ingeneral, a dialectical philosophy, which syn-

thesizes an initial proposition or thesis that isopposed by a contradictory antithesis, helps to

provide this balance. For example, an organiz-

ing assumption dialectically considers clientsto radically be doing the best that they can

while at the same time recognizing that theyneed to do better and behave more effectively.

In the case of BPD, one of the most fre-quent dialectical tensions is that a behavior,

such as self-injury behavior, is both functional(it helps thepatient reducedistress in theshort

term) and dysfunctional (the self-injury pro-duces negative effects on health and inter-

personal functioning in the long term, andis associated with the risk of suicide). The

dialectical tension is resolved by finding the

synthesis, by seeking to find what is being leftout of the thesis and antithesis (e.g., validat-

ing the need to relieve distress while help-

ing the client utilize skills that function to

reduce stress and the long-term negative con-sequences of repeated self-injury). The mid-

dle path approach of dialectics is an inherentfeature of Zen, and DBT utilizes these prin-

ciples in an effort to help clients behave moreeffectively and live more balanced lives.

Functions and Modes of DialecticalBehavior Therapy

DBT is a comprehensive treatment designed

to serve five functions (seeTable 1) throughinterventions delivered in four modes of ther-

apy. The first mode of therapy involves a tra-ditional dyadic relationshipbetweenthe client

and his or her individual therapist. The indi-vidual DBT therapist takes primary respon-

sibility for a clients treatment by overseeingprogress toward therapy goals, integrationof therapy modes, and management of life-

threatening behaviors and crises. Individ-ual DBT therapy is organized around the

following target hierarchy: (a) eliminatinglife-threatening behaviors including suicide

attempts and intentional self-injury, (b) elimi-nating therapy-interfering behavior including

nonattendance or not doing homework, and(c) ameliorating behaviors and factors leading

to decreased quality of life including home-lessness,drugdependence,orothersevereaxis

I disorders.

The second mode of therapy, skills train-ing, is a more didactic intervention that

teaches clients four primary skill sets: mind-fulness, distress tolerance, emotion regula-

tion, and interpersonal effectiveness. Mind-fulness primarily has to do with the quality

of awareness that an individual brings to thepresent experience. Mindfulness practice of-

ten involves letting go of attachments and be-coming one with current experience, with-

out judgment or any effort to change whatis. At the same time, mindfulness involves

the use of skillful means and the finding ofa middle path between extremes or polari-

ties. Skills taught in this module include ob-

serving, describing, fully participating, being

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nonjudgmental, focusing on one thing in the

present moment, and being effective over be-ing right. Distress-tolerance training attempts

to equip clients with a range of specific meth-ods aimed at improving the clients capac-

ity to tolerate aversive situations, feelings, orthoughts; to survive crises; and to radically ac-

cept that which cannot be changed. Emotion-regulation training tends to be more changefocused and includes specific methods de-

signed to identify what emotion is being ex-perienced, to decide whether the emotion is

justified or fits the current circumstances, andthen to learn ways to modulate the emotion

if the client decides he or she would like tochange his or her emotional experience. Fi-

nally, interpersonal effectiveness training isdesigned to help clients interact with others

in ways that allow them to improve relation-ships while simultaneously maintaining their

own personal values and self-respect.

A third mode of therapy in DBT, skillsgeneralization, focuses on helping clients in-

tegrate theskills andprinciples taughtin DBTinto real-life situations. In practice, this usu-

ally translates into telephone contact outsideof normal therapy hours (i.e., coaching calls).

These calls are typically brief interactions fo-cused on helping clients apply specific skills in

specific circumstances.The fourth mode of therapy employed

in DBT is a consultation team designed tosupport the therapists in working with diffi-

cult clients. The teams serve several impor-

tant functions, including reducing therapistburnout, providing therapy for the thera-

pist, improving phenomenological empathyfor clients, and providing consultation for in-

dividual therapists or group skills trainers re-garding specific client difficulties.

The goal of the treatment approaches out-lined above can be distilled down into the

following process: the reduction of ineffec-tive action tendencies linked with dysregu-

lated emotions (Chapman & Linehan 2006).The core problem in BPD is hypothesized

to not be excessively intense emotions, but

instead the pervasive habitual breakdown of

the patients cognitive, behavioral, and emo-

tional regulation systems when he or she ex-periences intense emotions (Linehan 1993b).

Consequently, the primary goal of treatmentis to help the patient to engage in functional,

life-enhancing behavior, even when intenseemotions are present. For example, mindful-

ness skills and opposite action (i.e., behav-ing opposite to the action urges of an unjus-

tified emotion) are hypothesized to work by

encouraging nonreinforced engagement withemotionally evocative stimuli, while blocking

dysfunctional escape, avoidance behaviors, orother ineffective responses to intense emo-

tions (Lynch et al. 2006a).

Four Stages of Dialectical BehaviorTherapy

DBT is a flexible treatment that varies in itsapproach depending on the clients current

level of disorder. This tailoring of approachto the clients current needs can be roughly

operationalized into four stages of treatment.A patient engaging in imminently dangerous

or deadly behaviors, such as suicidal behav-iors or severe heroin addiction, enters DBT

at the first stage of treatment. Treatment dur-ing this stage is focused on eliminating the

most severely disabling and dangerous behav-iors. Once behavioral dysfunction is under

control, patients move to stage two of treat-

ment, which focuses on shifting from quietdesperation to emotional experiencing. Stage

two may include helping clients experienceemotions after a lifetime of avoiding emo-

tions or inhibited grieving associated withposttraumatic stress disorder. Stage three ad-

dresses problems in living, such as uncompli-cated axis I disorders, career problems, and

marital problems. Finally, stage four involveshelping the client develop the capacity for

freedom and joy. Treatment targets in stagefour may include working on reducing feel-

ings of emptiness or loneliness and increasing

experiences associated with feeling complete.Stage one targets are the focus of most of the

empirical research available on DBT to date.



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However, the ultimate goal of DBT is to pro-

vide a comprehensive treatment designed tohelp clients at all levels of psychological dis-

tress achieve optimal functioning.

Therapy Adherence in DialecticalBehavior Therapy

There is no agreed upon approach for con-ducting manipulation checks in psychother-

apy outcome studies (Am. Psychiatr. Assoc.2001).Inaddition,inareviewoftheliterature,

only approximately 26% of recently com-pleted psychotherapy outcome studies even

used specific treatment protocols, less thanhalf these studies reported therapist training,

and only 13% documented therapist compe-tence (Luborsky et al. 1997). Including rat-

ings of adherence in intervention research isimportant, however, because adherence pro-vides information about the purity and dose

of a treatment that is received. Additionally,adherence ratings allow researchers to exam-

ine interventions that are specific to a par-ticular treatment modality and those that are

common to multiple treatment modalities. InDBT-specific treatment, protocols have been

developed and validated, and rating systemshave been established to examine adherence

to treatment protocols (Linehan & Korslund2003). In contrast to adherence, competence

ratings provide a qualitative assessment oftherapist skill in providing the prescribed ele-

ments of the treatment, and this type of rating

is typically employed by experts using video-taped sessions (Miller & Binder 2002). How-

ever, measures of competence also should takeinto account contextual issues, such as the

stage in therapy, patient difficulty, and pre-senting problems (Waltz et al. 1993).

The DBT rating instrument generates asingle item index of DBT adherence and sub-

scale scores for the 12 DBT strategy domains.The rating scale comprises 66 items reflec-

tive of the major DBT strategies, each oper-ationalized with behaviorally defined anchor

points in the corresponding DBT adherence

strategy manual (Linehan & Korslund 2003).

Anchor points for each item range between

0 and 5. Each item is scored according to anexpert judgment-scoring algorithm based on

the DBT adherence strategy manual. Condi-tions for scoring in the form of if-then rules

take into account the necessity and sufficiencyof each strategy given the context of the ses-

sion and the prescriptions/proscriptions of theDBT treatment manual. Scores of above 3.9

indicate an adherent session. Inter-rater reli-

abilities of mean scores of the strategy itemsrange from 0.78 to 0.83. Correlationsbetween

the mean score of the items and the globalrating range from 0.89 to 0.99 (Linehan &

Korslund 2003).Of the RCTs for BPD reviewed here, all

but Turner (2000a) included measures of ad-herence monitoring using the scale developed

by Linehan and Korslund. No studies reportcompetence ratings as this type of rating scale

has yet to be developed. Obtaining ratings ofadherence can be an expensive proposition,

as it requires a reliably trained therapist ex-

pert in DBT to watch and code a session inreal time. Consequently, it is recommended

that researchers budget and plan for how theywill obtain reliable ratings of adherence dur-

ing the early stages of study development.In an effort to maximize the number of sites

that have adherence rating ability, the Line-han team recently trained a small group of

DBT researchers from institutions outsidethe University of Washington (UW) in the

DBT adherence scale. There are currentlynine reliable coders: four at the UW, one in

private practice, one in New York City, one

in Canada, one in the Netherlands, and onein Spain (K. Korslund, personal communica-

tion). All coding is coordinated through theUW regardless of the coders physical loca-

tion. Several other groups of coders are intraining presently (both in the United States

and abroad). However, more raters need tobe trained to facilitate DBT research. That

said, a significant strength of the existing ap-proach is that a reliable measure has been

developed, and expert raters using the mea-sure are tested to reliability on an ongoing

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basis. Given this measures strength, it is un-

likely that the field would benefit from thedevelopment of additional or alternative ad-

herence measures. On the contrary, useof multiple scales would make comparisons

across studies more difficult. Thus, at least fornow, it is probably best to consider the UW

scale as the gold standard.

RANDOMIZED CONTROLLEDTRIALS OF DIALECTICALBEHAVIOR THERAPY FORBORDERLINE PERSONALITYDISORDER

Linehan et al. 1991, 1993, 1994

Linehan and colleagues at the UW under-

took the first major RCT of DBT, which re-sulted in three published manuscripts exam-ining different aspects of the data (Linehan

et al. 1991, 1993, 1994). As this study hasbeen reviewed in detail elsewhere (Robins &

Chapman 2004, Scheel 2000), we only dis-cuss it briefly here (see Table 2 for a sum-

mary of RCTs). The study involved 44 sub-jects with BPD and a history of recent and

repeated intentionalself-injury and/or suicideattemptswhowererandomizedtoeitherDBT

(N =22) or treatment as usual (TAU) in thecommunity (N =22). The results indicated

several statistically and clinically significant

advantages for DBT over TAU. These in-cluded substantially greater reductions in in-

tentional self-injury rate and associated med-ical risk, total psychiatric inpatient hospital

days, treatment dropout, self-rated anger, andgreater improvements in global and social

role functioning among DBT clients (Line-han et al. 1991, 1993, 1994). Both groups

improved similarly on measures of suicidalideation (SI) and depression.

Certainly, this original study represented aseminal achievement. However, it wasan early

efficacy study of an as-yet unproven treat-

ment. As such, it does suffer from some ofthe methodological limitations that are typi-

calofsuchstudies.Theseincludesmallsample

TAU: treatment asusual

SI: suicidal ideation

size and limited ability to control for nonspe-

cific factors in the comparison treatment suchas the intensity, stability, and affordability of

therapy and the amount of training and su-pervision received by therapists. In addition,

two subjects assigned to the DBT conditionwere not included in some of the final sta-

tistical analyses because they dropped out af-ter four or fewer sessions. Although this ismethodologically appropriate in many cases,

particularly where statistical power is limitedby small sample size, it is relatively less infor-

mative than the gold-standard intent-to-treat(ITT) analysis, in which all subjects who are

randomized to a treatment condition are in-cluded in all analyses regardless of whether

they actually received the treatment.Secondary analyses of the data in which

many of these issues arestatistically controlledfor have been reported and indicate that the

advantages found for DBT are maintained

even when these factors are taken into account(see Linehan et al. 1991, 1993, 1994). How-

ever, although reassuring, such post-hoc anal-yses do not provide a true substitute for a pri-

ori experimental control. Fortunately, sincethe completion of this original study, six ad-

ditional and more methodologically refinedRCTs have been published that examine the

use of DBT for treatment of BPD or BPD co-morbidwith substance abuse andsubstantially

address these issues.

Koons et al. 2001

An independent research team at Duke Uni-

versity (Koons et al. 2001) compared outpa-tient DBT with TAU for borderline women

veterans being treated at the Durham Vet-erans Affairs Medical Center. This study at-

tempted to replicate Linehans original find-ings as well as examine DBTs efficacy with a

less severely afflicted group of patients. Theresearchers hypothesized that lower symp-

tomatic acuity would allow a shift in treat-

ment focus from imminently life-threateningbehaviors to treatment targets lower on the

therapeutic hierarchy, including depression,



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Table 2 Summary of randomized controlled trials of dialectical behavior therapy (DBT)

Treatments (number of

patients) Inclusion criteria Length Main effects Reference(s)

Trials of DBT for BPD

DBT (N =24) versus

community mental

health TAU (N =22)

BPD + suicide attempt in

past 8 weeks + one other

in past 5 years

Female

1 year ISI frequency and medical

risk, treatment retention,

emergency/inpatient

treatment, anger, social andglobal adjustment

Linehan et al. 1991,

1993, 1994

DBT (N =12) versus

TAU (N =16)

BPD + current drug

dependence

Female

1 year Illicit drug use, social and

global adjustment,

treatment retention

Linehan et al. 1999

DBT + LAAM (N =11)

versus CVT + 12-step +

LAAM (N =12)

Females with BPD +

current opiate

dependence

1 year Opiate use Linehan et al. 2002

DBT-oriented (N =12)

versus CCT (N =12)

BPD + referral from

emergency services for

suicide attempt

1 year ISI/suicide attempts,

impulsiveness, anger,

depression, global

adjustment, inpatient

treatment

Turner 2000a

DBT (N =10) versus

Veterans Administration

TAU (N =10)

BPD

Female

6 months ISI/suicide attempts (trend),

hopelessness, suicidal

ideation, depression, anger

expression

Koons et al. 2001

DBT (N =31) versus

TAU (N =33)

BPD

Female

1 year ISI/suicide attempts (trend),

treatment retention,

self-damaging impulsivity

van den Bosch et al.

2002, 2005;

Verheul et al. 2003

DBT (N =52) versus

CTBE (N =51)

BPD + recent and

recurrent self-injury

Female

1 year Suicide attempts, treatment

retention, emergency and

inpatient treatment

Linehan et al. 2006b

Trials of DBT modifications for non-BPD diagnoses

DBT +MED (N = 17)versus MED alone

(N = 17)

Age 60Current major depression

28 weeks Remission at 6-monthfollow-up

Lynch et al. 2003

DBT +MED (N =21)

versus MED alone

(N = 14)

Age 55 + personality

disorder

Current depressive

symptoms

Nonresponse to MED

trial

24 weeks Interpersonal sensitivity,

interpersonal aggression,

depression (trend)

Lynch et al. 2006b

Modified DBT skills

training (N =14) versus

wait list (N =15)

Females age 1865

Binge/purge at least once

per week for 12 weeks

20 weeks Binge episodes, binge days,

eating in response to

aversive emotions (trend)

Safer et al. 2001

Modified DBT skillstraining (N =22) versus

wait list (N =22)

Females age 1865Binge eating disorder

20 weeks Binge episodes; binge days;anger; concerns about

weight, body shape, and

eating

Telch et al. 2001

BPD, borderline personality disorder; CCT, client-centered therapy; CTBE, community treatment by psychotherapy experts in suicide and BPD;

CVT, comprehensive validation therapy; ISI, intentional self-injury; LAAM, levo-alpha-acetylmethadol; MED, antidepressant pharmacotherapy;

TAU, treatment as usual.

188 Lynch et al.


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the first to employ a structured, theory-driven

comparison treatment.A local emergency room referred poten-

tial subjects after they were seen for a suicideattempt. All subjects met full DSM-III crite-

ria for BPD according to standardized inter-view. Subjects with psychosis, bipolar disor-

der, mental retardation, or an organic mentaldisorder were excluded; however, unlike mostother DBT RCTs, both men and women were

included. Thirty-three of 62 potential subjectsmet study criteria and consented to partici-

pate. Of these, 7 dropped out prior to ran-domization and an additional 2 dropped out

after learning treatment assignment, leaving amodified ITT sample of 24 (12 in each group;

19 women and 5 men). The subjects tendedto be young (average age 22, with a range of

18 to 27), and 83% carried a diagnosis of non-nicotine substance abuse.

The active comparator, CCT, was based

on a treatment model developed by Carkuff.CCT emphasizes empathic understanding of

the patients sense of aloneness and provid-ing a supportive atmosphere for individua-

tion (Turner 2000a, p. 416). Therapeutic in-terpretation and confrontation were generally

proscribedin CCT. Whenever possible, CCTclients were seen twice weekly (three times

weekly in case of crisis). Frequency of individ-ual therapy for DBT was not specifically men-

tioned. Both treatments lasted for 12 months,and a total of six group sessions were of-

fered to all participants over the course of the

year. The group format was focused looselyaround traditional DBT skills training, but

there was no mention of the specific skillsaddressed.

The same four clinicians delivered bothtreatments. The therapists had an average

of 22 years experience and reported back-grounds in family systems, client-centered,

and psychodynamic treatments. Instruction inDBT consisted of five lectures and 12 90-

minute training sessions over three months.Although the therapists were generally famil-

iar with CCT, each attended a weekly edu-

cational seminar for 12 weeks in an effort to

control for effects of the DBT training course.

Each therapist attended two weekly group su-pervision sessions: a DBT supervision group

led by the author and a CCT supervisiongroup led by thesenior clinic therapist.Group

supervision focused on improving treatmentadherence by reviewing videotaped sessions.

No formal adherence ratings were reported.Although subjects in both treatments

tended to improve, the results strongly fa-

vored DBT over CCT. Significant between-group differences were found for all three

primary outcomes, representing compositemeasures of suicidality, affective dysregula-

tion, and global mental health functioning.Secondary analyses of individual measures re-

vealed significant between-group differencesfavoring DBT on rates of suicide and inten-

tional self-injury, depression, SI, hospitaliza-tion days, a global score on a brief psychiatric

rating scale, impulsiveness, and anger.As noted above, the Turner study has sev-

eral characteristics that weaken its status as an

authentic DBT study. Perhaps most contro-versial in this respect is the incorporation of

some psychodynamic principlesinto the DBTcondition. In addition, although the mention

of weekly supervision to promote adherenceissomewhat reassuring, there is no mention of

what sort of formal training the DBT supervi-sor (Turner) had obtained, and no formal ad-

herence rating was used. Although these con-cerns are valid and might justifiably exclude

thisstudyfromaformalmeta-analysisofDBTRCTs, they may also be viewed as evidence

that therapists who accept DBT assumptions

and make a sincere effort to apply DBT canachieve beneficial results.

Van den Bosch et al. 2002, 2005;Verheul et al. 2003

A third independent research team led by Ver-heul, van den Bosch, andcolleagues compared

standard DBT with TAU for the treatment of

women with BPD who were attending com-munity psychiatry and substance-abuse clin-

ics in Amsterdam (van den Bosch et al. 2002,

190 Lynch et al.


11/27

2005; Verheul et al. 2003). The study was the

first large-scale RCT of standard DBT un-dertaken in a nonacademic setting. Subjects

were mostly referred from psychiatric and ad-diction treatment centers, and each referring

provider was required to sign a letter statingthat he or she was willing to treat the patient

for 12 months if the patient was assigned tothe control condition. Subjects referred by ageneral practitioner or self-referred were re-

quired to obtain a similar letter from a psychi-atrist or psychologist prior to acceptance into

the study.The comparison condition was a true TAU

condition. The setting was similar betweengroups, but the treatments differed in several

other ways. Treatment intensity was substan-tially higher in the DBT condition and con-

sisted of the full DBT program as describedby Linehan et al. (1993). Subjects assigned

to TAU, by contrast, attended generally no

more than two sessions per month (Verheulet al. 2003, p. 136). Between-group differ-

ences in clinician characteristics were not ex-plicitly addressed but may have been impor-

tant as well. DBT therapists (4 psychiatristsand 12 clinical psychologists) may have had

more overall education than TAU therapists(a mix of psychiatrists, psychologists, and so-

cial workers) and were probably more enthu-siasticaboutthetreatmentgiventhattheDBT

therapists were volunteers, whereas the TAUtherapists were the same clinicians who had

originally referred subjects for potential treat-

ment elsewhere. DBT therapists also receivedintensive training and supervision that were

not provided to TAU therapists. Althoughthese differences are notable, they are also

typical for a comparison of a new treatmentwith TAU and demonstrate that DBT can

be applied in nonacademic community set-tings. In light of significant limitations, how-

ever, it is probably best to interpret the resultsconservatively.

A total of 94 subjects were referred, ofwhom 64 were randomized to either DBT

(N =31) or TAU (N =33). Two subjects in

each group dropped out prior to the first ses-

sion, and an additional two subjects in the

DBT group dropped out after attending onlyone session. Analyses were performed on a

modified ITT sample excluding these six sub-jects (27 DBT, 31 TAU). Despite high treat-

ment dropout from the TAU condition, 78%of all assessments were completed with no

difference between groups. Significant differ-ences in outcomes between groups were ev-

ident. Subjects assigned to DBT had signif-

icantly greater reductions in self-mutilatingand self-damaging impulsive behaviors and

were significantly more likely to stay in treat-ment than TAU subjects. Fewer DBT sub-

jects attempted suicide (2 out of 27 versus 8out of 31), but this difference was not statis-

tically significant (Fishers exact p =0.0871).Post-hoc analyses employing a severity factor

(defined by a median split on lifetime numberof parasuicidal acts) found that DBTs advan-

tage over TAU for treating suicidal and self-mutilating behavior was most pronounced

among severely afflicted subjects. DBT was

not associated with a differential reductionin prescription psychotropic medication use.

Unfortunately, the study did not present dataregarding the use of crisis services, depres-

sion/anxiety ratings, SI, or global function-ing. A follow-up assessment six months after

treatment ended found that the superior gainsassociated with DBT were maintained, al-

though DBTs advantage was less pronouncedthan it was immediately post-treatment.

A secondary objective of this study wasto examine the efficacy of DBT among bor-

derline subjects with active substance abuse

and dependence diagnoses. The study foundDBT to be equally effective for subjects with

and without substance dependence in termsof reducing target behaviors (i.e., intentional

self-injury, self-mutilation). However, gener-alization of improvements to nontarget be-

haviors (i.e., substance abuse) appeared to belimited. Analysis of 10 variablesreflecting sub-

stance misuse found only one significant dif-ference between groups (group multiplied by

time treatment effect for alcohol use) (van denBosch et al. 2002, 2005).



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CVT:comprehensivevalidation therapy

Recognizing the importance of treating

substance-abuse issues among borderline pa-tients, Linehans group undertook the first

significant modification of standard DBT inthe mid-1990s. Specific modifications were

based largely on early clinical experienceswith substance-abusing clients and included

(a) more aggressively targeting treatmentdropout by introducing a set of attachmentstrategies and increasing the positive emo-

tional valence of therapy, (b) encouraging pa-tients with opiate and stimulant addictions

to use replacement pharmacotherapy, and (c)providing targeted case management to ad-

dress issues related to housing, finances, andthelegalsystem.Theirworkculminatedinthe

creation of a treatment manual for comorbidBPD andsubstance disorder in 1997 (Linehan

& Dimeff 1997).

Linehan et al. 1999

Results of the first randomized trial of the

modified treatment were published in 1999(Linehan et al. 1999). This trial compared

DBT with community TAU and involved 28women with comorbid BPD and substance-

use disorder. Using a minimization proce-dure to match for age, severityof dependence,

readiness to change, and Global AssessmentFunctioning score, the investigators assigned

12 subjects to DBT and 16 to TAU. They

ran analyses on both the ITT sample and thetreated sample, defined as those subjects in

either group who attended more than six ses-sions and for whom outcome assessments be-

yond pretreatment were available (N =18; 7DBT, 11 TAU).

Results from the ITT analyses indicatedan advantage for DBT in terms of treatment

retention (7 out of 12 DBT versus 3 out of16 TAU; Fishers exact p =0.0497). Included

among DBT dropouts was one subject whodied during the study, apparently as the re-

sultof an accidentaloverdose. Among subjects

who attended at least one session (11 DBT,11 TAU), a nonsignificant trend favoring bet-

ter retention in DBT was seen (4 out of 11

DBT versus 8 out of 11 TAU). The primary

drug-use outcome was based on structured in-terviews at baseline and at 4, 8, 12, and 16

months. ITT analyses using one-tailed t-testsindicated significant advantages for DBT on

this measure for the treatment year overall aswell as at the 4- and 16-month assessments.

Treatment-effect size estimates at all timepoints were in the moderate to large range

per Cohens (1988) recommendations, possi-

bly indicating that the study was underpow-ered to detect a clinically significant differ-

ence between treatments. Urine drug screenswere only performed on a maximum of six oc-

casions (once at each assessment and once atrandom during the study). Urine-drug-screen

results tended to favor DBT at all time pointsaccording to ITT analysis, nearly reaching

statistical significance at 4 and 16 months. Es-timated between-groups effect sizes for this

outcome were generally small to moderate.No between-groups differences emerged for

intentional self-injury, anger, global adjust-

ment, or social adjustment during treatment,but significant differences favoring DBTwere

found for social adjustment and global ad-justment at 4 months post-treatment. Inter-

estingly, better adherence to DBT protocolmay have produced better results, as indicated

by a post-hoc analysis revealing that adherentDBT therapist-client dyads had a higher pro-

portion of negative urinalyses throughout thestudy.

Linehan et al. 2002

Building on the results of the 1999 study, afollow-up study compared DBT with a highly

structured control condition for the treat-ment of comorbid BPD and opiate depen-

dence (Linehan et al. 2002). Women who metDSM-IV criteria for both disorders were ran-

domly assigned to DBT or a combination ofcomprehensive validation therapy anda struc-

tured 12-step program (CVT+ 12-step). The

CVT + 12-step control condition was de-signed to more thoroughly control for the in-

fluence of nonspecific treatment variables on

192 Lynch et al.


13/27

treatment outcome. Essentially, CVT repre-

sents only the acceptance side of the accep-tance/change dialectic that underlies DBT. As

such, CVT therapists employ all of the valida-tion techniques used in DBT, but they do not

use cognitive-behavioral change techniques,give overt advice, or actively direct the ther-

apy session beyond insisting that drug use bebrought up at least once. To control for group-therapy hours, the study required that CVT

subjects attend a weekly Narcotics Anony-mous 12 and 12 meeting conducted by the

two CVT therapists who were also recoveringaddicts. As part of the 12-step program, sub-

jects in this condition were also encouragedto meet with an NA sponsor weekly.

The DBT protocol was essentially identi-cal to the one used in the 1999 study, except

that an additional 30-minute individual skills-training session was offered to DBT clients to

control for the weekly 12-step sponsor meet-

ings in the control group. Women in bothgroups received opiate replacement therapy

throughout the study. Twenty-four womenwere randomized (12 to each arm). One sub-

ject was subsequently dropped from the DBTcondition after it was discovered that she did

not meet inclusion criteria, leaving a modi-fied ITT sample of 23 for analyses. Significant

decreases in opiate use were evident in bothtreatment arms, and primary outcomes analy-

ses found no significant differences betweengroups on the main measures of drug use

and parasuicidal behavior. Secondary analy-

ses revealed a significantly lower proportionof opiate-positive drug screens among DBT

clients over the course of the treatment, pri-marily resulting from some rebound in drug

use among CVT clients over the last fourmonths of treatment. An additional finding

of interest was that self-report of drug use wassignificantly more accurate in the DBT group

as corroborated by thrice weekly urine drugscreens throughout treatment. Remarkably,

not a single subject dropped out of the CVTgroup over the entire 12 months of treatment.

This was attributed to the supportive and val-

idating environment fostered by CVT.

CTBE: communitytreatment by expertsin suicide andborderlinepersonality disorder

The results of this study reinforce the

importance of controlling for nonspecifictreatment factors in therapy trials, and they

perhaps also speak to concerns regarding theempirical rigor with which DBT has been

evaluated. Thecontrol treatmenthere wasnota so-called paper tiger designed to empha-

size DBTs effectivenesswhileproviding somesemblance of experimental control. Instead,CVT+ 12-step was both efficacious and skill-

fully executed, as evidenced by the remarkable100% retention rate of clients who have his-

torically been difficult to keep in treatment.The increasing sophistication of the control

conditions used in DBT trials also reflects aguiding principle that has been embraced by

Linehan and others examining DBT, whichholds that subject safety and well-being must

be of paramount concern.

Linehan et al. 2006b

In the largest and most rigorously controlled

RCT of DBT to date, Linehan et al. (2006b)compared standard DBT with community

treatment by experts (CTBE). This study wasdesigned to replicate the results of the origi-

nal study while controlling for a wide rangeof potential confounds not specifically ad-

dressed in that study. Subjects in the twogroups were matched according to total num-

ber of lifetime suicide attempts and nonsui-

cidal self-injuries combined, number of psy-chiatric hospitalizations, history of bona fide

suicide attempts versus nonsuicidal self-injuryonly, age, and presence of negative prognos-

tic factors (severe depression and severelyimpaired interviewer-assessed global func-

tioning). The comparator condition (CTBE)was carefully designed to control for a vari-

ety of nonspecific treatment effects, includ-ing treatment availability; ease of obtaining

and traveling to the first appointment; hoursof individual psychotherapy offered; insti-

tutional prestige associated with treatment;

and therapist factors including gender, alle-giance to treatment offered, formal education

(i.e., doctoral versus masters degree), clinical



14/27

experience, and availability of supervision and

group clinical consultation.Subjects were women between the ages of

18 and 45 who met DSM-IV diagnostic cri-teria for BPD and who had attempted suicide

and/or self-injured at least once in the pasteight weeks and twice in the past five years.

Potential subjects were excluded if they hada psychotic disorder, bipolar disorder, mentalretardation, a seizure disorder requiring med-

ication, or if treatment was mandated. One-hundred andeleven subjects were randomized

to either DBT (60) or CTBE (51). Eight DBTtraining cases and two CTBE pilot subjects

were not included in the analyses, leaving afinal ITT sample of 101 (52 DBT, 49 CTBE).

CTBE therapists were nominated by localmental health leaders based on reputation for

expertise with especially difficult and chron-ically suicidal clients. Of 94 therapists nomi-

nated, 38 were selected for the study and 25

accepted at least one study client. To avoidcross-contamination of treatment techniques,

only therapists who described their treatmentapproach as nonbehavioral or mostly psycho-

dynamic were selected for the CTBE condi-tion. To optimize therapist allegiance to the

delivered treatment, CTBE therapists wereinstructed to provide the dose and type of

therapy that they felt was most appropriatefor the client, with the single requirement that

individual therapy be offered at least once perweek. To control for both the effects of the

DBT therapist consultation team and client

expectations linked to institutional prestige,all CTBE therapists were encouraged to at-

tend a weekly group supervision session led bythe training director of the Seattle Psychoan-

alyticSociety. To ensure optimal treatment af-fordability and availability in both conditions,

CTBE therapists were paid with study funds,and the study coordinator helped clients con-

tact therapists and arrange transportation tothe first meeting.

Standard DBT was administered by 16therapists who were nominated by colleagues

based on theirpotential to be good DBT ther-

apists. Of the 16, 8 had no prior DBT ex-

posure, and 5 were either graduate students

or postdoctorates. DBT training consisted of45 hours of training followed by supervised

practice, and therapists were hired after beingrated to adherence on six out of eight consec-

utive training case sessions. The two groupsof therapists were matched according to ed-

ucation (i.e., doctoral versus masters degree)and gender. However, therapists in the CTBE

group had significantly more experience than

did DBT therapists on average.Although subjects in both conditions

showed substantial improvements, the DBTgroup generally exhibited better treatmentre-

sponse, particularly on outcomes related tobehaviors specifically targeted by treatment.

Subjects assigned to DBT were half as likelyto attempt suicide as those assigned to CTBE

(23.1% with at least one suicide attempt inDBT versus 46% in CTBE; p =0.01). A sim-

ilar, although not statistically significant, ad-vantage was seen when considering only non-

ambivalent suicide attempts (5.8% in DBT

versus 13.3% in CTBE; p = 0.18). Amongsubjects who did engage in self-injurious or

suicidal behaviors, ratings of medical risk as-sociated with these behaviors were signifi-

cantly lower in the DBT group. Although nosignificant difference was found for nonsuici-

dal self-injury between groups, a greater re-duction was documented for the DBT group

as indicated by an estimated between-grouptreatment effect size of 0.49 (moderate ef-

fect perCohen 1988).Subjects receiving DBTalso used significantly fewer crisis services

(e.g., psychiatric emergency room visits and

inpatient admissions) than subjects assignedto CTBE. Although a significant difference

was seen for all psychiatric emergency roomvisits and admissions in general, it was espe-

cially evident when considering only emer-gency room visits and admissions due to

SI. During the treatment year, CTBE sub-jects were twice as likely as DBT subjects

to visit the emergency room for SI (33.3%CTBE versus 15.6% DBT) and three times

as likely to be admitted for SI (35.6% CTBEversus 9.8% DBT) (Linehan et al. 2006b).

194 Lynch et al.


15/27

Consistentwithpriorstudies,subjectsinDBT

were also significantly less likely to changetherapists or drop out of treatment. Both

groups improved significantly and similarlyon measures of depression, hopelessness, sui-

cidality, and reasons for living. No measuredoutcomes favored CTBE.

RANDOMIZED CONTROLLEDTRIALS OF DIALECTICALBEHAVIOR THERAPY FORCLIENTS WITH OTHERDIAGNOSES

Dialectical Behavior Therapy forDepression and Other PersonalityDisorders

Several RCTs have examined applications ofDBT for populations other than individualswith BPD. In one such pilot study, Lynch

et al. (2003) randomly assigned 34 adultsover the age of 60 in a current major de-

pressive episode to either an antidepressantmedication alone condition or an antidepres-

sant medication plus a modified form of DBTcondition. The modified form of DBT con-

sisted of 28 weeks of a skills-training groupas well as six months of weekly 30-minute

phone contact with an individual therapist,followed by three months of once every two

weeks and three months of once every three

weeks 30-minute phone contact. Phone con-tacts in the first six months focused on re-

view of diary cards and problem-solving dif-ficulties with applying skills, whereas phone

contacts in the second six months focused onuse of skills to prevent depression relapse.

Those in the DBT condition showed sig-nificantly greater improvements than those

in the medication-alone condition in areasincluding self-rated depression at treatment

end and interviewer-rated depression scoresat six-month follow-up. Post-treatment in-

terviewer ratings of depression indicated that

71% of clients in the DBT condition metcriteria for remission, whereas only 47% of

clients on medication alone met remission

criteria. Furthermore, at a six-month follow-

up evaluation, clients in the DBT conditionhadsignificantly higher remission rates (75%)

than those in the medication-only condition(31%). Clients in the DBT condition also had

significant improvement on measures of adap-tive coping and dependency, whereas those in

the medication-alone condition did not. Theauthors hypothesize that the improvements in

these areas reduce vulnerability to depression.

The main objective of this first study(Lynch et al. 2003) was to determine the feasi-

bility of a group intervention with a skills ori-entation for older adults. Encouraged by these

findings, a second randomized clinical trialwas conducted to apply standard DBT (both

group and individual) to older adults with ma-jor depression and personality disorder with

the goal of modifying the DBT specificallyfor this population (Lynch et al. 2006b).

In this second study, 35 adults over the ageof 55 with personality disorders and comorbid

depressive symptoms were randomly assigned

to either 24 weeks of medication manage-ment alone or 24 weeks of medication man-

agement plus standard DBT. The DBT con-dition included in-person weekly individual

sessionsandgroupskillstraining.ThoseintheDBT condition showed significantly greater

decreases in interpersonal sensitivity and in-terpersonal aggression compared with medi-

cation alone. Additionally, assessment at thetime point corresponding with the end of the

DBTskillsgroupindicatedthat71%ofclientsin the DBT condition met criteria for remis-

sion of depression, whereas only 50% of those

in the medication-alone condition met crite-ria for remission. Clients in both conditions

showed significant reductions on standard-ized, clinician-administered ratings of depres-

sion, with a nonsignificant difference favoringDBT seen at end of treatment and follow-up

assessments. Nine clients in the DBT condi-tion and seven clients in the medication-alone

condition no longer met diagnostic criteriafor personality disorder after treatment com-

pletion. Moderate effect sizes on several vari-ables suggest that this study may have been



16/27


17/27

Table 3 Summary of quasi-experimental studies of dialectical behavior therapy (DBT)

Treatment(s) Participants Length Main effects Reference

Adapted inpatient

DBT (N = 31) versus

waiting list with

community TAU

(N = 19)

Women with BPD 12 weeks Group comparisons: depression,

anxiety, interpersonal functioning,

social adjustment, global

psychopathology, and

self-mutilation

Bohus et al. 2004

Adapted DBT(N = 29) versus

supportive-dynamic

therapy+ family

therapy (N =82)

Adolescent inpatients indepression/suicide

program; those with

suicide attempt and 3

BPD criteria assigned to

DBT

12 weeks Group comparisons: treatmentretention, psychiatric

hospitalization

Pre-/post-DBT comparison:

suicidal ideation, general

psychiatric symptoms, BPD

symptoms

Rathus & Miller2002

Adapted DBT

(N = 32) versus TAU

(N = 30)

Adolescent inpatients

with suicide attempt or

ideation

2 weeks Group comparisons: problem

behavior on the ward

Katz et al. 2004

Pre-/postincorporation

of DBT onto adult

inpatient unit(N = 130)

Consecutive admissions

during transition from

psychodynamic to DBT+ psychodynamic

treatment

Average stay

106 days

Pre-/postincorporation of DBT:

mean monthly self-harm rate on

the unit

Barley et al. 1993

Adapted adult inpatient

DBT (N =24)

Females with BPD + 2

suicide attempts and/or

ISI incidents in 2 years

Average stay

94 days

Pre-/postincorporation of DBT:

self-harm behaviors, depression,

dissociation, anxiety, global stress

Bohus et al. 2000

Adapted DBT

(N = 21) versus TAU

(N = 14)

Inpatients on adult

forensic unit with at

least three BPD criteria

20 months Depressed and hostile mood,

paranoia, psychotic behaviors,

maladaptive coping, adaptive

coping, staff burn-out (trend)

McCann et al.

2000

Adapted DBT Inpatient adolescent

females on a forensic

unit

Variable Pre-/postincorporation of DBT:

behavioral problems; staff use of

restrictive punishments;

participation in therapeutic,

educational, and vocational

services

Trupin et al. 2002

Adapted DBT for

binge eating disorder

(N =11)

Females age 1865 with

binge eating disorder

20 weeks Pre-/postincorporation of DBT:

binge episodes, binge days

Telch et al. 2000

BPD, borderline personality disorder; ISI, intentional self-injury; TAU, treatment as usual.

GENERAL ISSUES

One issue that has reverberated throughoutthe BPD and personality disorder research

field has been a concern as to whether DBTcan be successfully translated to the commu-

nity settings that serve many of the individualsit was designed to treat. Recent developments

immediately suggest that this issue may be less

relevant. To date five independent research

labs have conducted DBT RCTs showingpositive between-group effects (Koons et al.

2001; Lynch et al. 2003, 2006b; Safer et al.2001; Telch et al. 2001;Turner2000a;Verheul

et al. 2003), suggesting clearly that theefficacy

of the treatment is not dependent on specificpeople or organizations. Two of these RCTs



18/27

(i.e., Turner 2000a, Verheul et al. 2003) were

conducted in nonacademic community clin-ics, indicating that dissemination of DBT to

community settings is both feasible and ef-fective. Further support for DBTs general-

izability comes from multiple published pre-/postdesign and nonrandomized controlled

studies (Brassington & Krawitz 2006, Bohuset al. 2004, Comtois et al. 2007, Katz et al.2004, McCann et al. 2000, Rathus & Miller

2002, Trupin et al. 2002) and from unpub-lished data from community clinics across the

country that have been compiled by Behav-ioral Tech, LLC, a training company focused

on the dissemination of evidence-based treat-ments (L. Dimeff, personal communication).

Additional issues that may impact gener-alizability include at least three primary char-

acteristics that can distinguish between aca-demic research and treatment programs in

which treatments are developed and the com-

munity treatment programs in which they aredisseminated: to clients, counselors, and set-

tings. A major strength of DBT is that it isexplicitly designed to treat clients who typ-

ically present for treatment in communitytreatment programs (e.g., highly symptomatic

individuals with a high degree of psychi-atric comorbidity). Accordingly, participants

in the RCTs described above included het-erogeneous samples of individuals with high

axis I and II comorbidity. Overall, additionalresearch in applying DBT in real-world set-

tings is needed, andthis includes an evaluation

of the effects training has on changing thera-pist behavior.

An additional concern regarding DBT re-search has been the influence of allegiance

effects on outcome (Westen 2000). Despitecriticisms regarding the importance of alle-

giance to therapy outcome (e.g., Chambless2002), it is reasonable to conclude that al-

legiance effects on psychotherapy outcomesmay influence what treatment wins (Luborsky

et al. 1999). How well has DBT dealt withthis issue? The most representative outcome

study that systematically controlled for alle-

giance effects has been a study comparing

DBT with CTBE (Linehan et al. 2006b). In

this study, the CTBE therapists were nom-inated by community mental health leaders

and were considered experts in treating dif-ficult clients. The content of the treatment

provided by them was not prescribed by theresearch study or interfered with, and insti-

tutional prestige was controlled for by havingthe base of operations for CTBE at the Seattle

Psychoanalytic Society and Institute. In addi-

tion, therapists were told to provide the treat-ment they had the greatest allegiance to (i.e.,

the treatment they thought would work best),and there were no differences between condi-

tions in expectancies. Thus, it is reasonable toconclude that allegiance was high in CTBE.

CURRENT DEVELOPMENTSAND FUTURE DIRECTIONS

The accumulated data clearly indicate that

DBT is an effective treatment for BPD.Across studies, DBT has resulted in reduc-

tions in several problems associated withBPD, including self-injurious behavior, sui-

cide attempts, SI, hopelessness, depression,and bulimic behavior. Nonetheless, further

advances in the treatment of this complex dis-order are needed. The question now involves

how best to move the field forward.

Are Direct Comparisons with OtherBorderline Personality Disorder

Treatments Needed?

In our opinion, a so-called horse-race study in

which another multicomponent treatment issystematically compared with DBT does not

appear warranted at this point. To date therehave been only two other RCTs for treatment

of BPD. The first was Bateman & Fonagys(1999) study of a psychodynamic partial hos-

pital program, but this has not been replicatedeither by the authors or in a second indepen-

dent lab. Interested readers may refer to a spe-

cial issue of the Journal of Personality Disor-ders(volume 16, issue 2) that was devoted to

the American Psychiatric Associations (2001)

198 Lynch et al.


19/27


20/27

were no better than 8 clients receiving non-

DBT individual therapy only. This suggeststhat skills training may be an important com-

ponent of the full treatment package, espe-cially for more severely affected populations.

A related dismantling study is currentlyongoing at UW (P.I. Linehan). In this study,

women with BPD and histories of suicidal andother self-injurious behaviors are randomlyassigned to one of three treatment conditions:

(a) standard DBT, (b) individual therapy plusactivity support group, in which the DBT

skills-training group is replaced by a struc-tured weekly group activity andDBT skills are

not taught in individual therapy, or (c) DBTskills training plus case management, which

includes no individual DBT therapy.Preliminary research regarding the rela-

tive importance of change versus acceptancestrategies in DBT has also been undertaken.

The study comparing DBT with CVT + 12-

step for treatment of comorbid BPD and sub-stance dependence (Linehan et al. 2002) rep-

resents the first step in this direction. Resultsof that study suggest that validation strategies

may be critical for preventing dropout amongsubjects with comorbid BPD and substance

dependence (Linehan et al. 2002). We can-not draw firm conclusions regarding the im-

portance of change strategies from that study,however, as change strategies were included

in the control condition as part of the struc-tured 12-step intervention. In another study,

Shearin & Linehan (1992) examined individ-

ual sessions and found that a combinationof change and validation strategies was im-

portant. Specifically, sessions in which clientsrated therapists as maintaining a balance be-

tween change and validation strategies wereassociated with greater reductions of parasui-

cidal behavior and ideation relative to sessionsduring which the therapist was rated as purely

accepting or change focused.Future studies must be designed in which

a strong association between the mechanismof action and both pretreatment variables

and post-treatment variables can be demon-

strated. Additionally, futurestudiesshould use

multiple measurement points to determine

both a gradient (dosage effect) as well as atime line (i.e., changes in the mechanism of

action precede changes in outcome). Finally,the proposed mechanism of action must stand

up to tests of plausibility and coherence. Inother words, there must be a credible expla-

nation forhow andwhy themechanism resultsin change. Theory, then, is an important over-

arching element in the testing of mechanisms

of action. The more assessment periods thatare included, the more fine grained the anal-

ysis of gradient and time line can be.Based on the data accumulated thus far,

Lynch et al. (2006a) have posited severalmechanisms of action specific to DBT that

distinguish this treatment from other behav-ioral interventions. For example, based on the

dialectical change theory, the authors sug-gest that a dialectical focus with a synthesis

of change and acceptance strategies may bean important mechanism of action in DBT.

They suggest that strategies specific to DBT

used in both individual sessions (e.g., utiliz-ing commitment strategies, focusing on DBT

skills such as opposite action, and high ther-apist self-disclosure) and group skills training

(e.g., mindfulness skills, emotion-regulationskills, interpersonal effectiveness skills, and

self-respect effectiveness skills) may accountfor significant clinical change.

In addition to the initiatives mentionedabove, ongoing research includes evaluation

of adaptations of DBT to non-BPD diag-noses, mediator/moderator studies, and basic

research examining the theoretical precepts of

DBT (e.g., biosocial theory; see Linehan et al.2006a for a review).

CONCLUSION

The primary purpose of this review was to

conservatively scrutinize the status of DBTresearch and evaluate the rigor with which

criticisms of prior research have been ad-

dressed to date. Using the criteria for man-ualized treatments established by Chambless

& Hollon (1998), we found that the current

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literature quickly reveals that DBT is the

only treatment for BPD considered well es-tablished or efficacious and specific. How-

ever, despite its strong empirical foundation,a number of gaps do remain in the DBT lit-

erature. These include a relative paucity ofRCTs involving male or minority clients and

little information on the relative importanceof DBTs different components to treatmentoutcomes. In addition, although preliminary

attempts to apply DBT to diagnoses otherthan BPD have been promising, these appli-

cations should still generally be consideredexperimental pending further evidence from

RCTs. Once it is known that a treatment is

efficacious, the next task is to improve thetreatment further by enhancing its efficiency

and efficacy (Linehan et al. 1999). This phaseof treatment development includes compo-

nent and process-analytic studies, dismantlingstudies, analysis of response predictors, and

large-sample effectiveness research in com-munity settings. We hope that this reviewpro-vides the impetus for others to expand re-

search efforts into these new domains andcontinue a tradition based on empirical ob-

servation to maximize the likelihood that thetreatment helps those it was designed to help.

SUMMARY POINTS

1. DBT has been reformulated and conceptualized as a treatment for multidiagnostic

treatment-resistant populations. It has been evaluated and found to be efficacious forthe treatment of BPD in seven well-controlled RCTs conducted across four indepen-

dent research teams.

2. Treatment approaches can be distilled down into the following process: the reduction

of ineffective action tendencies linked with dysregulated emotions. However, studiesexamining specific mechanisms of change need further development.

3. There is a reliable measure of treatmentadherencethat generates a singleitemindexofDBT adherence and subscale scores for the 12 DBT strategy domains. Dissemination

of the treatment may be slowed by an overreliance on the UW site for adherenceratings. However, until a convincing argument can be made that a new adherence

scale is needed, it is probably best to consider the UW scale as the gold standard.

4. DBT has demonstrated efficacy in RCTs for chronically depressed older adults, older

depressed adults with comorbid personality disorder, and eating-disordered individu-als. Although preliminary attempts to apply DBT to diagnoses other than BPD have

been promising, these applications should still generally be considered experimentalpending further evidence from RCTs.

5. DBT can be successfully conducted outside of UW as evidenced by the positive out-comes from independent research teams, adherence ratings of therapists, and com-

munity treatment involvement. Allegiance effects have been recently controlled forin a rigorous randomized trial (Linehan et al. 2006a).

FUTURE ISSUES

1. Future research should focus on component and process-analytic studies, dismantling

studies, and studies designed to analyze response predictors.

2. New adaptations of DBT require further testing using evidence from RCTs.



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Annual Review

Clinical Psycho

Volume 3, 2007

Contents

Mediators and Mechanisms of Change in Psychotherapy Research

Alan E. Kazdin 1

Evidence-Based Assessment

John Hunsley and Eric J. Mash 29

Internet Methods for Delivering Behavioral and Health-Related

Interventions (eHealth)

Victor Strecher 53

Drug Abuse in African American and Hispanic Adolescents: Culture,

Development, and Behavior

Jose Szapocznik, Guillermo Prado, Ann Kathleen Burlew, Robert A. Williams,

and Daniel A. Santisteban 77

Depression in Mothers

Sherryl H. Goodman 107

Prevalence, Comorbidity, and Service Utilization for Mood Disordersin the United States at the Beginning of the Twenty-first Century

Ronald C. Kessler, Kathleen R. Merikangas, and Philip S. Wang 137

Stimulating the Development of Drug Treatments to Improve

Cognition in Schizophrenia

Michael F. Green 159

Dialectical Behavior Therapy for Borderline Personality Disorder

Thomas R. Lynch, William T. Trost, Nicholas Salsman,

and Marsha M. Linehan 181

A Meta-Analytic Review of Eating Disorder Prevention Programs:Encouraging Findings

Eric Stice, Heather Shaw, and C. Nathan Marti 207

Sexual Dysfunctions in Women

Cindy M. Meston and Andrea Bradford 233

Relapse and Relapse Prevention

Thomas H. Brandon, Jennifer Irvin Vidrine, and Erika B. Litvin 257

vii


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Marital and Family Processes in the Context of Alcohol Use and

Alcohol Disorders

Kenneth E. Leonard and Rina D. Eiden

Unwarranted Assumptions about Childrens Testimonial Accuracy

Stephen J. Ceci, Sarah Kulkofsky, J. Zoe Klemfuss, Charlotte D. Sweeney,

and Maggie Bruck

Expressed Emotion and Relapse of Psychopathology

Jill M. Hooley

Sexual Orientation and Mental Health

Gregory M. Herek and Linda D. Garnets

Coping Resources, Coping Processes, and Mental Health

Shelley E. Taylor and Annette L. Stanton

Indexes

Cumulative Index of Contributing Authors, Volumes 13

Cumulative Index of Chapter Titles, Volumes 13

Errata

An online log of corrections toAnnual Review of Clinical Psychologychapters (if an

may be found at http://clinpsy.AnnualReviews.org

annual review of clinical psychology volume 3 issue 1 2007 [doi...

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