Case Analysis – Treatment Format Prior to beginning work on this week’s journal, read the PSY650 Week Four Treatment Plan , Case 15: Borderline Personality Disorder in Gorenstein and Comer (2014),

An Overview of Dialectical Behavior Therapy for Professional Psychologists Shireen L. Rizvi, Lauren M. Steffel, and Amanda Carson-Wong Rutgers University Dialectical Behavior Therapy (DBT) is a comprehensive psychosocial treatment originally designed for individuals meeting criteria for borderline personality disorder (BPD). The purpose of this article is to provide an overview of the principles and techniques of DBT for BPD, summarize current research, and discuss the implications for psychologists who wish to implement DBT. The four modes in DBT (individual therapy, skills training, as-needed consultation between sessions, and therapist consultation meetings) are reviewed. The three overarching theories that guide and help organize DBT treatment (biosocial theory, behavioral theory, and dialectical philosophy) are also summarized. DBT has been the subject of much research and has been adapted for different settings, disorders, and populations, including substance abuse and BPD, eating disorders, treatment-resistant depression, ADHD, and forensic settings. This research is critically reviewed. Finally, we examine the implications and appli- cations for practicing psychologists who seek training in DBT and work in independent practice.

Keywords:Dialectical Behavior Therapy, borderline personality disorder, emotion dysregulation, evidence-based treatment Dialectical Behavior Therapy (DBT) is a psychosocial treatment initially developed by Marsha Linehan for the treatment of indi- viduals diagnosed with borderline personality disorder (BPD).

Since DBT was first described in the literature (Linehan, 1987), the treatment has exploded in popularity among psychologists and other mental health workers in the US and internationally. Despite its popularity, there is still much about DBT that is misunderstood or misinterpreted by clinicians. The purpose of this article is to provide an overview of the principles and intervention techniques of DBT, summarize the existing research on DBT for BPD and other mental health problems, and discuss implications for prac- ticing psychologists.

It is unlikely that a practicing psychologist can avoid working with individuals with BPD and such work is often stressful. Esti- mates of the prevalence of BPD suggest that up to 6% of the general population meet criteria for the disorder (Grant et al., 2008), yet this prevalence rate increases dramatically when exam-ining individuals receiving mental health treatment. For example, it has been found that 8 to 11% of individuals receiving outpatient services and up to 20% of psychiatric inpatients meet criteria for the disorder (Widiger & Frances, 1989). In individuals with BPD, rates of nonsuicidal self-injury (NSSI) range from 69 to 80%, up to 75% attempt suicide at least once, and approximately 8 to 10% die by suicide (Black, Blum, Pfohl, & Hale, 2004;Gunderson, 1984;Linehan, Rizvi, Welch, & Page, 2000). In comparison, lifetime suicide attempt rates in the general public are much lower (1.9 – 8.7%), although suicide attempt rates for individuals with major depressive disorder (MDD) are comparable (Bolton & Rob- inson, 2010;Nock et al., 2008). The percentage of suicide attempts attributed to BPD is greater than attempts attributed to substance abuse, anxiety disorders, psychotic disorders, and other personality disorders (Bolton & Robinson, 2010). In addition, BPD is associ- ated with higher rates of Axis I comorbidity as well as a greater number of Axis I diagnoses when compared to non-BPD psychi- atric patients (Zimmerman & Mattia, 1999).

The relatively high prevalence rates and the associated stress of working with individuals with BPD call attention to the need for effective interventions for this population. In recent years, a num- ber of psychotherapies have been developed and evaluated for BPD. Of these interventions, DBT has been the subject of the most study and is the most widely practiced.Swenson (2000)has suggested a few reasons for DBT’s apparent popularity among clinicians: strong empirical support for the treatment, the incorpo- ration and integration of four domains (biological, social– environmental, spiritual, and behavioral) in a single treatment in a way that appeals to those of different backgrounds, the synthesis of acceptance and change strategies as well as practical and theoret- ically sophisticated strategies, and specific structures that address the therapists’ own need for support while treating a difficult population.

This article was published Online First September 3, 2012.

SHIREEN L. R IZVI , PhD, received her doctorate from the University of Washington. She is assistant professor of clinical psychology at the Grad- uate School of Applied and Professional Psychology at Rutgers University.

She also provides workshops and consultation on DBT for Behavioral Tech, LLC.

L AUREN M. S TEFFEL is a predoctoral student at the Graduate School of Applied and Professional Psychology at Rutgers University. Her primary research interests include DBT, BPD, and trauma.

A MANDA CARSON -W ONG is a doctoral student at Rutgers University. Her primary research interests include DBT and BPD.

C ORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Shireen L. Rizvi, Graduate School of Applied and Professional Psychology, Rut- gers University, 152 Frelinghuysen Road, Piscataway, NJ 08854. E-mail:

[email protected] This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Professional Psychology: Research and Practice© 2012 American Psychological Association 2013, Vol. 44, No. 2, 73– 800735-7028/13/$12.00 DOI:10.1037/a0029808 73 Overview of DBT DBT is a cognitive– behavioral treatment originally designed for outpatient settings (Linehan, 1993a). DBT contains four treatment modes that are designed to address five functions. Modes of treatment are individual therapy, skills training (usually in group form), as-needed consultation between client and therapist outside of session, and therapist consultation team meetings. The five functions of treatment are functions of most comprehensive treat- ments and not unique to DBT, although DBT explicitly labels and addresses them. These functions are to increase the client’s moti- vation to change, enhance the client’s capabilities, generalize the client’s gains to his or her larger environment, structure the envi- ronment to reinforce the client’s gains, and increase therapist motivation and competence. It is important to note that the vast majority of research trials on DBT for BPD have included the four standard modes of treatment conducted over 12 months. There is a lack of studies that separate DBT components in order to identify the specific and active ingredients for change. Thus, it is unclear whether modifications of DBT that would include additional com- ponents or offer fewer modes would be as effective.

The practice of DBT is guided by three overarching theories— the biosocial theory of the development and maintenance of BPD behaviors, behavioral theory, and dialectical philosophy. The bio- social theory put forth byLinehan (1993a)posits that the core feature of BPD, pervasive emotion dysregulation, stems from a transaction over time between a biological dysfunction in the emotion regulation system and an invalidating environment. The biological dysfunction is presumed to be a heightened emotional sensitivity, greater emotional reactivity, and slower return to emo- tional baseline (Crowell, Beauchaine, & Linehan, 2009;Linehan, 1993a). Based on empirical research that has been conducted since Linehan’s original formulation, a recent update to the biosocial theory suggests that an early vulnerability, expressed in childhood as impulsivity, is also an important biological factor in the devel- opment of BPD (Crowell et al., 2009).

The invalidating environment is defined as one that pervasively invalidates an individual’s communication of internal experiences, including emotions. One way in which emotions may not be validated is when the expression of private emotional experiences is not tolerated by important people in the individual’s environ- ment. Also, emotions expressed by the individual may be inter- mittently reinforced such that emotional expressions may be ig- nored or invalidated until they reach a high enough level that someone in the environment finally attends to the heightened emotions. When this happens, the individual learns, often without conscious awareness, that intense emotional expressions are nec- essary to communicate effectively. Additionally, in the invalidat- ing environment, effective skills at regulating emotion are not modeled or taught so that the individual does not learn to under- stand, label, tolerate, or regulate emotional experience. The trans- actional nature of the biosocial theory suggests that each factor affects the other, such that the more emotional the individual is, the greater the likelihood of receiving invalidation from the environ- ment, which leads to greater emotionality.

The second theoretical influence on DBT is behavioral theory.

As a behavioral treatment, DBT conceptualizes behavior broadly.

“Behavior” refers to anything an individual does, and includes thoughts, feelings, and overt action. Behavioral theory shapes allaspects of DBT, including the way problems are defined, how behaviors are assessed, which interventions are to be used, and how the case is conceptualized. Interventions are designed to increase the frequency of adaptive behaviors and decrease the frequency of maladaptive behaviors. For example, a behavioral definition of “chronic self-injury” would specifically include the topography (e.g., cutting on one’s upper arm with a razor blade), intensity (e.g., deep cuts which lead to bleeding and scarring), frequency (e.g., one to two times a week for the past three years), antecedents (e.g., fights with a significant other), and conse- quences (e.g., immediate feelings of relief, delayed disapproval from others). A behavioral treatment goal would be to decrease incidents of self-harm from an average of two times a week to zero times per week.

Behavioral theory posits that any behavior can be conceptual- ized according to the principles of classical and operant condition- ing and observational learning (modeling). It thus contributes to the nonjudgmental stance in DBT that every behavior is caused.

Behavioral change can occur by looking to the behavioral factors that contribute to the development and maintenance of the behav- ior, then breaking associations and manipulating the consequences of the behavior, and working to develop alternative models for new behavior. Behavioral theory posits that the maintenance of prob- lem behaviors is the result of skills deficits, problematic contin- gencies, deficiencies in emotional processing, and cognitive fac- tors. With this hypothesis, behavioral treatment interventions are focused on skills training, contingency management, exposure, and cognitive restructuring, all of which are strategies utilized in DBT.

Briefly summarized, dialectical theory states that reality is in- terrelated and connected, made of opposing forces, and always changing. In DBT, dialectics take the form of both a fundamental worldview as well as a method of persuasion (i.e., a set of com- munication strategies that the therapist uses to elicit change). In DBT, the therapist may use dialectics when therapy comes to an impasse. In this case, the therapist will take a dialectical stance by holding the opposing viewpoints simultaneously and looking for the truth in both positions. According to the philosophy, opposite views can exist in one person at the same time (e.g., “I want to die” and “I want to live,” or “I wish to be sober” and “I want to continue to use substances”), leading to tension and conflict, and conflict may be necessary to bring about change. This notion can be particularly helpful when conceptualizing the problems of clients who are highly judgmental of themselves and others, or who have difficulty tolerating contradictory beliefs, which is often true for individuals who have experienced invalidation during childhood.

In DBT, dialectics can also be a strategy to help the client move past an impasse. The primary dialectic in DBT is between change and acceptance. A therapist’s intervention can focus on both change and acceptance strategies in which clients are taught skills to change behavior and also taught methods for accepting them- selves and reality as they are.

These three theoretical foundations influence all aspects of DBT but may be most prominent within the context of individual therapy. Individual therapy in DBT is considered a principle-based treatment that incorporates protocols as needed, in contrast to a protocol-based treatment. A protocol-based treatment typically applies a session-by-session guide for the treatment of a specific disorder in a structured and linear fashion (the skills-training mode is protocol-based). In contrast, principle-based treatments do not This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 74 RIZVI, STEFFEL, AND CARSON-WONG offer guidelines for what to do at each session; rather, various principles of the treatment are employed to help the therapist determine what to do when. The biosocial theory, behavioral theory, and dialectical philosophy inform the principles of the treatment, as do a target hierarchy and collaborative, idiographic treatment goals. DBT is organized into five stages of treatment, including pretreatment and stages one through four. In pretreat- ment, treatment goals are set and a commitment to therapy is obtained. Following pretreatment, a hierarchical list of problem behaviors is developed according to the stage of treatment and the threat each problem poses to the client’s quality of life. The ultimate goal is for the client to gain a life worth living.

The primary goal of Stage I is to reduce behavioral dyscontrol.

Clients with the most severe problems, which may threaten sur- vival or greatly detract from quality of life, are considered to be in Stage I. In this stage, the targets of treatment are (in this order) reducing life threatening behaviors, reducing therapy interfering behaviors, decreasing quality of life interfering behaviors, and increasing behavioral skills. The targets for a specific client are largely addressed in individual therapy although DBT skills train- ing directly aims to increase behavioral skills. Stage II attends to feelings of misery and “quiet desperation” that become more palpable once behaviors are under control. Next, clients begin to work on residual problems such as Axis I disorders, sequelae of invalidation, inhibited grieving, boredom, and emptiness. Stage III focuses on more “ordinary” and less pathological problems in living. In this stage, clients begin to work towards increasing self-respect and improving quality of life. Stage IV is the final treatment stage, and the focus is on awareness of self, feelings of incompleteness, and spiritual fulfillment. While the DBT treatment is laid out in a linear and forward progressing fashion, stages in treatment frequently overlap and often a client will progress to a stage only to move back again. For example, it is not uncommon for a client who had previously stopped binge drinking to engage in this behavior again as the therapist begins to work on avoidance in Stage II.

The structure of a typical DBT individual therapy session in Stage I is informed by the target hierarchy described above. To determine what targets must be addressed in session, the therapist first reviews the Diary Card, a monitoring tool on which clients record daily ratings of emotions, problem behaviors, and skills use.

If suicidal or self-injurious behaviors have occurred, these are the primary targets of the session. Next in the hierarchy are therapy- interfering behaviors such as homework noncompletion or lateness to session. This is followed by quality of life interfering behaviors, such as substance use or moderate to severe depression, and behavioral skills building. The therapist and client address the highest order target with a behavior chain analysis in which they identify links (thoughts, feelings, behaviors, and external events) that lead up to a problem behavior as well as consequences of behavior. A solution analysis is then used to identify points of intervention that would disrupt this chain of events and prevent the problem behavior from recurring (for a thorough description of chain analysis, seeLinehan, 1993a). The therapist uses DBT strategies to increase commitment to trying the new behavior.

Role-plays and imaginational rehearsal are used in session to help the client practice new behaviors.

Clients in Stage I receiving the full package of DBT will receive concurrent skills training in addition to individual therapy sessions.The mode of skills training generally occurs in weekly groups.

Groups are conducted in a psychoeducational format in four mod- ules: Mindfulness, Interpersonal Effectiveness, Emotion Regula- tion, and Distress Tolerance. Groups typically last 2.5 hr and have a leader and coleader. In standard outpatient DBT, it takes approx- imately 6 months to teach the full set of skills. The first half of group is typically devoted to homework review and the second half is devoted to teaching new skills. Groups follow the protocol and content provided in the DBT skills training manual (Linehan, 1993b).

Phone coaching is used on an as-needed basis to help clients generalize skills use outside of the therapy room. Clients are encouraged to call their individual therapist when they either need help utilizing a particular skill or when they do not know what skill to use. These calls typically last between five and 15 min, during which the therapist quickly assesses the client’s problem and helps the client identify skills most appropriate to the situation. Notably, the “24-hr rule” prohibits calling for phone coaching within 24 hr of self-injury. This rule exists for two reasons: first, because the client has already “solved” the problem of emotional distress in a maladaptive way rather than seeking assistance identifying an adaptive coping skill and second, to avoid potentially reinforcing self-injury via therapist attention.

Throughout the treatment, therapists should be engaged in a consultation team, which functions to enhance the therapists’ mo- tivation and capability to deliver effective treatment and to adhere to DBT principles. The team is typically comprised of 4 to 8 therapists who meet weekly for 60 to 120 min. Team meetings are conducted by a leader who guides the team in a mindfulness exercise and then sets the agenda according to members’ needs.

Team members may seek help applying DBT to individual cases or may ask for support when feeling burned out. Team members may offer consultation, constructive feedback, alternative viewpoints (highlighting the dialectic), or they may cheerlead each other as needed. Review of Research on DBT Randomized Controlled Trials of DBT for BPD DBT is considered an evidence-based and empirically supported treatment for BPD and suicidal and self-injurious behaviors (American Psychiatric Association, 2006). To date, more than a dozen randomized controlled trials (RCT) have investigated the efficacy of DBT. The first RCTs compared standard 12 months of DBT to treatment as usual (TAU) and found a greater reduction in the frequency and medical severity of self-injurious behaviors, the frequency and length of inpatient hospitalization, and treatment drop out, as well as some evidence for reduction in anger, depres- sion, hopelessness, suicidal ideation, NSSI, and alcohol abuse (Koons et al., 2001;Linehan et al., 1999;Linehan, Armstrong, Suarez, Allmon, & Heard, 1991;van den Bosch, Koeter, Stijnen, Verheul, & van den Brink, 2005;Verheul et al., 2003). Some studies have also found evidence of efficacy for a shorter, 6-month course of DBT, including reductions in self-injurious behaviors, hopelessness, depression, and the number of hospitalizations (Carter, Willcox, Lewin, Conrad & Bendit, 2010;Koons et al., 2001;Stanley, Brodsky, Nelson, & Dulit, 2007). This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 75 OVERVIEW OF DBT Recent RCTs have compared DBT with more active and con- trolled treatments than TAU. In order to more directly test the unique effects of DBT, one study compared DBT to “community treatment by experts,” a treatment specifically designed to control for factors considered to be effective across different types of treatment. Participants in the DBT condition had half as many suicide attempts, were twice as likely to stay in treatment, had reduced emergency department and inpatient psychiatric care use, and demonstrated less lethal or medically risky suicide attempts (Linehan et al., 2006). Both treatment groups demonstrated sig- nificant reductions in NSSI and ratings of depression, and no between-groups differences were detected in anxiety or eating disorders (Harned et al., 2008). A comparison of DBT to a struc- tured, psychodynamic treatment, transference-focused psychother- apy (TFP) found that individuals in both groups improved on suicidal behaviors but that TFP was associated with improvement across more domains (Clarkin et al., 2007). No significant differ- ences were found between DBT and the psychodynamically in- formed treatment-by-experts on primary outcome variables (Mc- Main et al., 2009). With the exception of the TFP study, one strength of these recent, controlled trials is in the inclusion of adherence rating data for the DBT condition, which allows for greater confidence that the treatment was delivered as intended.

The results of studies that compare DBT to more rigorous treat- ments show that BPD appears to respond well to structured treat- ments, dispelling the long-held myth that BPD is untreatable.

It is also worth noting that the majority of BPD research has been conducted with entirely or primarily female populations, and there are no studies that specifically examine DBT in the context of minority or multicultural populations. The gender bias is largely due to the disproportionately higher rates of BPD diagnoses in females as compared to males (which may be a result of diagnostic bias rather than reflective of actual gender differences;Simmons, 1992). To date, only two studies of DBT have been conducted with male populations and both occurred in forensic settings (Evershed et al., 2003;Shelton et al., 2011). Investigation of DBT in different minority and ethnic groups and more in-depth study of gender differences are important areas for future research.

Adaptations of DBT The targeting of behavioral problems and skills deficits that are common to individuals affected by a variety of disorders has led to many DBT adaptations for different populations. DBT’s effective- ness in helping patients regulate extreme emotions and reduce problematic behaviors as well as its potential to balance accep- tance and change strategies makes it an attractive treatment for a range of disorders.

DBT for substance abuse and BPD.DBT has been investi- gated for the treatment of BPD and co-occurring substance use disorders (SUD). Comorbid BPD and SUD is common; the prev- alence of SUDs among people receiving treatment for BPD ranges from 25 to 67% (Dulit, Fyer, Haas, Sullivan, & Frances, 1990).

Enhancements to standard DBT for the treatment of comorbid BPD and SUD include the use of specific attachment strategies designed to reduce dropouts and missed sessions common in this population, and skills for structuring time and reducing environ- mental cues for drug use. These specific strategies include orient- ing the client to the barrier to engaging in treatment, increasedtherapist-client contact via additional sessions, phone calls, or other methods, building connections to the client’s social network, providing shorter or longer sessions as needed by the client, actively pursuing clients that miss appointments, mobilizing the treatment team when the therapist becomes overwhelmed, and building the client’s connection with the treatment team (McMain et al., 2007).

Three RCTs have been used to investigate DBT for a comorbid BPD and SUD population. In two of these RCTs, DBT was compared to TAU (Linehan et al., 1999) and an active control treatment called “comprehensive validation therapy” plus Alco- holics Anonymous-informed 12-step treatment (Linehan et al., 2002). Both of these trials indicated DBT’s superiority in terms of greater reduction in drug use, larger periods of abstinence, and better social and global role adjustment at follow up (Linehan et al., 1999;Linehan et al., 2002). However, a study byvan den Bosch et al. (2005)of DBT versus TAU found that those in the DBT condition maintained a decrease in NSSI, impulsive behav- iors, and alcohol use, but it did not show any differences in drug use frequency between treatment conditions at 6-month follow up.

These studies indicate mixed results for DBT in the treatment of comorbid SUD and BPD, as it may be more effective than com- munity TAU and may be comparable to other comprehensive substance abuse treatments, but further study as well as refinement of the treatment are needed. To date, no studies have investigated the use of DBT for substance abuse for individuals without co- morbid BPD.

DBT for eating disorders.DBT has been investigated in a number of studies for the treatment of eating disorders, including Bulimia Nervosa (BN), Binge Eating Disorder (BED), and An- orexia Nervosa (AN). Disordered eating may be a behavioral attempt to control negative affective states (Linehan & Chen, 2005), and there is some evidence that individuals who do not respond well to other treatments for eating disorders have prob- lems with emotion dysregulation (Stice et al., 2001;Stice, 1999;).

Poor response to treatment of BED has been associated with co-occurring Cluster B disorders (i.e., histrionic, narcissistic, an- tisocial, and borderline personality disorders;Stice et al., 2001; Wilfley et al., 2000), and poor response to BN treatment has been associated with impulsivity (Agras et al., 2000). The use of DBT adapted for eating disorders may address problems of emotion dysregulation and impulsivity as they relate to disordered eating behaviors.

DBT adaptations were developed at Stanford University for the treatment of BN and BED, without comorbid BPD, and consist of three of four DBT skills modules (emotion regulation, distress tolerance, and mindfulness) plus behavioral analyses, delivered in either group or individual format. Four RCTs (Hill, Craighead, & Safer, 2011;Safer & Jo, 2010;Safer, Telch & Agras, 2001;Telch, Agras & Linehan, 2001) have been conducted on these models.

DBT has been found to be superior to a wait-list condition (in which participants are not in active treatment) in the reduction of binge eating and purging behaviors as well as improvements in anger, eating concerns, and body image (Hill et al., 2011;Safer et al., 2001;Telch et al., 2001;Telch, Agras, & Linehan, 2000). In addition, a study comparing DBT to an active comparison group therapy for BED found that participants in both conditions expe- rienced significant improvements in binge eating, but DBT had fewer treatment dropouts and faster reductions in binge eating This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 76 RIZVI, STEFFEL, AND CARSON-WONG episodes and binge abstinence (Safer & Joyce, 2011). Another study examined an inpatient DBT adaptation for women with BPD and treatment-resistant AN or BN (Kröger et al., 2010). DBT was augmented with an eating-disorder-specific module that included weekly weighing, weekly group psychoeducation about weight, meals in group settings, and coaching provided on-site by the nursing staff. Kröger et al. found remission rates of 54% for BN and 33% for AN at follow up, with significant improvements in self-rated eating complaints, general psychopathology, and ratings on global psychosocial functioning. These studies indicate that DBT is potentially efficacious for eating disorders, but given the substantial number of clients who continued to meet ED criteria, there is still a need for treatment improvement.

DBT for adolescents.There is a growing body of research on DBT for adolescents with self-injurious and suicidal behaviors, though no RCTs have been published to date. Suicide is the third leading cause of death among young people ages 10 to 24 (Centers for Disease Control & Prevention, 2008), and adolescents who struggle with problems that DBT addresses, specifically self- injury, impulsivity, and mood lability, may benefit similarly to adults from the treatment. Some adaptations of DBT for adoles- cents have been used to create age-appropriate skills training materials, and some have been used to incorporate the family into skills-training groups. Uncontrolled studies focusing on self- injuring adolescents found that DBT was associated with a de- crease in depression, BPD criteria, anxiety, anger, impulsivity, and NSSI when compared to TAU (Fleischhaker et al., 2011;Hjal- marsson, Kaver, Perseius, Cederberg, & Ghaderi, 2008;James, Winmill, Anderson, & Alfoadari, 2011;Woodberry & Popenoe, 2008). In addition, a nonrandomized, controlled trial of DBT for adolescents found lower rates of depression, suicidal ideation, psychopathology, drop out, and inpatient psychiatric admissions compared to TAU (Rathus & Miller, 2002). Quasi-experimental studies for adolescents also found adolescent participants in DBT had fewer NSSI episodes and behavioral problems, and used medication less either at prepost or when compared to TAU (Katz, Cox, Gunasekara, & Miller, 2004;McDonell et al., 2010). Other pilot studies show some support for efficacy of DBT as a treatment for adolescents with bipolar disorder (Goldstein, Axelson, Birma- her, & Brent, 2007) and eating disorders (Salbach-Andrae, Boh- nekamp, Pfeiffer, Lehmkuhl, & Miller, 2008).

Other adaptations of DBT.DBT has also been investigated for treatment-resistant depression (TRD), attention-deficit and hyperac- tivity disorder (ADHD), and in forensic settings.Lynch et al. (2000, 2003)adapted DBT for TRD in the elderly and identified skills particularly relevant to this population, including radical acceptances, awareness without judgment (mindfulness), distress tolerance for pain, opposite action toward depressive urges, and interpersonal ef- fectiveness. They found that medication plus DBT (MED DBT) resulted in significant decreases on self-reported depression scores and improvements on dependency and adaptive coping while medication-alone (MED) did not. At follow up, MED DBT had significantly higher TRD remission rates than the MED group (75% vs. 31%;Lynch, Morse, Mendelson, & Robins, 2003). Another study comparing a 16-session DBT skills groups versus wait list for adults with TRD found that DBT participants showed significantly lower depression scores with large effect sizes (Harley, Sprich, Safren, & Jacobo, 2008).Hesslinger et al. (2002)adapted DBT for patients with ADHD, selecting three of the four skills modules (mindfulness, emotion regulation, and distress tolerance) with the aim of helping individ- uals improve the ability to focus attention, accept difficult life events, reduce impulsivity, and regulate extreme emotions. Partic- ipants in their 13-week adaptation demonstrated significant de- creases in depression and ADHD symptoms as well as improve- ments in neuropsychological tests of selective and split attention in an uncontrolled trial (Hesslinger et al., 2002).

DBT has also been used in correctional and forensic settings, both because BPD is diagnosed in higher rates in prison popula- tions and because DBT directly aims to reduce impulsive, aggres- sive, or life-threatening behaviors and addresses staff burnout (McCann, Ivanoff, Schmidt, & Beach, 2007). DBT has been adapted for use with a variety of populations in forensic settings, including female offenders, juveniles, sexual abusers, male batter- ers, and inmates with BPD and other personality disorders. The outcome data is limited and mixed, but in some settings DBT has been found to be effective in reducing anger, hostility, depression, the number and severity of suicidal and aggressive behaviors, as well as the number of staff punitive actions and staff burnout (Evershed et al., 2003;McCann & Ball, n.d.;Shelton, Kesten, Zhang, & Trestman, 2011;Trupin, Stewart, Beach, & Boesky, 2002). Implications and Applications for Practicing Psychologists DBT has received considerable attention from academic psy- chologists interested in determining its effectiveness and popula- tions for which it is helpful. As noted, a number of RCT and quasi-experimental studies support the efficacy of comprehensive DBT for BPD when compared to TAU, wait-list conditions, and active treatments, and there is a small but growing body of liter- ature on DBT for other disorders. However, there is also a clear need for more research on effectiveness of adaptations as well as the predictors of outcomes and mechanisms of change. As noted, dismantling studies that seek to identify the active ingredients of change among DBT’s many components are lacking and are an important area for future investigation. However, even with these limitations, DBT as an evidence-based treatment for BPD is pop- ular among mental health clinicians, and it is often considered a frontline treatment for BPD. As such, we anticipate a continuing interest in implementing DBT in professional settings. We offer several considerations for psychologists interested in learning and practicing DBT. Training in DBT Comprehensive DBT is a complex treatment for a complex population, and learning DBT takes time and dedication. Although it is likely that the principles of DBT will come easier to those previously educated in behavioral therapy, anyone who sets out to learn DBT “from scratch” will likely need extensive training.

Hawkins and Sinha (1998)found that the ability for practicing clinicians to utilize and apply the DBT model correlated strongly to the levels of training the clinicians received. Most of the variance in how to correctly utilize DBT resulted from formal DBT training rather than the clinicians’ prior education or back- This document is copyrighted by the American Psychological Association or one of its allied publishers.

This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 77 OVERVIEW OF DBT ground in conducting other psychotherapy. Fortunately, there are now a number of resources available to clinicians and budding clinicians. Aside from Linehan’s training clinic at the University of Washington (Lungu, Gonzalez, & Linehan, 2012), there are a growing number of other doctoral programs in clinical psychology that offer training in DBT for predoctoral students (e.g., Rutgers University and University of Nevada at Reno) as well as external practicum sites at which predoctoral students can be trained. In- ternship sites are also more likely to offer training in DBT, and internship applicants can search for sites that specifically offer intensive rotations in DBT. There are also research and clinical postdoctoral fellowships with DBT as the primary treatment method.

For practicing psychologists (and other clinicians) at the post- doctoral level, a number of companies now offer different training opportunities to learn DBT. Some even offer online opportunities by way of interactive e-learning experiences or online communi- ties that support each other in learning DBT. Beginning and advanced clinicians alike should review the two DBT manuals (Linehan, 1993a, 1993b). Online tutorials are also available that cover specific DBT strategies, such as how to conduct a behavioral chain analysis and how to use validation strategies. A number of books have been published in recent years that aim to help clini- cians implement DBT in practice (e.g.,Dimeff & Koerner, 2007; Koerner, 2012). Transparency About Comprehensive DBT Versus Components of DBT Comprehensive DBT is a multimodal treatment that includes individual therapy, skills training usually in the form of groups, as-needed consultations between clients and therapists outside the therapy hour, and team consultation meetings for DBT therapists.

The vast majority of the research that has shown that DBT is effective for BPD has included all four of these modes. Thus, offering fewer than the four modes of DBT might best be thought of as an “off label” use of DBT. This is not to say that fewer modes of DBT are not effective but rather that we do not yet have sufficient data to determine whether fewer modes are as effective as the full package or for whom fewer modes might be useful. It is a disservice to our clients to say that we offer DBT when in fact we are only offering certain components (e.g., skills training).

Clients may think that they do not like DBT or have “failed” at DBT without realizing that they did not get the full treatment package. If it is determined that due to resources or training or other issues that comprehensive DBT cannot be offered, clinicians should be transparent and specific about what services are being offered. Clients should be informed that they are not receiving comprehensive DBT, and they should be provided with a rationale for why only the chosen component might benefit them. DBT in Private Practice Many clinicians wonder if comprehensive DBT can be offered in independent practice where psychologists traditionally work independently. It is true that solo practitioners cannot offer com- prehensive DBT since individuals cannot serve as lone members of their own consultation team. A team needs to consist of at least three members, preferably more, in order to provide dialecticalbalance. In addition, as a sole practitioner, it would be difficult work and a likely recipe for burnout to treat all individual clients in a skills group together.

However, these obstacles do not mean that psychologists in independent practice cannot offer comprehensive DBT. Rather, being a DBT therapist offers the opportunity to establish connec- tions with like-minded individuals in the same community. In addition, advances in technology, such as Web-based consultation, have made it possible for therapists in isolated areas to form a consultation team with DBT therapists who live in different com- munities. Once a group gets past the initial hurdle of finding a mutually agreeable meeting place and time, independent practice therapists can function as much as a team as any DBT consultation team in institutions or agencies. It is important to note that clients need to be informed that their therapists are part of a consultation team with other therapists in the community and that aspects of their treatment are discussed (this orientation is a part of DBT in any setting but may need to be emphasized when therapists are in independent practice because it is not the traditional model). The therapists on the team can decide who will offer skills groups and how to refer individual clients to each other’s groups. The indi- vidual therapist may also benefit from backup support from other team members. For example, the individual therapist is held re- sponsible for phone coaching, and team therapists can serve as backups for coaching when an individual therapist might be un- reachable (e.g., during travel or other scenarios that would impede the client’s ability to reach the therapist). Conclusion DBT is an increasingly popular treatment with mounting evi- dence for its efficacy in treating BPD and suicidal behaviors.

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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 80 RIZVI, STEFFEL, AND CARSON-WONG