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Article Excerpt
Dialectical behavior therapy (DBT; Linehan, 1993a) is a systematic and integrative orientation to treating borderline personality disorder Borderline personality disorder, or BPD, may present a myriad of challenges and difficulties for the beginning as well as the seasoned mental health professional Although some empirical support exists for DBT, more is needed. The current article is, in essence, a call for research, but is also an effort at introducing DBT and its foundations and stages of individual and group therapy. The goal is to give the reader a clearer understanding of DBT through a review of the empirical evidence, the therapeutic process, and the implications for mental health counselors.
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Very few client populations are as challenging for mental health professionals as people with borderline personality disorder (BPD; Linehan, Cochran, & Kehrer, 2001). BPD has a prevalence rate of approximately 2% in the general population, but makes up about 10% of clients in outpatient mental health clinics (American Psychiatric Association, 2000). People with BPD are generally very demanding, stretching the boundaries of most mental health clinicians. For example, clients with BPD tend to display suicidal ideation, inflict self-harm, and have frequent crises. Further, because very few treatments have been found to be effective for people with BPD, many clients may seesaw between the outpatient mental health clinic and the local psychiatric hospital. To compound matters, training may be inadequate, colleagues and institutions may offer little support, and supervisors may lack the experience to help deal with the interpersonal demands required of counseling someone with BPD (Koons, Sloan, & Bellizi, 2002).
Although several approaches such as psychodynamic or interpersonal therapies have met with limited success in the past (Linehan et al., 2001), few theoretical orientations have the empirical support to back up their claims of effectiveness for treatment of people with BPD. One approach to treating BPD has stood out among other theories due to its integrative approach to therapy and its successful, though limited, outcomes in empirical studies. Dialectical behavior therapy (DBT; Linehan, 1993a), developed primarily for dealing with parasuicidal behaviors in women, has now been extended for work with BPD and on inpatient units, with adolescents, and for drug dependence (Katz, Gunasekara, & Miller, 2002; Koons et al., 2001; Linehan et al., 1999; Telch, Agras, & Linehan, 2000). DBT combines a dialectical worldview with standard cognitive-behavioral therapy to produce a unique combination of interventions that balances acceptance and change.
EMPIRICAL SUPPORT FOR DBT
Several studies have examined DBT in conjunction with BPD symptomology with persons who self-harm. Much of the research has compared DBT with the standard practice by therapists in the institution or clinic within which the study was conducted. This standard practice in each institution will be referred to as treatment as usual. With women who inflict self-harm, DBT has significantly reduced hopelessness, depression, anger, suicidal acts, dissociation, and frequency of parasuicidal behavior (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, and Heard, 1991). Studies also found that women were less angry, had better self-reported social adjustment, had fewer inpatient days in the hospital at 4, 8, and 12 months post treatment (Linehan et al.; Linehan, Tutek, Heard, & Armstrong, 1994), and maintained higher global functioning (Linehan, Heard, and Armstrong, 1993) after undergoing DBT. In another study with clients who inflicted harm on themselves, DBT decreased self-harm, dissociative experiences, depressive symptoms, suicidal ideation, and impulsivity (Low, Jones, Duggan, Power, & MacLeod, 2001), while another study's suicidal adolescent participants showed fewer psychiatric symptoms, less suicidal ideation, and fewer symptoms of BPD after 12 weeks (Rathus & Miller, 2002). Miller, Wyman, Huppert, Glassman, and Rathus (2000) found that specific skills such as mindfulness and distress tolerance skills increased and were found to be helpful to suicidal adolescents involved in DBT treatment. In another study (Turner, 2000) comparing DBT to client-centered therapy in individuals with BPD, the DBT group had fewer self-harm incidents, suicide attempts, and inpatient days than did the client-centered group, and the therapeutic alliance had a significant influence on outcomes.
DBT has also been applied to other treatment groups. In a pilot study with depressed elderly adults, medication plus DBT skills training decreased self-reported depression (Lynch, Morse, Mendelson, & Robins, 2003). With eating disordered clients, DBT has been implemented with limited success. Studies have found that after undergoing group skills training, women with a binge eating disorder were not bingeing at the conclusion of the training (Safer, Telch, & Agras, 2001) or at follow-up (Telch et al., 2000). The two largest predictors of relapse were early age of onset of binge eating disorder and dietary restraint (Safer, Lively, Telch, & Agras, 2002). In examining people with dual diagnoses of BPD and drug dependence, DBT treatment has met with mixed results. In one study (Linehan et al., 1999), dropout rates were higher in the treatment as usual group than in the DBT group, and the DBT group had reduced drug use. In another study, Linehan et al. (2002) reported on the effectiveness of DBT or DBT plus a 12-step program with...
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