Dialectical Behavior Therapy

**Efficacy and Clinical Applications**

Dialectical Behavior therapy is an evidence-based psychological intervention developed for the treatment of Borderline Personality Disorder (BPD). It has shown widespread efficacy, not only for the treatment of BPD, but also suicidality and parasuicidality, binge-eating disorders, and substance use disorders. Applying DBT in various settings and with various disorders has shown a substantial reduction in symptomology, particularly among disorders that previously had seemed resistant to the existing interventions. Providing facets of DBT treatment has been shown to be effective in both short-term and long-term settings as well as across the lifespan, from adolescents to senior citizens.

DBT was developed by Marsha Linehan and is the result of years of research and clinical practice treating patients with complex presentations who are struggling with, among other challenges, suicidal ideation. In applying the existing intervention strategies targeted to suicidality including cognitive and behavioral approaches, Linehan did not see the improvements she had expected. She found that the focus on problematic or maladaptive thoughts and behaviors made patients feel judged, criticized, and invalidated, which often led to them dropping out of or disengaging from treatment. Linehan endeavored to develop a comprehensive intervention that would address maladaptive thoughts and cognitions while also providing validation to increase retention in treatment. The product of years of her clinical research and practice is Dialectical Behavior Therapy.

**Major Tenets of DBT**

While facets of DBT may seem familiar to those who have utilized cognitive-behavioral approaches prior, there are a few key aspects of DBT that distinguishes it from other interventions. Firstly, DBT, unlike other treatment approaches, transcends the therapist’s office. While other interventions are delivered by one clinician to one patient, DBT is implemented across a variety of settings and modalities, including individual therapy, group skills training, phone consultation with a clinician, and therapist consultation teams. Many have found the DBT skills training to be the specific element of the intervention that provides the most wide-reaching benefits to patients across a variety of diagnostic profiles as it focuses on patients learning concrete strategies to challenge their cognitions, build social skills, regulate their emotions, and tolerate distress.  DBT skills groups encapsulate one of the many functions of DBT, including enhancing and generalizing the patient’s capabilities, improving their motivation, reducing dysfunctional behavior, structuring the patient’s environment, and enhancing the providers’ capabilities.

In addition to the main functions and goals of DBT, what distinguishes DBT from other interventions is its integration of biosocial therapy, acceptance and mindfulness, and dialectical philosophy. While many therapy modalities consider the biosocial experience of the patient, DBT targets it directly and implements it into every facet of the intervention. Given the predominant social experience of Borderline Personality Disorder patients with invalidation as well as biological predisposition to reactivity and emotional vulnerability, they can often experience challenges with identifying and regulating their own emotions and may utilize maladaptive methods for coping. For this reason, DBT includes specific focus on teaching patients behavioral skills focused on identifying and regulating emotions.  In addition, DBT focuses on the skills from which it derives its name, Dialetical Philosophy. Dialectical philosophy in DBT treatment focuses on supporting clients and their families in tolerating two or more opposing truths in their lives. This can often manifest in therapy as the clinician offering both acceptance-based and change-based support such as combining validation with suggestions for problem solving.  The final tenet of DBT therapy is incorporation of acceptance and mindfulness. Much of the emotional and physiological arousal that can be caused by psychiatric symptomology can be addressed by increased focus on the present moment, an important hallmark of mindfulness. Acceptance is included in DBT interventions through practicing acceptance towards parts of their life they cannot change as well as the clinician conveying validation and acceptance towards the patient.

**Cultural Adaptations for Practice**

As one looks to apply DBT strategies to their own clinical practice, it is important to understand ways to best adapt the framework to meet the unique needs of the client. Of course, with any manualized treatment, clinicians should practice caution before significantly changing strategies, ensuring to uphold the values and intentions of the intervention.  Swales and colleagues implemented a DBT intervention in a rural British community and found that, given the “American” context within which DBT was founded, there tended to be cultural distinctions that were helpful to be mindful of. In particular, given the focus on diagnostic training in America, they felt it was important for clinicians in other contexts to have a trained cohort of at least three other clinicians to support them in delivering all of the facets of the intervention. They also found there was a noticeable tension in diagnosing patients with BPD, which may have impeded their access to DBT interventions. In this way, communities in which there is a stigma around specific diagnoses would benefit from providing psychoeducation around the symptomology DBT is designed to address as well as widen eligibility criteria where appropriate. Where there seemed to be the most room for cultural adaptation stemmed from the resources provided in the DBT skills group and handout. The research team found that some patients struggled with how “American” the language was. They suggest looking at the language and adapting the resources prior to delivering the intervention to best fit the needs of the clients one is serving.

In a systematic review of culturally adapted DBT interventions, Haft and colleagues found researchers and interventionists focused their cultural adaptations in specific areas of the treatment. Most intervention teams had prioritized adaptations to the language of the intervention, aiming to have the language that was used in intervention materials reflect the language of the community within which it was being delivered. Of particular note was not only translating resources into the language of the clients, but also tailoring language to reflect the cultural values of the community, such as shifts away from “self-respect” to “respect for others” in more collectivistic communities. In addition, where appropriate, intervention teams replaced metaphors drafted by Linehan to explain concepts such as distress tolerance or radical acceptance, with metaphors that had more cultural relevance within the context of delivery, pulling from influences such as Confucianism and Latinx storytelling.  In addition, some teams shifted the methods of delivery to accommodate for stigma within the clients’ communities. Some teams who were serving more collectivistic communities chose to provide only individual therapy without group skills training to reduce stigma felt within the group setting, while others chose to only provide group therapy and skills training without the individual therapy sessions as way to destigmatize the symptoms and normalize clients’ experiences. Further research is still needed to understand the efficacy of these cultural adaptations compared to traditional DBT interventions, and how cultural adaptations can become more standardized to increase accessibility and impact. In addition, DBT intervention materials still do not explicitly address systemic racism, acculturative stress, or transgenerational trauma. These facets of the human experience can most certainly inform a client’s experience with symptoms and are going to be an important stressor for clinicians to be mindful of and incorporate into their treatment where appropriate.

It is evident there is still room to grow to increase the cultural sensitivity and accessibility of DBT treatment. There is much work being done in this field, and with that will come even more support and healing for patients who are struggling with a challenging constellation of symptoms.

**Dialectical Behavioral Therapy and Eating Disorders**

Dialectical Behavioral Therapy is the gold standard in the practice of many diagnoses like Borderline-Personality Disorder. In addition, researches have begun to study the use DBT in treating is Eating Disorders. Patients who receive DBT treatment for BPD and also have comorbid ED have become the prime candidates in determining the further effectiveness of DBT with ED. In preliminary studies it has been reported that a beneficial feature of DBT focuses in on emotion regulation that is a key component in treating Eating Disorders. In a study by Brown et al. (2021) they reported that participants who suffer from Eating Disorders further note that DBT skills like Radical Acceptance are the most applicable and beneficial in their treatment. Overall, the initial consensus is that DBT will be helpful when utilized in the treatment of eating disorders.

In addition, the effectiveness of eating disorders is explored in a study conducted by Reilly et al. (2020) specifically in the adolescent population. In this study they expanded on previous data that stated how beneficial DBT is in the treatment of eating disorder and have found in their preliminary findings that DBT is most effective in adolescents with eating disorders. To maximize the impact of DBT the researchers suggest utilizing Family Based Therapy in conjunction to provide emotional support in FBT. Given that the research on DBT and Eating disorders is a relatively new topic there is a push to further the research in order to determine which adolescents benefit the most from the use of DBT.While there is a lot of research to be explored on the topic of DBT and eating disorders the initial work presents a hopeful outlook on research to come.

**References**

1. ↑ 1.0 1.1 O’Connell, B., & Dowling, M. (2014). Dialectical behaviour therapy (DBT) in the treatment of borderline personality disorder. *Journal of Psychiatric and Mental Health Nursing*, *21*(6), 518–525. https://doi.org/10.1111/jpm.12116
2. ↑ McCauley, E., Berk, M. S., Asarnow, J. R., Adrian, M., Cohen, J., Korslund, K., Avina, C., Hughes, J., Harned, M., Gallop, R., & Linehan, M. M. (2018). Efficacy of dialectical behavior therapy for adolescents at high risk for suicide: A randomized clinical trial. *JAMA Psychiatry*, *75*(8), 777–785. https://doi.org/10.1001/jamapsychiatry.2018.1109
3. ↑ Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. *Journal of Consulting and Clinical Psychology*, *69*(6), 1061–1065. https://doi.org/10.1037//0022-006x.69.6.1061
4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Chapman, A. (2006). Dialectical behavior therapy: Current indications and unique elements. *Psychiatry (Edgmont (Pa. : Township))*, *3*, 62–68.
5. ↑ Agako, A., Burckell, L., McCabe, R. E., Frey, B. N., Barrett, E., Silang, K., & Green, S. M. (2022). A pilot study examining the effectiveness of a short-term, DBT informed, skills group for emotion dysregulation during the perinatal period. *Psychological Services*. https://doi.org/10.1037/ser0000662
6. ↑ Fleischhaker, C., Böhme, R., Sixt, B., Brück, C., Schneider, C., & Schulz, E. (2011). Dialectical Behavioral Therapy for Adolescents (DBT-A): A clinical Trial for Patients with suicidal and self-injurious Behavior and Borderline Symptoms with a one-year Follow-up. *Child and Adolescent Psychiatry and Mental Health*, *5*(1), 3. https://doi.org/10.1186/1753-2000-5-3
7. ↑ 7.0 7.1 7.2 7.3 Linehan, M., Yalom, V., Yalom, M.-H., & Psychotherapy.net. (2013). *Dialectical behavior therapy*. http://www.kanopystreaming.com/node/94903
8. ↑ 8.0 8.1 Lindenboim, N., Lungu, A., & Linehan, M. M. (2017). DBT and Treatment Engagement in the Context of Highly Suicidal Complex Clients. In W. O’Donohue, L. James, & C. Snipes (Eds.), *Practical Strategies and Tools to Promote Treatment Engagement* (pp. 45–74). Springer International Publishing. https://doi.org/10.1007/978-3-319-49206-3\_4
9. ↑ 9.0 9.1 Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., McDavid, J., Comtois, K. A., & Murray-Gregory, A. M. (2015). Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. *JAMA Psychiatry*, *72*(5), 475–482. https://doi.org/10.1001/jamapsychiatry.2014.3039
10. ↑ 10.0 10.1 Malivoire, B. L. (2020). Exploring DBT skills training as a treatment avenue for generalized anxiety disorder. *Clinical Psychology: Science and Practice*, *27*(4), e12339. https://doi.org/10.1111/cpsp.12339
11. ↑ 11.0 11.1 11.2 Swales, H. L. H., J. Mark G. Williams, Michaela. (2000). Linehan’s Dialectical Behaviour Therapy (DBT) for borderline personality disorder: Overview and adaptation. *Journal of Mental Health*, *9*(1), 7–23. https://doi.org/10.1080/09638230016921
12. ↑ 12.0 12.1 12.2 12.3 Haft, S. L., O’Grady, S. M., Shaller, E. A. L., & Liu, N. H. (2022). Cultural adaptations of dialectical behavior therapy: A systematic review. *Journal of Consulting and Clinical Psychology*. https://doi.org/10.1037/ccp0000730
13. ↑ 13.0 13.1 Ben-Porath, Denise & Duthu, Florencia & Luo, Tana & Gonidakis, Fragiskos & Compte, Emilio & Wisniewski, Lucene. (2020). Dialectical behavioral therapy: an update and review of the existing treatment models adapted for adults with eating disorders. Eating Disorders. 28.
14. ↑ 14.0 14.1 Brown, T. A., Wisniewski, L., & Anderson, L. K. (2020). Dialectical behavior therapy for eating disorders: State of the research and new directions. *Eating Disorders: The Journal of Treatment & Prevention*, *28*(2), 97–100.
15. ↑ 15.0 15.1 15.2 15.3 Reilly, E. E., Orloff, N. C., Luo, T., Berner, L. A., Brown, T. A., Claudat, K., Kaye, W. H., & Anderson, L. K. (2020). Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions. *Eating disorders*, *28*(2), 122–141.