Research Studies on Dialectical Behavior Therapy

Ten Randomized Controlled Trials of DBT


1a) Linehan,M.M., Armstrong,H.E., Suarez,A., Allmon,D., Heard,H.L. (1991). Cognitive-behavioral treatment of chronically parasuicidal border­line patients. Archives of Gen eral Psy chi a try, 48, 1060–1064.
Compared 2 groups: 22 females (aged 18–45 yrs) with parasuicidal borderline per­sonality disorder (PBPD) who under went DBT for 1 yr and 22 matched females with PBPD who underwent treatment as usual in the community. Ss were assessed at pretreatment and at 4, 8, and 12 mo posttreatment. There was a significant reduc­tion in the frequency and medical risk of parasuicidal behavior among Ss who received DBT compared with Ss who received treatment as usual. DBT effectively retained patients in therapy. The number of days of inpatient psychiatric hospital­ization was fewer for Ss who received DBT than for controls. These effects occurred despite the fact that DBT was not differentially effective in improving patients’ depression, hopelessness, suicide ideation, or reasons for living.

1b) Linehan,M.M., Heard,H.L. (1993) “Impact of treatment accessibility on clinical course of para suicidal patients”: Reply. Archives of General-Psychiatry, 50(2): 157–158.
Replies to a comment by R. E. Hoffman on an article by M.M. Linehan et al on the treatment of parasuicidal patients with borderline personality disorder. In contrast to Hoffman, the authors believe that they have provided evidence that dialectical behavioral therapy per se, as opposed to economic and other complicating factors, produces clinical outcomes superior to treatment as usual.

1c) Linehan,M.M., Heard,H.L., Armstrong,H.E. (1993). Nat u ral is tic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of Ge eral Psychiatry, 50, 971–974.
Evaluated whether the superior performance of DBT for borderline personality disorder (BPD) was maintained during a 1-year posttreatment follow-up of Ss from a previous study (see record 1992-13734-001). 39 women with BPD who had a history of parasuicidal behavior participated. Ss were assigned to DBT, a cognitive behavioral therapy that combines psychotherapy with group behavioral skills training, or to treatment-as-usual, which may or may not have included individual psychotherapy. Efficacy was measured on parasuicidal behavior, psychiatric inpatient days, anger, global functioning, and social adjustment. Throughout the follow-up, DBT Ss had significantly higher global functioning. During the initial 6 months, DBT Ss had significant less parasuicidal behavior, less anger, and better self-rated social adjustment. During the final 6 months, Ss had fewer inpatient days and better interviewer-rated social adjustment.

1d) Linehan.M.M., Heard,H.L., Armstrong,H.E. (1994). “Nat u ral is tic follow-up of a behavioral treatment for chronically parasuicidal borderline patients”: Erratum. Archives of General Psychiatry, 51, 422.
Reports an error in the original article my M.M. Linehan et al. (Archives of General Psychiatry, 1993, Vol 50[12], 971-974). A correction is made to the 2nd sentence of the “Results” section on page 973.

1e) Linehan,M.M., Tutek,D.A., Heard,H.L., Armstrong,H.E. (1994). Interper­sonal outcome of cognitive behavioral treatment for chronically suicidal bor­derline patients. American Journal of Psychiatry, 151, 1771–1776.
Examined the efficacy of a cognitive behavioral outpatient treatment on interpersonal outcome variables for patients diagnosed with borderline personality disorder. 26 female patients with borderline personality disorder were randomly assigned to either DBT or a treatment-as-usual comparison condition. In both the intent-to-treat and treatment completion groups, Ss completing DBT had significantly better scores on measures of anger, interviewer-rated global social adjustment, and the Global Assessment Scale and tended to rate themselves better on overall social adjustment than did treatment-as-usual Ss. Results suggest that DBT is a promising psychosocial intervention for improving interpersonal functioning among severely dysfunctional patients with borderline personality disorder.

2) Linehan,M.M., Schmidt,H., Dimeff,L.A., Craft,J.C., Kanter,J., Comtois,K.A. (1999). Dialectical behavior therapy for patients with border­line personality dis or der and drug-dependence. American Journal on Addiction, 8(4), 279–292.
Compared results obtained from DBT and a treatment-as-usual (TAU) regimen for drug-dependent suicidal women display ing borderline personality disorder. 28 women (aged 18–45 yrs) were randomly assigned to DBT or TAU groups. The 12 Ss receiving DBT, which comprises strategies from cognitive and behavioral thera­pies and acceptance strategies adapted from Zen teaching, participated in individ­ual psychotherapy, group skills training sessions, and skills coaching phone calls when needed. Those receiving TAU were referred to alternative substance abuse or mental health counselors and community programs, or continued with their own psychotherapists. Results show a drop-out rate of 36% from DBT compared with a rate of 73% from TAU. Urinalysis showed a significant reduction in substance abuse among the DBT Ss, and significant improvements in social and global adjust­ment in DBT Ss at 16-mo follow-up. Findings suggest that DBT is an effective treat­ment for severely dysfunctional drug-dependent patients.

3) Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S., Heagerty, P., Kivla han, D.R. (2002). Dialectical behav ior therapy versus comprehensive validation plus 12-step for the treatment of opioid depen­dent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence, 67(1), 13–26.
Compared the effects of the use of DBT and comprehensive validation therapy in conjunction with a 12-step program (CVT + 12S) on the drug usage of heroin-dependent females. During a 12-mo period, 23 heroin-dependent females (mean age 36.1 yrs) diagnosed with borderline personality disorder received either DBT, a treatment that synthesizes behavioral change with radical acceptance strategies, or CVT + 12S, a manualized approach that provides DBT in combination with par­ticipation in a 12-step program. In addition, Ss received concurrent opiate agonist therapy with levomethadyl acetate hydrochloride oral solution. Subjects (Ss) were assessed for drug use through urinalyses, interviews, and self-reports. Results show that both treatment conditions were effective in reducing opiate use relative to baseline. At 4 months following treatment termination, all Ss exhibited a low propor­tion of opiate-positive urinalyses. Ss assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment, while those assigned to CVT +12S treatment significantly increased opiate use during the last 4 months of treatment. Possibly confounding these results was that all 12 CVT + 12S Ss completed the 12 months of treatment, while only 64% of Ss completed DBT.

4) Koons, C.R., Robins, C.J., Tweed, J.L., Lynch, T.R., Gon za lez, A.M., Morse, J.Q., Bishop, G.K., But ter field, M.I., Bas t ian, L.A. (2001). Efficacy of dialectical behavior therapy in women veterans with borderline personal­ity disorder. Behavior Therapy, 32(2), 371–390.
Twenty women veterans (aged 21–46 yrs) who met criteria for borderline personal­ity disorder (BPD) were randomly assigned to DBT or to treatment as usual (TAU) for 6 months. Compared with patients in TAU, those in DBT reported significantly greater decreases in suicidal ideation, hopelessness, depression, and anger expression. In addition, only patients in DBT demonstrated significant decreases in number of parasuicidal acts, anger experienced but not expressed, and dissocia­tion, and a strong trend on number of hospitalizations, although treatment group differences were not statistically significant on these variables. Patients in both con­ditions reported significant decreases in depressive symptoms and in number of BPD criterion behavior patterns, but no decrease in anxiety. Results of this pilot study suggest that DBT can be provided effectively independent of the treatment’s developer, and that larger efficacy and effectiveness studies are warranted.

5a) van den Bosch, L.M.C., Ver heul, R., Schip pers, G.M., van den Brink, W. (2002). Dialectical Behavior Therapy of border line patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911–923.
Examined whether standard DBT (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. The implementation of DBT was examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 18-70 year old female borderline patients with (n=31) and without (n=27) SA. Results show that standard DBT can be applied in a group of borderline patients with and without comorbid SA. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. It is concluded that Standard DBT can be effectively applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT, however, is not more efficacious than TAU in reducing substance use problems.

5b) Ver heul, R., van den Bosch, L.M.C., Koeter, M.W.J., de Ridder, M.A.J., Stijnen, T., van den Brink, W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in the Netherlands. British Journal of Psychiatry, 182, 135–140.
Dialectical behavior therapy (DBT) is widely considered to be a promising treatment for borderline personality disorder (BPD). However, the evidence for its efficacy published thus far should be regarded as preliminary. This study compared the effectiveness of DBT with treatment as usual for patients with BPD and examined the impact of baseline severity on effectiveness. 58 women (mean age 34.9 years) with BPD were randomly assigned to either 12 months of DBT or usual treatment in a randomized controlled study. Subjects were recruited through clinical referrals from both adduction treatment and psychiatric services. Outcome measures included treatment retention and the course of suicidal, self-mutiliatin, and self-damaging impulsive behaviors. DBT resulted in better retention rates and greater reduction of self-mutilating and self-damaging impulsive behaviors compared with usual treatment, especially among those with a history of frequent self-mutilation. Findings show that DBT is superior to usual treatment in reducing high-risk behaviors in patients with BPD.

6) Telch, C.F., Agras, W.S., Linehan, M.M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psy­chol ogy, 69(6), 1061–1065.
This study evaluated the use of DBT adapted for binge eating disorder (BED). Women with BED (n=44) were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. Treated women evidence significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment for BED.

7) Safer, D.L., Telch, C.F., Agras, W.S. (2001). Dialectical behavior ther­apy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632–634.
The effects of DBT adapted for the treatment of binge/purge behaviors were examined. 31 (aged 18-65 years) were randomly assigned to 20 weeks o DBT or 20 weeks of a waiting-list comparison condition. The manual-based dialectical behavior therapy focused on training in emotion regulation skills. An intent-to-treat analysis showed highly significant decreases in binge/purge behavior with dialectical behavior therapy compared to the waiting-list condition. No significant group differences were found on any of the secondary measures. The use of dialectical behavior therapy adapted for treatment of bulimia nervosa was associated with a promising decrease in binge/purge behaviors.

8) Lynch, T.R., Morse, J.Q., Mendelson, T., Robins, C.J. (2003). Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry, 11(1), 33–45.
Assessed the benefits of augmenting medication with group psychotherapy in depressed older adults. The authors randomly assigned 34 (largely chronically) depressed individuals age 60 years and older to receive 28 weeks of antidepressant medication plus clinical management, either alone (MED) or with the addition of dialectical behavior therapy skills-training and scheduled telephone coaching sessions (MED+DBT). Only MED+DBT showed significant decreases on mean self-rated depression scores, and both treatment groups demonstrated significant and roughly equivalent decreases on interviewer-rated depression scores. However, on interviewer-rated depression, 71% of MED+DBT patients were in remission at post-treatment, in contrast to 47% of MED patients. At a 6 month followup, 75% of MED+DBT patients were in remission, compared with only 31% of MED patients, a significant difference. Only patients receiving MED+DBT showed significant improvements from pre- to post-treatment on dependency and adaptive coping that are proposed to create vulnerability to depression. Results suggest that DBt skills training and telephone coaching may offer promise to effectively augment the effects of antidepressant medication in depressed older adults.

9) Line han et al (2006) NIMH 3 Two-Year Ran dom ized Con trol Trial and Fol low up of DBT
Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-document efficacy. OBJECTIVE: to evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non-behavioral psychotherapy experts. DESIGN: One-year randomized controlled trial, plus 1 year of post-treatment followup. SETTING: University outpatient clinic and community practice. PARTICIPANTS: 101 clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched no condition on age, suicide attempt history. negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. INTERVENTION: One year of DBT or one year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige). MAIN OUTCOME MEASURES: Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were associated by blinded assessors. RESULTS: DBT was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and followup period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P=.005), required less hospitalization for suicide ideation (F(1,92)=7.3;P=.004), and had lower medical risk (F(1,50)=3.2;P=.04) across all suicide attempts and self-injurius acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2;P<.001) and had fewer psychiatric hospitalizations (F(1,92)=6.0;P=.007) and psychiatric emergency department visits (F(1,92)=2.9;P=.04) CONCLUSIONS: Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.

10) Line han, M.,M. et al (2008) Olan za p ine Plus DBT for Women with High Irritability.pdf
This double-blind study examined whether olanzapine augments the efficacy of dialectical behavior therapy (DBT) in reducing anger and hostility in borderline personality disorder patients. Twenty-four women with borderline personality disorder (DSM-IV criteria) and high levels of irritability and anger received 6 months of DBT. Subjects were randomly assigned to receive either low-dose olanzapine or placebo and were assessed with standardized measure in a double-blind manner. It was found that Olanzapine may promote more rapid reduction of irritability and aggression than placebo for highly irritable women with borderline personality disorder. Effect sizes were moderate to large, with the small sample size likely limiting the ability to detect significant results. Overall, there were large and consistent reductions in irritability, aggression, depression, and self-injury for both groups of subjects receiving DBT.

Six Non-Randomized Trials of DBT

1) Rathus, J.H., Miller, A.L. (2002). Dialectical Behavior Therapy adapted for suicidal adolescents. Suicide and Life-Threatening Behavior, 32(2), 146–157.
Reports a quasi-experimental investigation of an adaptation of DBT with a group of suicidal adolescents with borderline personality features. The DBT group (n=29) received 12 weeks of twice weekly therapy consisting of individual therapy and a multifamily skills training group. The treatment as usual (TAU) group (n=82) received 12 weeks of twice weekly supportive-psychodynamic individual therapy plus weekly family therapy. Despite more severe pretreatment symptomatology in the DBT group, at posttreatment this group had significantly fewer psychiatric hospitalizations during treatment, and a significantly higher rate of treatment completion than the TAU group. There were no significant differences in the number of suicide attempts made during treatment. Examining pre-post change within the DBT group, there were significant reductions in suicidal ideation, general psychiatric symptoms, and symptoms of borderline personality. DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics.

2) Trupin, E.W., Stew art, D.G., Beach, B, Boesky, L. (2002). Effectiveness of a dialectical behaviour therapy program for incarcerated female juve­nile offenders. Child and Adolescent Mental Health, 7, 121–127.
The State of Washington Governor’s Juvenile Justice Advisory Committee sponsored a collaborative project conducted by a research team from the University of Washington and the staff at a juvenile rehabilitative center to evaluate the effectiveness of a DBT intervention. Pre-post intervention records were compared for female offenders from a mental health and a general population unit where DBT was implemented. Youth on a third unit served as a comparison group. Youth behavior problems, staff punitive responses were compared before and after the intervention period. Youth behavior problems and use of punitive responses by staff changes were noted on another. The evaluation demonstrated the efficacy of providing DBT to female offenders in a residential setting and yielded mixed results on behavior change during the study period that may relate to quality of training and prior youth behavior problems.

3) Bohus, M., Haaf, B., Stiglmayr, C., Pohl, U., Boehme, R., Line han, M. (2000). Eval u a tion of inpa tient Dialectical-Behavioral Ther apy for Bor der­line Per son al ity Disorder–A prospec tive study. Behav iour Research and Ther apy, 38(9): 875–887.
Developed and evaluated a treatment program of inpatient therapy for chronically suicidal patients with BPD that was based on M. Linehan’s (see record 1993-97864-000) Dialectical-Behavioral Therapy for Borderline Personality Disorder (DBT). Subjects were 24 female patients (aged 17.4 to 44.4 years) with BPD who had committed at least 2 parasuicide acts (PAs; consciously intended, resultant physical injury) and/or 1 suicide attempt within the past 2 years. The program consisted of a 3-month inpatient treatment prior to long-term outpatient therapy. Subjects were compared at admission to the hospital, and at 1 month after discharge on a variety of instruments. Specifically, the authors wanted to determine if there was a reduction of the number of PA’s and an improvement in emotion regulation and general indices of psychopathology pre-versus posttreatment. The results indicate significant improvements in ratings of depression, dissociation, anxiety and global stress between assessments. Further, a highly significant decrease in the number of PAs is also reported. The authors state that inpatient DBT focuses upon self-injuries as high-ranking problem areas and works continuously towards developing skills for distress tolerance and emotion regulation.

4) Barley, W.D., Buie, S.E., Peterson, E.W., Hollingsworth, A.S., Griva, M., Hickerson, S.C., Lawson, J.E., Bailey, B.J. (1993). The development of an inpatient cognitive-behavioral treatment program for border line personal­ity disorder. Journal of Personality Disorders, 7(3), 232–240.
Describes an inpatient treatment program for borderline personality disorder that evolved from a purely psychodynamic to a more cognitive-behavioral treatment approach emphasizing M.M. Linehan’s (1993) dialectical behavior therapy (DBT). Inpatient DBT immerses borderline patients in a culture of support for their attempts to skillfully solve problems with emotion regulation and related dysfunctions. Data are presented that suggest that this approach is associated with decreased rates of parasuicide on the inpatient unit.

5) Stanley, B., Ivanoff, A., Brodsky, B, Oppenheim, S. (November, 1998). Comparison of DBT and “treatment as usual” in suicidal and self-mutilating behavior.
Paper presented at the 32nd annual convention of the Association for the Advancement of Behavior Therapy, Washington D.C.

6a) McCann, R.A., Ball, E.M., Ivanoff, A. (2000). DBT with an Inpatient Forensic Population: The CMHIP Forensic model. Cognitive and Behavioral Practice, 7, 447–456.
Implementation of DBT in a forensic or criminal justice setting differs dramatically from standard outpatient DBT. Forensic patients are multiproblem patients with violent histories and multiple diagnoses including borderline personality, antisocial personality disorder, and concomitant Axis I psychotic or mood disorders. DBT was selected for this population because of its emphasis on treating life-threatening behaviors of patients and therapy-interfering behaviors of both patients and staff. The forensic inpatient DBT model described here includes modification of agreements, targets, skills training groups, and dialectical dilemmas. An additional skills module, the Crime Review, was developed to supplement standard DBT. Conclusions and recommendations for applying DBT in a forensic setting are presented.

6b) McCann, R.A., Ball E.M. (2000). The effec tive ness of DBT with Foren­sic Inpa tients. Insti tute for Foren sic Psychiatry.
The objective of the study was to determine the effectiveness of DBT with 21 primarily male forensic inpatients. The 21 DBT patients were compared with 14 Treatment as Usual patients over a 20 month period. Preliminary analyses suggested that DBT patients’ depressed or hostile mood, paranoia, and psychotic symptoms significantly decreased between November 1994 and July 1996. Similarly DBT patients significantly decreased several maladaptive interpersonal coping styles and increased an adaptive coping strategy. TAU patients did not change significantly on these measures.

Other Articles on DBT and BPD

1) Lieb, K., Zanarini, M., Schmahl, C., Linehan, M., Bohus, M Borderline Pers. Dis.pdf

2) Swenson, C.R., Sanderson, C., Dulit, R.A., Linehan, M.M. (2001). The application of dialectical behavior therapy for patients with borderline per­sonality disorder on inpatient units. Psychiatric Quarterly, 72(4), 307–324.
Notes that inpatient treatment of individuals with BPD is typically fraught with difficulty and failure. Patients and staff often become entangled in intense negative therapeutic spirals that obliterate the potential for focused, realistic, and effective treatment interventions. The authors describe an inpatient treatment approach to BPD patients which is an application of DBT, a cognitive-behavioral therapy for patients with BPD which has been shown to be effective in reducing suicidal behavior, hospitalization, and treatment dropout and improving interpersonal functioning and anger management. The inpatient DBT staff creates a validating treatment milieu and focuses on orienting and educating new patients and identifying the prioritizing their treatment targets. Inpatient DBT treatment techniques include contingency management procedures, skills training and coaching, behavioral analysis, structured response protocols to suicidal and egregious behaviors on the unit, and consultation team meetings for DBT staff.

3) Dimeff, L.A., Linehan, M.M. (2008) Dialectical Behavior Therapy for Sub­stance Abusers. Addiction Science & Clinical Practice. 40, 39–47.
DBT is a well-established treatment for individuals with multiple and severe psychosocial disorders, including those who are chronically suicidal. Because many such patients have substance use disorders, the authors developed DBT for substance abusers, which incorporates concepts and modalities designed to promote abstinence and to reduce the length and adverse impact of relapses. Among these are dialectical abstinence, clear mind, and attachment strategies that include off-site counseling as well as active attempts to find patients who miss session. Several randomized clinical trials have found that DBT for substance abusers decreased substance abuse in patients with borderline personality disorder. The treatment also may be helpful for patients who have other severe disorders co-ocurring with SUDs or who have not responded to other evidence-based SUD therapies.