1. Dialectical Behavior Therapy for Borderline Personality Disorder
Milton Z. Brown, Ph.D.
Alliant International University
DBT Center of San Diego

2. A first DBT session is a lot like a first DBT class Clients and students should know what to expect and make an explicit and firm informed commitment

3. Class Participation Modeling is essential Practice is essential
TIB, like arriving late
Awake – ask about nonverbal behaviors in class
Awake – comment on dysfunctional behaviors
DONB - problematic comments (e.g., judgment)
Practice is essential
in-class role-play
practice awake and DONB on other in class
weekly practice of DBT skills
daily sitting mindfulness practice –

4. Commitment Identify goals of client (or students)
Clear and thorough discussion of what therapy (or class) could involve and why
Collaborative discussion of what can be done to help client (or students) meet their goals
Elicit explicit and firm commitment to specific behaviors
Devil’s advocate strategy
highlight disadvantages of committing
highlight choice: “Are you sure? You don’t have to” –

5. Commitment from Patient
1. By the end of the first session
commit to no suicide before the next session
removing lethal means
2. By the end of the fourth session
long-term commitment to not attempting suicide
long-term commitment to no self-harm
to work on therapy interfering behavior (target #2)
to do diary card and therapy homework
to engage in regular structured productive activities
to work on not avoiding everything

6. Commitment to Patient 1. Commit to four sessions
to decide if you can help the client
for client to decide if she will commit to therapy
2. By the end of the fourth session
make a time-limited commitment (e.g., 1 year)
specify progress required for you to agree to additional therapy after time period ends

7. DBT Interventions are based on Theory of BPD and Theories of Change
DBT was designed for this type of patient, not BPD
Parasuicide = suicide attempts (e.g., overdose) or nonsuicidal self-injury (e.g., self-mutilation)
- nonfatal intentional acute self-injury with or without intent to die, or imminent risk of harm
126 combinations of 5 of 9 criteria!
DBT principles can help with treatment for these difficult patients, even if not BPD

8. Development of BPD Linehan’s Biosocial Theory
Biological and environmental factors account for BPD
BPD individuals are born with emotional vulnerability
BPD individuals grow up in invalidating environments
Reciprocal influences between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system.
Mutual coercion (don’t repeat this!)
BPD becomes noticeable in early adolescence, but begins long before that
Invalidation = when the “communication of private experiences and self-generated behavior is met by erratic, inappropriate, and extreme responses” independent of the actual validity of the responses
Oversimplifies
Trivializes - does not take child’s communications seriously (struggle/pain/need for help)
– often escalation is taken seriously though
Pathologizing
Punitive parenting based on aversive control (i.e., shame-based parenting)
– often backs off when child escalates emotion, violence, and self-harm
– mutual coercion escalation (G. Patterson)
Effects of invalidating environment
-worsen emotionality due to trauma
-self-hate/anger/depression
-failure to learn emotion regulation
-suppression coping style leads to suppression rebound
-increased escalation reinforced
Transactional process (reciprocal influences) explains origins of problems and transactions in therapy

9. Development of BPD Linehan’s Biosocial Theory
BPD individuals grow up in invalidating environments
their emotions and struggles get trivialized, disregarded, ignored, or punished (even when normal)
non-extreme efforts to get help get ignored
only extreme communications/behaviors taken seriously
sexual abuse
Why?
parents are cruel (invalidated or abused as children)
low empathy and skill: don’t understand child’s struggle

10. Development of BPD Linehan’s Biosocial Theory
BPD individuals learn to invalidate themselves
intolerant of their own emotions and struggles (punish, suppress, and judge their emotions, even when normal)
They easily “feel invalidated” by others
They still influence others via extreme behaviors
self-injury/suicidality to get help
aggression, self-injury, and suicidality to get others to back off
Punitive parenting based on aversive control (i.e., shame-based parenting)
– often backs off when child escalates emotion, violence, and self-harm
– mutual coercion escalation (G. Patterson)
Effects of invalidating environment
-worsen emotionality due to trauma
-self-hate/anger/depression
-failure to learn emotion regulation
-suppression coping style leads to suppression rebound
-increased escalation reinforced

11. Most Good Treatments Don’t Work for BPD Patients
BPD has been associated with worse outcomes in treatments of Axis I disorders such as…
Major depression
Anxiety disorders
Eating disorders
Substance abuse
probably because BPD patients have low tolerance for change-focused treatments.
High dropouts and poor compliance. BPD patients feel invalidated and judged.
Our validation therapy had no dropouts
So an effective treatment must be balanced!
Also too much parasuicide and TIB

12. Why DBT was Developed? 1. BPD patients resist efforts to change them
2. BPD patients insist you help them change
3. Parasuicidal behaviors destroy therapy
4. Many behaviors interfering with therapy
5. Too hard for a single therapist to respond to crises and provide both skills training
6. Burnout and negative reactions to patients are common and often lead to iatrogenic behaviors.

13. The Central Dialectic Acceptance and Change
BPD clients often feel invalidated when:
others focus on change (they feel blamed), but also insist that their pain ends NOW
others try to get them to tolerate and accept
BPD clients need to
build a better life and accept life as it is
feel better and tolerate emotions better
Only striving for change is doomed to fail
blocking emotions perpetuates suffering
disappointed when change is too slow 13

14. Theory of BPD Numerous serious problems
suicidal behavior and nonsuicidal self-injury
multiple disorders
crisis-generating behaviors (self-sabotage)
Too many therapy-interfering behaviors
non-compliance
strong emotional reactions to therapists
therapist overwhelm, helplessness, and burnout
therapists judge/blame clients 14

15. Core Problem: Emotion Dysregulation
Theory of BPD
Core Problem: Emotion Dysregulation
pervasive problem with emotions
high sensitivity/reactivity (i.e., easily triggered)
high emotional intensity
slow recovery (return to baseline)
inability to change emotions
inability to tolerate emotions (emotion phobia)
vicious circle (upward spiral)
desperate attempts to escape emotions
vacillate between inhibition and intrusion
inhibited grieving
history of invalidation for emotions
self-invalidation and shame
inability to control behaviors (when emotional)
Impulsive behavior directly elicited by emotions or they function to reduce them 15

16. THE PROBLEM AVOIDANCE OR ESCAPE e.g., interpersonal conflict
(abandon, invalidation)
EMOTION
DYSREGULATION
PROBLEM BEHAVIOR
Alcohol & Drugs
Self-injury
Aggression
CUE
Trigger: interpersonal conflict or demands (conditioned emotional responses)
Example 1: SELF-INJURY: anger/fear/SHAME, low tolerance, slippery slope, cut, internal relief, others back off, support/kindness from others --> RELIEF
Example 2: AGGRESSION: ANGER/fear/shame, low tolerance, hostility, others back off --> RELIEF
Escape conditioning model -
The emotion relief provided by self-injury makes the behavior very resistent to change, through process of escape conditioning and negative reinforcement
The individual experiences extreme anguish, engages in self-injury, and experiences emotion relief which makes the behavior even more likely to occur the next time the individual experiences similar distress. The behavior becomes habitual and automatic.
why does it relieve emotions?
TEMPORARY RELIEF
e.g., others back off
Reinforcement strengthens
this whole process

17. Why Self-harm Must Stop
It is incompatible with a life-worth living 1. It is an escape behavior that removes the opportunity to learn new ways of dealing with difficult events (compare to drugs) 2. Continued sensitivity to triggers (suffering) 3. Strengthens self-hatred and shame. 4. Causes relationship and medical problems 5. I care about someone and let it continue

18. Core Problem: Avoidance
Theory of BPD
Core Problem: Avoidance
Denial of problems (avoiding feedback)
Non-assertiveness and social avoidance
Drug and alcohol abuse
Self-injury, suicide attempts , and suicide
Self-punishment, self-criticism (block emotions)
Dissociation and emotional numbing
Anger to block other (more painful) emotions
Anger to divert away from sensitive interactions
Hospitalization to escape stressful circumstances
The chaos in their lives results from elaborate and pervasive habits of avoidance (often impulsive)
– crisis-generating behaviors
The SOLUTION IS THE PROBLEM (crisis generating behaviors)
They have elaborate fears about “falling into the abyss” if they did not manage to avoid—unendurable suffering and unimaginable catastrophes
Shame avoids anger
Anger/aggression avoids depression/shame

19. The Central Treatment Dialectic
Acceptance and Change
Soothing versus pushing the client
Validation versus demanding
This is the main dialectic in treatment
Our validation treatment had no dropouts

20. The Central Treatment Dialectic
Balancing Acceptance and Change
Balance therapist strategies
validation and Rogerian skills
CBT: problem-solving, skills, exposure, cognitive restructuring, contingency management
Balance coping skills
skills to change emotions and events
acceptance skills are necessary since not enough change occurs and not fast enough 20

21. DBT Targets
Serious problem behaviors targeted immediately and directly
suicidal behavior and nonsuicidal self-injury
excessive hospitalization
therapy-interfering behaviors
Start with stabilization (coping skills)
reduce life chaos (problem solving)
build structure (e.g., work)
distraction and emotion regulation 21

22. Principles of DBT Functions: Enhance capabilities
Improve emotion regulation
Activate non-mood-dependent behavior
Enhance motivation
Assure generalization
Structure the environment
Enhance capability and motivation of therapists
Enhance capabilities (esp. emotion regulation and distress tolerance)
Reduce emotion vulnerabilities (e.g., habituation)
Activate non-mood-dependent behavior (Jacobson behavioral activation)
Enhance motivation
Generalization (enhance capabilities in all relevant contexts): homework, emotion in sessions, audiotapes, phone calls, variety of skills/solutions, work real problems with therapist/therapy
Treatment of the therapist – cue exposure to hostile attacks from clients, support, restructuring, validation, how to not backdown

23. DBT is a Principle-Driven Treatment
minimal use of protocols
flexible use of multiple strategies
based on behavioral analysis (theory of client)
based on theory of BPD
function supersedes form
Multiple modes and strategies
skills training separate from individual
telephone skills coaching
consultation team (therapist support)
Hug therapy 23

24. DBT Strategies Individual therapy
weekly sessions (usually 60 minutes)
telephone skills coaching
telephone crisis management
Skill training (usually group of 5-10)
clients do not talk about self-injury or suicidal intent or behavior
very structured didactic format
not a process group
Not yet known if both components are necessary
Skills training probably does not need to be in a group
We will focus on Individual DBT

25. DBT INTERVENES X X X X Teach how to prevent triggers
AVOIDANCE OR ESCAPE X
EMOTION
DYSREGULATION
Regulate or
tolerate distress
PROBLEM BEHAVIOR
Teach how to stop this behavior
Teach
alternative ways to avoid or
distract
CUE X X
Reduce power
of triggers and emotion vulnerabillity
TEMPORARY RELIEF X
Stop problem
behavior or
reinforcement
Without escape,
emotion dysregulation
should improve

26. DBT INTERVENES X X X Problem solving or AVOIDANCE OR ESCAPE
stimulus control
AVOIDANCE OR ESCAPE X
EMOTION
DYSREGULATION
Regulate or
tolerate distress
PROBLEM BEHAVIOR
Stop behavior:
self-management
Crisis Survival Skills
CUE X
Non-reinforced
exposure,
PLEASE,
increase pos events
Problem solving – offer solutions, teach prob solving skills, interpersonal skills
Reduce vulnerability to emotions (factors that enhance power of triggers, i.e., lower threshold)
-PLEASE – take care of body: sleep, diet, exercise, illness, drugs
-increase positive experiences: mastery, pleasure, positive emotions
Stop problem behavior is one way to stop reinforcement of behavior and avoidance of emotion (exposure to emotions)
Or stop reinforcing consequences following behavior (extinction)
TEMPORARY RELIEF X
Stop reinforcement (extinction)
Without escape,
emotion dysregulation
should improve

27. Focus on Emotion Regulation
DBT Strategies
Focus on Emotion Regulation
Reduce emotional reactivity/sensitivity
exercise, and balanced eating and sleep
exposure therapy
Reduce intensity of emotion episodes
heavy focus on distraction early on, which is a less destructive form of avoidance
Increase emotional tolerance
mindfulness
block avoidance
Act effectively despite emotional arousal 27

28. Self-injury Intervention Options
Prevent, avoid, or solve interpersonal conflict
Reduce emotional reactivity to conflict
Regulate and tolerate emotions
Alternative short-term escape (e.g., distraction)
Behavioral control (e.g., highlight disadvantages, reduce opportunities/means)
Stop relief
naltrexone
do not back off
--these also apply to drug use and aggression
Reduce emotional reactivity to cues and reduce general emotion vulnerability (e.g., PLEASE skills)
Regulate and tolerate emotions – relaxation, activities, cog restruct, mindfulness, acceptance, ice
Alternative short-term escape/distraction as a last resort (e.g., denial, vacation, dissociation/suppression)
Stop relief - make the behavior have no benefit

29. Dialectical Behavior Therapy Treatment Strategies
Problem-solving
Skills-focus* (new skills manual)
Exposure and opposite action
Reinforcement principles
Cognitive modification
Support/Validation/Acceptance
Dialectical Strategies
Problem-solving is often very practical – e.g., block access to lethal means (razors/pills)
*change and acceptance skills; often in a group format; telephone calls from generalization
Inhibit mood-dependent behaviors and structure and reinforce non-mood-dependent behaviors

30. Levels of Validation Listen and pay attention Show you understand
paraphrase what the client said
articulate the non-obvious (mind-reading)
Describe how their behaviors/emotions…
make sense given their past experiences
make sense given their thoughts/beliefs/biology
are normal or make sense now
Communicate that the client is capable/valid
actively “cheerlead”
don’t treat them like they’re “fragile” or a mental patient
Valid = true/correct, normal response to antecedents, effective for one’s goals
Search for the kernel of truth
Invalidate the dysfunctional
DIALECTICS:
V4 – makes sense historically, but not currently (although something in current environment set it off)
Valid conclusions (responses), but invalid thoughts (e.g., premises are distortions)
Right, but not effective
Effective for short-term but not long-term goals

31. Validation What (“yes, that’s true” “of course”)
Emotional pain “makes sense”
Task difficulty “It IS hard”
Ultimate goals of the client
Sense of out-of-control (not choice)
How
Verbal (explicit) validation
Implicit validation
acting as if the client makes sense
responsiveness (taking the client seriously)

32. Functions of Validation
Increases client willingness to change
Strengthens therapeutic relationship
Reinforces staying in therapy
Reinforces clinical progress
Provides feedback to shape behavior
Increases self-validation by modeling validation
Increases positive expectancies (believing in client)

33. Self-Validation Get the patient to say:
“It makes perfect sense that I … because…”
it is normal or make sense now
of my past experiences
of the brain I was born with
of my thoughts/beliefs
Get the patient to act as if she makes sense:
non-ashamed, non-angry nonverbal behavior
confident tone of voice
Sexual arousal at pain + violent fantasies
Abuse of child
Too much faith in others and then got abused by black men and by husband

34. Marsha / Stacey Chain Analysis
From session 2 video
write on white board

35. Agenda Mindfulness practice DBT Listserve Chain analysis
today
regular practice
DBT Listserve
Chain analysis
Self-validation rational-emotional role-play
Observing limits

36. Problem Solving Functional analysis (chain analysis) Solution analysis
accept, tolerate, mindfulness
change, regulate
self vs. environment
Anticipate and solve obstacles
Skills acquisition (model)
Rehearse – “dragging out new behavior”
Commitment
What will the client do differently next time?
Skills acquisition: describe, model, cognitive restructuring, validation
Didactic
Describe recurrent patterns
Highlighting consequences

37. Problem Solving Targeting
Figuring out what to focus on:
Self-injury
Therapy-interfering behavior
Emotion regulation and skillful behavior
shame and self-invalidation (judgment)
anger and hostility (judgment)
dissociation and avoidance
In-session behavior
Targeting
-diary card and homework
-target hierarchy
-check progress in DBT skills group
Impulsive behaviors
Panic disorder
PTSD
Depression – behavioral activation

38. Understand the Problem
Do detailed behavioral analyses to discover:
environmental trigger
key problem emotions (and thoughts)
what happened right before the start of the urge?
what problem did the behavior solve?
and conceptualize the problem (i.e., identify factors that interfere with solving the problem)
Review the audiotape of the session

39. Understand the Problem
Identify factors that Interfere with solving the problem
Lack of ability for effective behavior
Effective behavior is not strong enough
Thoughts, emotions, or other stronger behaviors interfere with effective behavior
Skills deficit – lack of interpersonal skills, emotion regulation, distress tolerance, mindfulness, self-validation
Behavior is not strong enough - Behavior is too low in response hierarchy (reinforcement)
Reducing behavior is interfered with by thoughts, emotions, or other stronger behaviors
-Exposure Strategies – a way to acquire/strengthen distress tolerance skills
-Cognitive Restructuring – a way to acquire/strengthen cognitive skills (e.g., self-validation)
-Contingency Strategies – extinction of dysfunctional behaviors (e.g., parasuicide) that compete with skillful behaviors

40. DBT Assertiveness Skill DEAR MAN GIVE FAST
Assertiveness is an effective alternative for
anger and aggression
helplessness (depression)

41. Therapy Interfering Behaviors (TIB)
arrives late
leaves early
passive or helpless
not do diary card
excessively talks (hard for therapist to talk)
complains but does not work in session
excessively angry
excessively judgmental/critical of therapist
EXAMPLE: client attacks/para when you do something
refuse to talk about a topic if a client only wants to

42. CBT for Anger Work on anger collaboratively Problem solving
motivational interviewing style (no labels)
frame the choice as “right versus effective”
validate what is valid
Problem solving
act on anger when it helps reduce a threat
Skills training
Cognitive restructuring (be careful!)
Exposure 42

43. Skills Training for Anger
Gently avoid (time out)
postpone for a specified amount of time
distraction
pros and cons
Relaxation
Assertive communication (DEAR MAN GIVE)
Empathy and explicit validation (no “should”)
Get help for a “reality check”
Ask a friend: “Am I over-reacting?”
What am I failing to understand about other person?
Is it worth the battle/loss (even if I am right)? 43

44. Cognitive Restructuring for Anger
Empathic interpretations of others
notice “shoulds”
external attributions (current causes)
benefit of the doubt
times client’s intent has been misunderstood
historical causes
Ask rather than assume
Humor
Acceptance and forgiveness 44

45. Exposure for Anger Thoroughly assess triggers In vivo exposure
role-play
verbal barbs
homework
Imaginal exposure
client can write a script in advance
Opposite action
validation
opposite thinking?
DMV in vivo homework example pg. 194 45

46. Responding to Anger in Session
Discourage simple venting/catharsis
Link behavior to clients goals
Refuse to talk about anger-inducing situations when not productive
Validate/apologize/repair to the extent that therapist made a mistake.
Do not avoid the issues that prompt the anger if they are reasonable to deal with
do not back down or appease 46

47. In-Session TIB Protocol Problematic Behavior Excess
EXTINCTION: block behaviors
“that’s ineffective” (broken record technique)
return to the trigger or first emotion
Validate or use humor/irreverence
Comment on the therapy interactions (process)
Illusion of choice in absence of alternatives
Elicit collaboration (turn the tables)
EXTINCTION: Do not respond (at all!)
EXAMPLE: client attacks/para when you do something
refuse to talk about a topic if a client only wants to complain but not work

48. TIB Protocol Problematic Behavior Excess
Other Consequences
Correction-Overcorrection (repair)
Negative judgment from therapist
Vacation from therapy
Therapy termination

49. “Boundaries” in DBT = Observing Limits
Hold natural rather than arbitrary limits
Keep your sanity
Model and reinforce effective interpersonal behavior
Reinforce independent coping

50. Common Contingencies in DBT
Observing limits
“drag out new behavior”
“talk it to death” (miss out on other topics)
fill out diary card in session; make it useful
schedule phone calls (not contingent on problems)
withdraw warmth (or slightly aversive tone)
minimize impact of hospitalization
24 hour rule
Client refuses to collaborate
-confront (learn when to let go, but come back to it later)
-illusion of choice in the absence of alternatives
-change topic quickly (if client chose topic)
-end session early
Improvement on DBT targets
-control agenda
-increased (decreased) length or duration of contacts (sessions or calls)
-more warmth, soothing, validation, reassurance
Recent parasuicidal behavior
-do not increase positive behaviors
-avoid heart-to-hearts
-withdraw warmth (slight aversive)
Client gets suicidal to get into hospital
-teach client to get admitted without suicidal behavior
-have client submit a hospital contingency plan to avoid reinforcement (don't make it too nice)
-help client get out soon
Suicide threats in session: judgments, threats (call family)
Extreme pervasive hopeless thinking (can't work on anything else): assess, orient to, and block avoidance
Highlighting consequences
-things might be worse after dead
-I don't care about dead people
-I won't attend you're funeral
-I'll tell everybody you killed yourself for revenge

51. Contingency Management: Dragging Out New Behavior
Redo dysfunctional in-session behaviors
“Hold the patient hostage" until they emit an adaptive behavior
shaping of successive approximations
modeling, encouragement, validation
Persist like “water over rocks (nagging)
Redo dysfunctional in-session behaviors (but could also be arbitrary rehearsal of solutions)
shaping -"setting the bar" too low (vs. too high)
Build relationship to reinforce new behavior in session (excitement+hope+satisfaction)
-make therapy time-limited so therapist can use therapy as a contingency
refuse to talk about a topic if a client only wants to complain but not work

52. Rational-Emotional Role-Play
1. Assess nuances of the intricate web of negative thoughts lingering
present rational thoughts to counter negative
instruct client to thoroughly discredit rational thoughts
model to client how to counter tricky negative thoughts
2. Have client rehearse rational thoughts
play role of Devil’s advocate (speak neg. thoughts)
prompt client to counter negative thoughts 52

53. Four Skills Modules Mindfulness Distress Tolerance Emotion Regulation
surviving crises
accepting reality
Emotion Regulation
reduce vulnerability
reduce emotion episodes
Interpersonal Effectiveness
assertiveness
INADVERTENT REINFORCEMENT – following dysfunctional behavior…
- adding/extending sessions/calls or end early
- diverting/changing topics (e.g., heart-to-heart)
- hospitalizing for suicidality
- more warmth/soothing or validation
- backing off (after hostile threats or suicide threats/hopelessness talk)
DO NOT REINFORCE DYSFUNCTIONAL BEHAVIOR!!
OVERALL, do not give more when they are worse, INSTEAD more when improvements
- no payoffs for dys. Behavior
- not get out of something/avoid
- do not collude with avoidance
If negative reinforcement (avoidance), persist! Do not back off (extinction burst)
- naltrexone (block internal reinforcement?)
If positive reinforcement, do not increase support/kindness (extinction burst)
- give noncontingent “reinforcement”
- reinforce adaptive behaviors
Punish dys behaviors
Build relationship to reinforce new behavior in session (excitement+hope+satisfaction)
-make therapy time-limited so therapist can use therapy as a contingency
SRS - Longer therapy sessions when she does exposure

54. "you can't say goodbye to something until you say hello to it"
No-where to Now-here
Be Loving and Openhearted with My Emotions

55. Skills for Reducing Emotions
Distraction
activities with focused attention
self-soothing
Intense exercise TIP
Relaxation
progressive muscle relaxation
slow diaphragmatic breathing
HRV biofeedback
Temperature
ice cubes in hands*
face in ice water (whole body dunk)

56. Relaxation Training Progressive Muscle Relaxation Slow breathing
breathe from the diaphragm
5-6 breaths per minute (4 sec in, 6 sec out)
exhale longer than inhale
maximize HRV 56

57. Skills for Persistent Worry
Focus on physical sensations
Imagery desensitization vs. coping imagery
Check the facts (relax or solve problem)
Acceptance
with the mind (“what is IS” “makes sense” “everything is as it should be”)
with body (relax muscles; breathe slowly)
with face (half-smile)
through acceptance actions (act “as if”)
Imagine accepting
Fully accept for one moment

58. Skills for Reducing Behavior
Pros/Cons of new behavior
Mindfulness of current emotion/urge
Postpone behavior for a specific small amount of time (fully commit)
Distract, relax, or self-soothe
Postpone behavior again
Do the behavior in slow motion
Do the behavior in a very different way
Add a negative consequence for behavior

59. Skills for Increasing Behavior
To get opposite action:
Pros/Cons of new behavior
Mindfulness of current emotion/urge
Break overwhelming tasks into small pieces and do first step
something always better than nothing
Problem solve; Build mastery

60. DBT Treatment Outcomes
DBT has better outcomes than TAU/TBE on:
suicidal behavior (self-injury)
psychiatric admissions and ER
treatment retention
angry behavior
global functioning
All treatments show improvement on:
suicide ideation
depressed mood
trait anger
DBT maintained its superior outcomes when compared to only those TAU subjects who received stable individual psychotherapy during the treatment year and when number of psychotherapy hours and number of telephone contacts were controlled.
Outcome results were weaker but generally maintained during a one-year follow-up.
Suicide ideation and depression decreased

61. DBT Treatment Outcomes
Linehan DBT Replication Study
Tx Year FU Year DBT TBE DBT TBE Suicide Attempt 23% 47% Psych ER 43% 58% 23% 30% Psych Inpatient 20% 49% 23% 24%
NIMH3 - N=101; Same reductions in emotions, but less experiential avoidance
-during follow-up yr, 1/4 of DBT and TBE had at least 1 psych ER, and 1/4 of DBT and TBE had at least 1 hospitalization
2 parasuicide BPD studies (Linehan) N=44, N=101
2 drug BPD studies (Linehan) TAU, CVTS
2 BPD studies in other labs (Koons, Verheul) better TAU
1 study of DBT-oriented therapy (Turner) vs. client-centered therapy
2 RCTs of DBT for eating disorders
1 RCT of DBT for geriatric depression

62. DBT Treatment Outcomes
UW Replication Study
Effects of DBT are not simply due to:
session attendance
getting good therapy (TBE)
therapist commitment and confidence
Expert therapists are better than treatment as usual
NIMH3 - N=101; Same reductions in emotions, but less experiential avoidance
-during follow-up yr, 1/4 of DBT and TBE had at least 1 psych ER, and 1/4 of DBT and TBE had at least 1 hospitalization
2 parasuicide BPD studies (Linehan) N=44, N=101
2 drug BPD studies (Linehan) TAU, CVTS
2 BPD studies in other labs (Koons, Verheul) better TAU
1 study of DBT-oriented therapy (Turner) vs. client-centered therapy
2 RCTs of DBT for eating disorders
1 RCT of DBT for geriatric depression

63. Is DBT feasible in the Real World?
Research patients have severe problems and multiple diagnoses
Treatment can provide a cost savings
sessions 3 hrs/wk + phone calls
Is treatment is too hard for average therapists to learn competently?
ongoing evaluation, consultation, and training is worth the cost
Many settings/clients require adaptations
little is known about core change process 63