CHAPTER 1

The Basics of DBT

Since the middle of the twentieth century, psychotherapy has essentially gone through three evo-
lutions: the development of behavior therapy in the 1950s, Aaron Beck’s development of cognitive
therapy in the 1970s, and a merging of these two therapies into the well-known and most-used
contemporary treatment—cognitive behavioral therapy (Ost, 2008). The last ten to fifteen years
have seen the rising of a “third wave” of cognitive and behavior therapy (Hayes, 2004), incorporat-
ing mindfulness and acceptance techniques. Dialectical behavior therapy is one of these third-wave
therapies and has been proven highly effective in the treatment of patients with borderline person-
ality disorder, who have difficulties regulating their emotions.

WHAT IS DBT?
DBT is a form of CBT. Palmer refers to it as “a strange hybrid” (2002, p. 12) of a number of differ-
ent therapies and techniques. Many people have asked me how DBT and CBT differ. I usually
respond that, in terms of the skills, DBT is really just CBT using a different language, with the
addition of mindfulness and acceptance techniques. DBT takes the judgment out of CBT so that
the way clients are thinking isn’t “wrong,” “erroneous,” or “distorted,” with the goal being to change
their way of thinking. Instead, DBT acknowledges that there is a problem with the way clients
think, but the therapist first encourages clients to accept this, rather than judge it, and then helps
them look at how they can make changes so that their thinking is more balanced.
However, looking at the entire model of DBT rather than just the skills reveals that this treat-
ment is quite different from CBT. The main distinction is that DBT is a principle-driven therapy,
whereas CBT tends to be a protocol-based therapy (Swales & Heard, 2009). In CBT, the therapist
follows specific procedures; for example, when a client presents with panic attacks, a certain set of
rules or procedures are followed to treat the panic, such as providing psychoeducation, teaching
abdominal breathing, and so on.
DBT Made Simple

In DBT, the therapist is instead guided by principles, allowing the therapist to be more flexible.
This is crucial in treating people who have difficulties managing their emotions—and specifically
those with a diagnosis of BPD—since these clients often face a variety of problems, making it
difficult to focus on just one issue in each session. When a client is experiencing a variety of prob-
lems, attempting to follow a highly structured treatment protocol that targets just one of these
problems is almost impossible (Swales & Heard, 2009) and would probably be perceived by the
client as invalidating.
A second major difference between DBT and CBT is in how treatment is delivered. CBT can
be provided in either a group or individual format but rarely occurs in both simultaneously, whereas
DBT consists of four different modes of therapy: individual therapy, skills group, telephone consul-
tation, and the therapy team (each of which will be outlined later in this chapter).
Like CBT, DBT incorporates self-monitoring; however, it’s taken to a different level in DBT
with the use of Behavior Tracking Sheets (see chapter 2). DBT also differs from CBT in the way
individual sessions are structured, addressing behaviors and stages of treatment in a hierarchy
determined by the severity and threat of target behaviors. DBT is also distinguished by its use of a
suicide risk and assessment protocol (see Linehan, 1993a, for detailed discussion).
Above and beyond the delivery of treatment, the use of the therapeutic relationship in DBT is
based on learning theory and quite distinct from the approach in CBT. Because DBT is a behavior-
ally focused treatment, the therapist views BPD as a pattern of learned behaviors. To help clients
unlearn these destructive behaviors, the DBT model emphasizes the importance of identifying the
triggers for dysfunctional behaviors and the contingencies that are maintaining these behaviors.
To facilitate this, the DBT therapist makes every effort to develop a deep and genuine thera-
peutic alliance with the client, which can then be used in a variety of ways (discussed in depth in
chapter 4) to help clients make the necessary changes. In CBT, clients learn many techniques to
help change distorted thinking; in DBT, clients are taught to accept themselves as they are, and
then they learn tools to help them change behaviors that are unhealthy or problematic in some way.
The therapeutic relationship (including therapist self-disclosure) becomes another tool that the
therapist uses to help clients make these difficult changes.
Having a relationship with a healthy, positive figure is especially important for clients who have
problems regulating their emotions, as you’ll see shortly when we look at the biosocial theory of
BPD. Before we address the theory of how emotion dysregulation develops, however, we must first
define emotion dysregulation itself.

WHAT IS EMOTION DYSREGULATION?

According to Linehan (1993a), emotion dysregulation results from a combination of high emotional
sensitivity or vulnerability and an inability to regulate or modulate one’s emotions.

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Emotional Vulnerability
Emotional vulnerability refers to a biological predisposition or temperament where an individual is
born more emotionally sensitive than most people. These individuals have a tendency to react
emotionally to things that others wouldn’t typically react to. Their emotional reaction is usually
more intense than warranted by the situation, and it takes them longer than the average person to
recover from that reaction and to return to their emotional baseline.
This idea of emotional vulnerability is similar to the concept of the highly sensitive person
written about extensively by Elaine Aron (1996). Aron believes that having a sensitive nervous
system is a relatively common neural trait, claiming that approximately 15 to 20 percent of the
population experiences this high level of sensitivity. Aron postulates that highly sensitive people
are more easily aroused (reacting emotionally to things that others wouldn’t typically react to) and
overaroused (experiencing a more intense reaction than is warranted by the situation).
Blakeslee and Blakeslee (2007) support the idea that this higher emotional awareness has a
neural, physiological basis. Further, Koerner and Dimeff (2007) note that differences in the central
nervous system have been found to play a role in making a person more emotionally vulnerable,
and that these central nervous system differences could be related to a variety of factors, including
genetics or trauma during fetal development or in early life.

Inability to Regulate Emotions

Emotion regulation refers to the processes we use (unconsciously, consciously, or even perhaps with
a tremendous amount of effort) to decrease, maintain, or increase an emotion or aspects of an
emotion (Werner & Gross, 2010). Most often we want to reduce the intensity of painful emotions
or make them go away altogether if possible. But sometimes we actually want to increase an emotion
(for example, someone who’s feeling depressed may want to increase feelings of enjoyment). Both
of these are considered emotion regulation.
It’s important to note that emotion regulation doesn’t mean suppressing emotions or trying to
hide them from others; in those cases, the emotion is still there and unregulated, although it may be
hidden. Instead, the goal of emotion regulation is to achieve a balanced state of consciously manag-
ing the experience and expression of the emotion (Greenberg & Paivio, 1997).
People who are unable to regulate their emotions usually find it difficult to identify or put a label
on the emotion they’re feeling, to understand why they feel that way, and to express the emotion
in an effective way. As a result, they have a hard time tolerating the emotions they experience.
Unlike the emotional vulnerability component to this equation, it seems that the ability to
regulate one’s emotions is more influenced by the environment a person grows up in. For example,
Miller, Rathus, and Linehan (2007) point to research that suggests that early abusive experiences
have a direct effect on people’s ability to regulate their emotions. On the positive side, this means
that children develop healthier abilities to regulate their emotions when their parents respond to

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their expression of painful emotions in an accepting and supportive way (Thompson & Goodman,
2010). Likewise, Koole (2009) reports that children’s ability to regulate their emotions is greatly
influenced by the quality of their social interactions with caregivers. Koole also notes that people’s
ability to regulate emotions changes across the life span, continuing to improve with age. So the
good news is that we can teach adults the skills they need to regulate their emotions if they didn’t
learn them as children.

THE BIOSOCIAL THEORY OF BORDERLINE

PERSONALITY DISORDER
Because Linehan originally developed her biosocial theory to aid in the understanding and treat-
ment of borderline personality disorder (1993a), I will refer only to BPD in this discussion. However,
at the end of this section I’ll take a look at two examples of how researchers are beginning to apply
this theory to other disorders.
According to Linehan’s biosocial theory (1993a), emotion dysregulation (emotional vulnerabil-
ity plus the inability to regulate one’s emotions) stems from a biological predisposition and the
individual’s interaction with the environment (Miller et al., 2007). We’ve just looked at the biologi-
cal predisposition—the emotional dysregulation component—and there is an abundance of
research showing that some people are just born more emotionally sensitive than others. However,
this doesn’t mean that all people who are born emotionally sensitive will develop BPD or other
mental health problems. This is only one part of the equation; the other part is the environment a
person grows up in. Problems tend to arise when a biologically vulnerable person is faced with a
pervasively invalidating environment (Linehan, 1993a).

The Invalidating Environment

Miller and colleagues (2007) define an invalidating environment as one in which there is a tendency
to deny or respond unpredictably and inappropriately to the child’s private experiences, and espe-
cially to private experiences such as emotions, physical sensations, and thoughts, which aren’t
accompanied by evidence to prove that this is, in fact, the child’s experience. In other words, when
a child expresses an emotion (a private experience), the people in her environment judge her for
this experience (e.g., telling her that she shouldn’t be feeling that way or that she’s overreacting);
tell her that her experience is incorrect or minimize her experience; punish her for talking about
her experience; ignore her expression of the experience; and so on.
In invalidating environments, the expectation is usually that the child should be able to control
the expression of her emotions (which, because of the emotional vulnerability of the child, is unre-
alistic) and should not express “negative” feelings (Miller et al., 2007). When she is unable to
succeed in meeting these expectations, the environment punishes her for communicating these

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negative experiences and responds to her emotional displays only when she escalates, essentially
teaching her to alternate between stifling her emotions and communicating emotions in extreme
ways in order to get help (Koerner & Dimeff, 2007).
The other important piece about invalidating environments is that often the message is con-
veyed that the individual should be able to easily solve the problem she’s experiencing. However,
in this type of environment, skills such as emotion regulation and problem solving are never prop-
erly taught to the emotionally sensitive child. So the message is that she should be able to help
herself feel better, but she has never learned skills for doing so. This obviously sets her up for failure
and leads to self-invalidation (for example, telling herself everyone says she should be able to do
this, and judging herself when she can’t).
There are many ways in which an environment can be invalidating. The next four sections
discuss some examples.

THE POOR FIT

Sometimes children are born into families in which they just don’t fit properly. An example
would be a creative child born into a family in which her parents and siblings are practical and
hardworking and see her creativity as a waste of time—something that will never earn her enough
money to be independent and therefore not to be pursued. Such parents may have their child’s best
interests at heart; they want her to succeed and to be happy, but they discourage her from pursuing
her creativity because they don’t think it’s in her best interests. The emotionally vulnerable child
will grow up in this invalidating environment feeling that her desire to be creative is wrong, and
that there is therefore something wrong with her for wanting to pursue it. She will also feel misun-
derstood by and different from the rest of her family.

THE CHAOTIC HOME

Some families have additional challenges that make it difficult for them to provide a validating
environment. Perhaps the parents themselves were invalidated as children and therefore never
learned how to provide validation for themselves or for others. Parents who have a mental health
problem of their own or an addiction, or who are financially unstable and therefore have a hard time
providing the necessities of life, will have a much more difficult time providing an emotionally safe
and healthy environment for their children.
It’s also important to note that highly emotionally sensitive children can be the cause of at least
some of the chaos in the home. Miller and colleagues (2007) note that just having an emotionally
vulnerable child in the family can be so challenging that the family system becomes overstressed,
possibly resulting in an invalidating environment. In other words, when an emotionally vulnerable
child is born into a family where others don’t share this trait, it’s difficult for the rest of the family
to understand, and this in itself can cause invalidation as parents become frustrated with the child
and don’t know how to help. We’ve all heard a parent telling an anxious child, “Don’t be silly;

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there’s nothing to be afraid of,” telling a hurt child, “Stop crying,” or telling an angry child, “You’re
not being very nice.” These parents don’t mean to invalidate the child; they’re just feeling frus-
trated themselves and don’t know how to effectively help their child in that moment. For an emo-
tionally vulnerable child, however, over time these messages add up to the idea that there’s
something wrong with her.

THE ABUSIVE HOME

Abuse doesn’t have to occur for BPD to develop, but it’s certainly not uncommon. For example,
one study (Stone, 1981) indicated that 75 percent of twelve hospitalized patients with a diagnosis
of BPD had a history of incest. A chart review (Herman, 1986) found that 67 percent of twelve
psychiatric outpatients with BPD had a history of abuse in childhood or adolescence. And a quali-
tative study (Bryer, Nelson, Miller, & Krol, 1987) found that 86 percent of fourteen hospitalized
patients with BPD had experienced sexual abuse before the age of sixteen.
An abusive environment is, of course, the ultimate invalidating environment. It can take many
forms, from physical abuse in response to the child’s expression of negative emotions or for the child’s
“own good” to sexual abuse in which the abuser tells the child that it’s okay but instructs her to not
tell anyone, possibly threatening her or those she loves if she does tell. In addition to this invalidation
by the abuser, many individuals experience further invalidation when they tell someone about the
abuse and are disbelieved, accused of lying, and possibly even blamed for the abuse (Linehan, 1993a).
Although neglect is a passive form of abuse, it can be just as damaging. With neglect, the child
learns that no matter what she does, her needs, wants, and emotions will be largely disregarded
(invalidated)—unless, of course, she escalates her behaviors to the point that her caregivers can no
longer ignore them.

OTHER INVALIDATING ENVIRONMENTS

While we generally look to the family and home environment to see where the problems lie,
invalidation can also happen outside the home: at school, at church, at the babysitter’s house, while
spending time with other family members, while engaging in extracurricular activities such as sports
or clubs, and so on. Of course, children spend a lot of time at school, and if the school is an unhealthy
environment, it will have negative consequences for the emotionally vulnerable child. Examples of
invalidation outside of the home include a child with attentional difficulties (such as ADD) whose
teacher accuses her of not trying or of purposely being disruptive in class, a child who is bullied by
peers (e.g., being teased for crying), a child who has difficulties making friends, or a child whose
coach focuses on the negative and tells her she should be able to do more or do better.

A TRANSACTIONAL MODEL
It’s important to emphasize that the biosocial theory is dialectical or transactional, meaning that
inter­actions take place over time between the environment and the individual, gradually leading to

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their adaptation to one another, and to the development of BPD. Therefore, therapists are encour-
aged to view client behaviors as natural reactions that occur in response to environmental reinforc-
ers (Lynch, Trost, Salsman, & Linehan, 2007). The individual cannot be blamed for being “too
sensitive,” and the environment is also not completely at fault. Without the interaction between
these two elements, the illness would be unlikely to develop.

Applying the Biosocial Theory to Other Disorders

As you can probably tell from your reading thus far, Linehan’s biosocial theory can probably be
applied to many clients, whether they have a diagnosis of BPD or not. In fact, difficulties regulating
emotions are not uncommon, accounting for more than 75 percent of the mental illnesses described
in the Diagnostic and Statistical Manual of Mental Disorders (Werner & Gross, 2010). This may also be an
issue for people who have no specific mental illness.
Applying the biosocial theory to the development of other illnesses makes a lot of sense, given
that emotion dysregulation is a component of so many different illnesses, and that this problem can
lead to emotional avoidance through engaging in unhealthy behaviors such as substance use, dis-
ordered eating, self-harm, and so on. I’m sure that anyone who works with individuals with mental
health problems regularly sees the impact that an invalidating environment can have on people.
While to date the biosocial theory has only been written about in regard to BPD, other person-
ality disorders, and eating disorders, in my professional experience it would also apply to many
clients with other diagnoses, and probably to individuals who might not have a diagnosable mental
illness but do have difficulties regulating their emotions. For now, let’s take a quick look at the
thinking on the biosocial theory in relation to other personality disorders and eating disorders.

Other personality disorders. Lynch and Cheavens (2007) have proposed that the biosocial model
can be applied to personality disorders other than BPD. They suggest that a biological predisposi-
tion toward increased negative affect interacts with an invalidating environment that reinforces
unhealthy forms of avoidance in a transactional way to produce the cognitive, emotional, and
behavioral patterns commonly seen in personality disorders, especially in the form of difficulties
maintaining interpersonal relationships, regulating emotions, and controlling impulses.

Eating disorders. Some authors have looked at applying the biosocial theory to binge-eating disor-
der and bulimia, based on the idea that people engage in disordered eating behaviors due to an
inability to regulate their emotions (Wisniewski, Safer, & Chen, 2007). Along these same lines,
Safer, Telch, and Chen (2009) propose that the underlying problem in both binge-eating disorder
and bulimia nervosa is an underdeveloped and insufficient emotion regulation system, leaving these
individuals unable to adequately monitor, assess, accept, and change their emotional experience.
Safer and colleagues theorize that these difficulties stem from the emotionally vulnerable child
being given the message that she should be able to regulate her emotions and solve problems even
though she hasn’t been taught the skills for doing so.

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THE DIALECTICAL THEORY OF DBT

In creating her treatment model, Linehan (1993a) was greatly influenced by the theory of dialectics,
a complex philosophical and scientific concept with three main principles:

• Everything is interconnected or interrelated. This idea helps us understand the impor-

tance of taking a whole-systems approach to identifying and managing change. It also
reminds us that the actions and reactions of the client will affect the therapist, who will
in turn affect the client, and so on (Feigenbaum, 2007).

• Reality is not static, but is in a process of continuous change (Swales & Heard, 2009).

• The truth (which is always evolving) can be found by integrating or synthesizing dif-
fering (and possibly opposite) views (Feigenbaum, 2007). This idea, of course, is con-
trary to the black-and-white thinking typical of people with emotion dysregulation.

So what, exactly, does this mean for therapy? Miller and colleagues (2007) note that thinking
dialectically means looking at both perspectives in a situation and then working toward synthesiz-
ing these possibly opposing perspectives. In other words, clients (and therapists!) need to learn to
tolerate the idea that two seemingly opposite things can coexist. In thinking dialectically, therapist
and client must remember that reality is not static and fixed, but is constantly changing and full of
apparent contradictions; for example, the assertion that clients are doing the best they can and that,
at the same time, they have to work harder and do more. Another common example, especially for
a client with difficulties regulating emotions, is the idea of experiencing two seemingly opposite
emotions at the same time; here it is the therapist’s job to help the client learn that she can, for
example, love her partner and be really angry at him at the same time.
Thinking dialectically means that we must practice acceptance while also continuing to work
toward change. In DBT, this is the primary dialectic—both therapist and client need to accept the
client as she is and also need to continue working toward changing the behaviors that are unhealthy
or self-destructive. However, there are many other ways that dialectical thinking comes into play
in therapy. For example, when disagreements arise in therapy or in the client’s life, dialectical think-
ing helps both therapist and client remember to search for what’s being left out of their reality so
they can try to see the bigger picture or different perspectives (Basseches, 1984).
Lynch and colleagues (2007) point out that one of the most frequent dialectical tensions is the
idea that an unhealthy or self-destructive behavior, such as cutting, can be both functional (in that
it helps people reduce their emotional distress in the short term) and dysfunctional (since the self-
injury results in a variety of negative consequences). In this dilemma, client and therapist need to
find the synthesis of these two apparent opposites; for example, validating the need for the client
to achieve some relief, while at the same time assisting her in learning and using skills that will
reduce the distress in a nonharmful way (Lynch et al., 2007).
Thinking dialectically means recognizing that all points of view can have aspects that are both
valid and incorrect. In therapy, it’s important to know that polarizations are inevitable; taking a

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dialectical perspective means acknowledging this inevitability, watching for the polarizations, and
not allowing yourself to get caught up in them when they occur. Lynch and colleagues (2007) note
that this dialectical idea of taking the middle path is an inherent feature of Zen, and that DBT
incorporates these ideas to help clients act in more effective ways and live more balanced lives.

THE DBT MODEL

As mentioned earlier, the DBT model is made up of four components. Although my professional
experience has been that DBT can be provided to clients in an effective way without including all of
these components, the majority of the research on DBT for BPD looks at the full model, which
includes skills training group, individual therapy, telephone consultation, and the consultation team.

Skills Training Group

The skills training group is a psychoeducational, structured group format designed to develop
and enhance client capabilities. The group takes place once weekly and is divided into four modules:
core mindfulness skills, interpersonal effectiveness skills, emotion regulation skills, and distress
tolerance skills.

Core mindfulness skills. Linehan (1993b) breaks mindfulness down into smaller parts to make it
easier for clients to understand and incorporate it into their lives. The aim of mindfulness in treat-
ing BPD is to reduce confusion about the self, but mindfulness is also helpful in many other ways.
Increasing self-awareness helps clients become aware of their thoughts, emotions, and urges and
gradually learn to manage them more effectively. Through mindfulness, clients also learn to toler-
ate the thoughts, emotions, and urges that they can’t do anything about, coming to see that internal
experiences don’t have to be acted upon, but can simply be acknowledged, and that these experi-
ences will gradually dissipate.

Interpersonal effectiveness skills. These skills aim to help clients reduce the interpersonal chaos that
is often present in their lives and are primarily about how to be more assertive. Clients are taught to
think about what they most want to get out of an interaction (for example, if they have a specific
objective, if they wish to keep or even improve the relationship, or if they wish to keep or improve
their self-respect) and then are taught skills that will make it more likely for them to reach this goal.

Emotion regulation skills. The goal of this module is to decrease mood lability. Clients are taught
general information about emotions, such as why we need them and why we don’t want to get rid
of them even though they can be quite painful at times. Clients learn about the connection between
their thoughts, feelings, and behaviors, and that by changing one of these they can have an impact
on the others. Self-validation is emphasized in this module, along with other skills to help clients
manage their emotions more effectively.

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Distress tolerance skills. These skills are also known as crisis survival skills, and the goal is simply that:
to help clients survive crises without making things worse by engaging in problem behaviors such
as suicide attempts, self-harm, substance abuse, and so on. These skills help clients soothe and
distract themselves from the problem, rather than dwelling on it and eventually acting on the urges
that accompany the painful emotions.
Teaching skills in a group format as opposed to in individual therapy is done for a variety of
reasons: First, clients with emotion regulation difficulties are often moving from one crisis to another,
and it’s extremely difficult to teach skills in an individual session when the client understandably
wants help with the current crisis. In addition, an important aspect of any group setting is validation,
as each client has the experience of being in a group with others who have similar problems. Another
benefit of groups is that the learning experience can be much richer as each client learns from the
experiences of fellow group members. Finally, because interpersonal issues often arise in groups, this
can be an excellent arena for practicing the skills being taught and also allows clients to receive
coaching from the group therapist on how to use the skills to act more effectively.

Individual Therapy
Clients usually attend individual sessions with a DBT therapist once weekly. The goal of indi-
vidual sessions is to help clients use the skills learned in group to reduce target behaviors such as
suicidality, self-harm, use of substances, and so on. As with group sessions, individual sessions have
a very clear structure and format, which will be discussed in detail in chapter 2.

Telephone Consultation
Telephone consultation is used to coach clients to use skills. Telephone consultation is meant to
be a brief interaction to help clients identify what skills might be most helpful in the situation
they’re facing, and to help them overcome obstacles to using these skills and acting effectively.

Consultation Team
According to Linehan, “There is no DBT without the team” (2011). The makeup of the DBT
consultation team will vary depending on the therapist’s environment. Typically, the team consists
of all the therapists in a DBT clinic: social workers, psychologists, psychiatrists, and anyone else
working in individual therapy and skills training groups with DBT clients. For therapists working in
clinic settings, this is fairly straightforward. For those of us who work in private practice, however,
it gets a little more complicated. Because the team is important in keeping therapists on track in
their practice, private therapists may want to develop a team consisting of other private DBT thera-
pists in their area or even online, provided that confidentiality is adhered to. As a DBT practitioner

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in private practice, I have been fortunate enough to have a psychiatrist who works in a DBT clinic
provide consultation for me on an ongoing basis. The team doesn’t have to be large; what matters
is that you receive objective feedback about your practice.
Whatever it consists of in your circumstances, the team is used in two ways: first, to provide
support to therapists and help them continue to develop their skills in working with clients using the
DBT model; and second, for case discussion. During case discussion, the team helps the therapist
ensure that she is adhering to DBT strategies and techniques. The team also addresses any feelings
of burnout and ineffectiveness. In consultation meetings, the team uses DBT techniques such as
taking a dialectical stance and being nonjudgmental to prevent team members from getting caught
up in power struggles and other dynamics that can disrupt the team and the therapeutic process.

BEING FLEXIBLE WITH DBT

Previously in my career, I’ve worked with a DBT team in both a hospital and a community setting.
We tried many variations of DBT due to the problem of limited resources. We were a small team of
about six therapists and case managers. We began by providing as much of the pure DBT model as
we could. We provided a skills training group once weekly and individual therapy biweekly, and we
had a consultation team meeting once a month, although the consultation meeting didn’t strictly
follow the DBT format. We were unable to provide twenty-four-hour telephone consultation, but
clients had access to a twenty-four-hour crisis line. If they contacted the crisis line and identified
themselves as DBT clients, they received coaching in distress tolerance skills to help them get
through the current crisis.
Because we were such a small team with no extra resources, we experimented with variations
on the pure DBT model in an attempt to reduce our workload, which was leading to feelings of
burnout and ineffectiveness. Of course, while being able to provide the full model is ideal, those in
the front lines know it’s not always possible. My belief is that sometimes a little DBT is better than
none. For instance, I find the DBT skills invaluable for many clients, especially the mindfulness and
acceptance skills, which many clients have never learned in other treatment modalities. Validating
clients and teaching them to validate themselves, given the environment they grew up in, is also
invaluable. In addition, incorporating the biosocial model into your practice, thereby reducing the
tendency to blame clients for their behaviors, will have a tremendous benefit both for your clients
and for the therapeutic relationship, which will help reduce the likelihood that you’ll burn out.

RESEARCH ON DBT FOR BPD

AND OTHER DISORDERS
Since DBT originated in 1980, a lot of research has looked at its effectiveness as a treatment for
BPD and, more recently, for other illnesses. In this section, I’ll outline the research on DBT for BPD

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as well as adaptations of the model, and then take a look at the emerging research on using DBT to
treat other mental health problems.

DBT for Borderline Personality Disorder

DBT was the first psychotherapeutic treatment for BPD that was tested in a clinical trial. The
original trial compared one year of DBT to treatment as usual and found that DBT was a superior
treatment, especially in terms of reductions in self-harm, overdosing, and hospitalization rates
(Linehan, Armstrong, Suarez, Allmon, & Heard, 1991). Other studies completed since the original
trial had similar findings (e.g., Koons et al., 2001; Verheul et al., 2003). In addition, in 2006, Linehan
and colleagues completed another study, this time comparing DBT for BPD to treatment provided
by community experts—therapists in the community who were selected because of their interest
in treating BPD and because they used a treatment modality they described as nonbehavioral, or
mostly psychodynamic. The results of this study also showed DBT to be a superior treatment, with
reductions in suicide attempts and hospitalization rates (Linehan et al., 2006).

Adapting DBT
Several authors have modified the original DBT model in an attempt to shorten the length of
Linehan’s original twelve-month treatment model and lower costs. For example, Bohus and col-
leagues (2004) adapted the model to provide a shorter, three-month version of DBT for individuals
with BPD on an inpatient unit. Similarly, Kleindienst and colleagues (2008) found three months of
DBT provided to clients with BPD on an inpatient unit to be highly effective, and the improvements
were maintained at a two-year follow-up. In addition, an outpatient study suggested that a six-month
adapted version of DBT was effective in treating BPD (Stanley, Brodsky, Nelson, & Dulit, 2007).
Obviously, more research is needed to determine the efficacy of adapted models of DBT.
However, my professional experience has been that you don’t have to provide the “pure” or com-
plete model of DBT for clients to benefit—especially clients without BPD. In fact, given that
resources are often scarce these days, I believe we need to be more flexible so clients can still
receive some sort of DBT treatment, even if it isn’t possible to adhere to the complete model.

DBT for Other Psychiatric Disorders

More and more research is being done on using DBT to treat illnesses other than BPD. Because
of the large body of research, I will provide only a brief summary here. In a 2008 paper, Harned
and colleagues noted that several studies have found DBT to be effective in reducing behaviors
associated with Axis I disorders, including substance use, bulimia, binge-eating disorder, depres-
sion, and anxiety. DBT has also been studied in the following contexts:

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 The Basics of DBT

• Harley, Sprich, Safren, Jacobo, and Fauva (2008) found significant improvement in
patients with treatment-resistant depression.

• Preliminary research has found DBT to be helpful in the treatment of bipolar disorder in
adolescents (Goldstein, Axelson, Birmhaer, & Brent, 2007), and DBT skills to be helpful
in the treatment of bipolar disorder in adults (Van Dijk, Jeffery, & Katz, in press).

• DBT skills training was determined to be feasible and promising in improving the
behavior of adolescents with oppositional defiant disorder (Nelson-Gray et al., 2006).

• DBT-enhanced habit-reversal treatment was found to be a promising adaptation for

trichotillomania, with improvements lasting at the six-month follow-up (Keuthen et
al., 2011).

• DBT modified to intensively treat post-traumatic stress disorder (PTSD) related to

childhood sexual abuse was found to be a promising approach (Steil, Dyer, Priebe,
Kleindienst, & Bohus, 2011).

• Perepletchikova and colleagues (2011) adapted DBT to treat children who were engag-
ing in nonsuicidal self-harming behaviors; the results were promising, with a signifi-
cant increase in adaptive coping skills and significant reduction in depression and
suicidal thoughts.

• Rajalin, Wickholm-Pethrus, Hursti, and Jokinen (2009) used DBT-based skills training
for family members of people who had attempted suicide. Results indicated significant
reductions in caregiver burden, improved emotional health, and increased satisfaction
regarding the relationship with the patient.

Interestingly, clinicians are also using DBT to treat illnesses and problems not related to Axis I
disorders. For example, Evershed and colleagues (2003) used DBT to treat anger in male forensic
patients and found that, compared to patients who received treatment as usual, the DBT group
made greater gains. More recently, Sakdalan, Shaw, and Collier (2010) found that DBT reduced
level of risk in suicidal forensic patients with intellectual disability, and Drossel, Fisher, and Mercer
(2011) found that DBT helped caregivers of loved ones with dementia increase appropriate help-
seeking behavior, improved their psychosocial adjustment, increased their ability to cope, enhanced
their emotional well-being, and reduced caregiver fatigue.
Again, in the spirit of reducing length and subsequent costs of treatment, some researchers
have been working on adapted models of DBT treatment for disorders other than BPD. Lynch,
Trost, Salsman, and Linehan (2007) note two studies that suggested that DBT skills training accom-
panied by only minimal individual therapy may be helpful for less severe psychiatric illnesses.
In spite of the length of this “brief” survey, it isn’t exhaustive. Many other studies have looked
at the efficacy of DBT in treating BPD and other illnesses. Hopefully, though, this short review has
illuminated the adaptability and flexibility of DBT.

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DBT Made Simple

WRAPPING UP
So far we’ve looked at what exactly DBT is as a treatment model: how it differs from CBT; its theo-
retical underpinnings; the different modes of treatment involved; that the model is flexible and can
be adapted to reduce length of treatment or be applied to other populations; and that research
supports the efficacy of both the pure DBT model and some adaptations of the model. In the next
chapter, I’ll discuss the DBT assumptions about clients with BPD (which can be applied to general
difficulties with emotion regulation); some techniques used to help reduce therapist burnout; the
stages of treatment; and how the individual sessions are structured.

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