by Michael D. Anestis, M.S.
As anyone who reads this site with any regularity has likely already figured out, I am a big fan of dialectical behavior therapy (DBT; Linehan, 1993). Now, of course, my being a fan of something has absolutely no impact on whether or not it is an effective treatment approach; however, as discussed previously on PBB, numerous studies have demonstrated that DBT is empirically supported as a treatment for borderline personality disorder (BPD) and supportive evidence is accumulating for the use of DBT in the treatment of both binge eating disorder (BED) and bulimia nervosa (BN). All this being said, however, there is one aspect of DBT that has always bothered me (and many of my colleagues): the required length of treatment.
One of the many benefits of empirically supported treatments (ESTs) is that the vast majority of them offer effective care over a short period of time and are thus more efficient, cost effective, and likely to prevent high rates of client drop-out than are alternative approaches. DBT, on the other hand, is theorized to require a minimum of one-year of treatment, with many clinicians recommending a two-year protocol. If data supports this length of treatment as optimal, than of course it makes sense to maintain such a long course of treatment. Unfortunately though, this idea has not been subject to a great deal of research.
In the initial study of DBT, Linehan and colleagues (1991) found that reductions in suicide attempts and non-suicidal self-injury (NSSI) occurred on average during the first four months of treatment. The subsequent eight months of treatment did not lead to further reductions in these behaviors and were instead conceptualized as a period for "consolidation of gains." Given that the impact of DBT on behavioral outcomes was so quick in the initial study, however, it seems worthwhile to examine whether treatment can be administered successfully in a period of time shorter than a calendar year. Stanley, Brodsky, Nelson, and Dulit (2007) did just this by conducting a study examining the utility of a brief version of DBT that required only six months of treatment.
The sample in this study consisted of twenty individuals (85% female) diagnosed with BPD through the use of semi-structured clinical interviews (see our assessment tools page for more information on diagnostic tools). All participants reported active suicidal ideation at baseline, meaning that the authors did not restrict treatment to individuals who exhibited only mild symptoms.
Data were collected at baseline and at the end of treatment, affording the authors a chance to examine changes over the course of six months. Their findings were quite remarkable. At six months, participants exhibited a significant reduction in all of the following variables:
- NSSI urges
- NSSI episodes
- Suicidal ideation
- Subjective distress
- Hopelessness
- Depression as measured by the Beck Depression Inventory - 2
Quite clearly, these results are highly promising. That being said, some caution is required in interpreting these results for a variety of reasons. First, because there was no comparison group that engaged in the standard DBT protocol, we can not use these data to determine the degree to which improvement in the brief protocol truly compares to improvement in the standard one-year format. Additionally, because no follow-up data were compiled, we can not determine the degree to which the benefits of the brief treatment are maintained after treatment is completed. The sample was not randomized, meaning that individuals who received treatment chose to receive that particular treatment and, although prior deconstruction studies have demonstrated that the effects of DBT are not due to common factors of therapy (Linehan et al., 2006), this nonetheless is a weakness that could be improved upon in further studies. Also, the sample size (n = 20) was quite small, thereby limiting the generalizablility of the findings and the power of the statistical analyses.
These limitations aside, this study was remarkably valuable and provides empirical evidence supportive of the idea that DBT can be administered successfully in shorter period of time for clients diagnosed with BPD. The treatment led to significant improvement in a variety of domains, both behavioral and emotional in nature. Additionally, the successful retention of 95% of the sample was highly impressive and supportive of the notion that a shorter treatment protocol might motivate clients to remain in treatment until it is completed. The authors noted that, while the brief version is only intended to last six months, there is no reason why clients and therapists could not then agree to remain in treatment for a longer period of time if both thought more treatment would be beneficial. In other words, the point is that treatment can be delivered in a shorter period of time, but that clients do not then need to be kicked out of treatment.
If you would like to learn more about dialectical behavior therapy, borderline personality disorder, suicide, or non-suicidal self-injury, we recommend the following resources, all of which are available through our online store:
Books
Cognitive-Behavioral Treatment of Borderline Personality Disorder
Skills Training Manual for Treating Borderline Personality Disorder
Dialectical Behavior Therapy for Binge Eating and Bulimia
Why People Die by Suicide
Understanding
Nonsuicidal Self-Injury: Origins, Assessment, and Treatment
DVD
Opposite Action: Changing Emotions You Want to Change
Treating Borderline Personality Disorder: The Dialectical Approach
This One Moment: Skills for Everyday Mindfulness
Crisis Survival Skills: Part One: Distracting and Self-Soothing
Crisis Survival Skills: Part Two: Improving the Moment and Pros and Cons
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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