J. Dialectical Behavior Therapy

BACKGROUND

Dialectical behavior therapy (DBT) is a comprehensive cognitive-behavioral treatment for complex, difficult-to-treat mental disorders, specifically designed to treat chronically suicidal individuals, and patients with multi-disordered individuals with borderline personality disorder (BPD).

DBT has since been adapted for other seemingly intractable behavioral disorders involving emotion dysregulation, including substance dependence in individuals with BPD and binge eating, to other clinical populations (e.g., depressed, suicidal adolescents), and to a variety of settings (e.g., inpatient, partial hospitalization, forensic).

While considerable evidence supports the use of exposure-based treatment for PTSD, its utilization may pose some problems for patients where the symptoms of PTSD are complicated. High rates of attrition, suicidality, dissociation, destructive impulsivity, and chaotic life problems are reasons cited by clinicians for abandoning empirically supported exposure treatment. Some practitioners have suggest that the approach of DBT, designed to address many of these issues, offers useful strategies for addressing the needs of patients considered poor candidates for exposure therapy.

The DBT approach incorporates what is valuable from other forms of therapy, and is based on a clear acknowledgement of the value of a strong relationship between therapist and patient. Therapy is structured in stages and at each stage a clear hierarchy of targets is defined. The techniques used in DBT are extensive and varied, addressing essentially every aspect of therapy. These techniques are underpinned by a dialectical philosophy that recommends a balanced, flexible and systemic approach to the work of therapy. Patient are helped to understand their problem behaviors and then deal with situations more effectively. They are taught the necessary skills to enable them to do so and helped to deal with any problems that they may have in applying those skills. Advice and support is available between sessions. Patient are encouraged and helped to take responsibility for dealing with life's challenges.

DISCUSSION

Although DBT is becoming more common as a technique for treating patients with BPD, no clinical trials have been reported in the literature for the use of DBT in patients with PTSD. The following studies concern patients with BPD who attempt some form of self-injury; however, for patients with PTSD and comorbid BPD, these studies may be applicable to the treatment decision process.

In a meta-analysis of RCTs of “psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare” for patients who had shown self-harm behaviors, Hawton et al. (2000) compared DBT vs standard after care and found that DBT significantly reduced rates of further self-harm (0.24; 0.06 to 0.93).” The authors caution, however, that “there still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor.”

van den Bosch et al.(2002) and Verheul et al. (2003) reported on the effectiveness of DBT in a group of 58 female BPD patients. For these women, DBT therapy “resulted in better retention rates and greater reductions of self-mutilating and self-damaging impulsive behaviours compared with usual treatment, especially among those with a history of frequent self-mutilation” (Verheul et al., 2003). In the same study group, van den Bosch et al. (2002) compared the results of therapy in women with and without comorbid substance abuse. They found that comorbid substance abuse did not dilute the effect of the DBT, but that the DBT therapy had no effect on the womens’ substance problems. Evans et al. (1999) compared the provision of self-help booklets alone to six sessions of cognitive therapy linked to the booklets, which contained elements of DBT (MACT) in 34 patients who had attempted self-harm. The authors reported that MACT therapy led to a lowering of the number of suicidal acts per month, and also improved self-rated depressive symptoms.

Linehan and colleagues (1993) conducted a RCT of 39 women with BPD, who were randomly assigned to DBT or usual care for one year, then followed-up at six and twelve months following treatment. The authors reported that DBT patients had significantly less parasuicidal behavior, less anger, and better self-reported social adjustment during the initial 6 months and significantly fewer psychiatric inpatient days and better interviewer-rated social adjustment during the final 6 months; overall, DBT subjects had significantly higher Global Assessment Scale scores during the follow-up year.

Telch et al. (2001) and Safer et al. (2001) expanded the DBT concept to treatment of women with binge eating disorder. In both studies, women were randomly assigned to DBT or a wait list (Telch study – 44 women; Safer study – 31 women) and the authors results were similar; patients improved significantly in reduction of binge/purge behaviors, but did not differ on any secondary measures.

Bohus et al. (2000) treated 24 female chronically suicidal patients with DBT and found significant improvements in ratings of depression, dissociation, anxiety and global stress and a highly significant decrease in the number of parasuicidal acts.

Gould et al. (2003) and Miller and Glinski (2000) identify DBT as a promising treatment for suicide, however, they acknowledge the need for RCTs. In their overview of the use of DBT, Koerner and Linehan (2000) also stress the need for longitudinal follow-up studies to determine suicide rates and maintenance of treatment gains.