1. Dialectical Behavioral Therapy
AMY LOPEZ, LCSW

2. What is DBT?
 DBT is Dialectical Behavioral Therapy.
 A model of therapy that uses skills training and the
therapeutic relationship to manage strong emotions and
behavioral dyscontrol.
 Originally created for treatment of symptoms of Borderline
Personality Disorder,
 Primarily suicide and self-harm
 Has been modified for a variety of treatment settings
 A bio/psycho/social model that builds on traditional
behavioral approaches
 Uses group work (skills training), individual therapy and self-
monitoring to change target behaviors.
 Provides support for clinicians to be able to work with a
difficult population.

3. DBT as Evidence Based Practice
 DBT vs TAU comparison group
 DBT had higher global functioning scales
 DBT had fewer parasuicidal (self-injurious) behaviors
 DBT had fewer psychiatric inpatient days
 Multiple Randomized Control Trials and Meta-Analyses Conducted
 Two separate meta-analysis reviewed effect sizes
 Evidence strongest for Suicidal Behaviors/Attempts, Self-Injury, Dropout
 Conflicting evidence for Axis I conditions – depression, anxiety, bi-polar
 Counterindicated for schizophrenia/psychosis, developmental delays, manic episodes
 Replicated across treatment conditions and different treatment manuals
 Substance Abuse (DBT-S)
 Eating Disorders
 Inpatient Settings, Forensics & Older Adults - not supported by RCT
 Evidence for clinicians
 Reduces clinician drop-out and clinician burnout

4. DBT requires fidelity
 DBT is a Manualized Treatment Program requiring treatment
fidelity
 Use of Linehan DBT treatment manual (others have not been tested)
 Intensive training for providers
 Must use all four components
 Individual Therapy
 Skills Training Group
 24 Hour access to skills coaching
 Consultation Team for providers
 Can only claim to be doing DBT with all of these components
 Skills training alone does not constitute DBT as an EBP
 “DBT Light”
 No consultation or fidelity checks required to implement program

5. What is Dialectics:
 The idea that two opposite or contradictory ideas can
exist simultaneously.
Emotions
Behaviors Thoughts
 Similar to CBT and behavior modification with addition of
recognition of emotion on thoughts and behaviors (and
VALIDATION of emotion)

6. Dialectical Dilemmas
Emotional
Vulnerabilities
Unrelenting
Active Passivity
Crises
Middle
Ground
Apparent Inhibited
Competence Grieving
Self-
Invalidation

7. Stages of Treatment
 Stage I Treatment
Stage IV  Life Threatening Behavior
Incompleteness  Therapy Interferring Behavior
 Life Interferring Behaviors
Stage III  Quiet Desperation
Problems in Living
 Inhibited Grieving
 Re-Learning to Experience
Stage II
Emotions
Quiet Desperation
 Problems in Living
Stage I  “Ordinary Unhappiness”
Life In Hell  Incompleteness
 Capacity for Joy (Existential)

8. Individual Treatment Strategies
 Every session follows the stages of treatment:
 “Let’s start with your diary card.”
 “Any life threatening behaviors this week?”
 Diary cards
 Ways to record impulses and behaviors
 Rewards for using skills
 Transitional Object – continues relationship outside office
 Behavior Chains
 Maps out rewards/consequences of certain behaviors
 Focused way for therapist and client to think about behaviors
 Can serve as negative reinforcement…
 Skills Review and in-session practice for life situations
 Role play skills for life situations
 Problem solving
 Therapist as participant
 Observes and addresses violations of personal boundaries
 Offers opinion, disappointment, uses relationship as both reward and consequence
 Allows patient to express all emotions, re-teach appropriate emotional response through relationship
 Middle ground solutions to dialectical dilemmas

9. Group Skills Training
 Skills Training – NOT Group therapy
 In CONJUNCTION with individual therapy – the
two compliment each other.
 Serves purpose of:
 Skill Acquisition
 Skills Strengthening
 Skills Generalization
 Builds relationship with skills groups leaders through therapist
modeling and reinforcement of skills.

10. Skills Group Training –
Acceptance Change
 Mindfulness Skills  Interpersonal
 Cognitive Dysregulation Effectiveness Skills
 Self-Dysregulation  Interpersonal
Dysregulation
 Distress Tolerance
Skills  Emotional Regulation
 Behavioral Dysregulation  Emotional Dysregulation

11. DBT Group Skills
Mindfulness Skills Distress Tolerance Skills
 Wise Mind  Wise Mind ACCEPTS
 The intersection of Emotion  Improve the Moment
and Rational Mind  Self-Soothe
 The What and How Skills  Pros/Cons
 Observe  Breathing Exercises
 Describe  Half-Smile
 Participate  Radical Acceptance
 One mindfully  Willingness vs.
 Effectively Willfulness
 Non-Judgementally  Turning the Mind

12. DBT Group Skills
Interpersonal
Effectiveness Emotional Regulation
 DEAR MAN  Model for Describing
 To make requests Emotions
 GIVE  Check the Facts
 To maintain relationship
 ABC Please
 FAST
 To maintain self-respect  Mindfulness of Emotions
 Intensity and Options for  Opposite Action
Asking  Brainstorming and
 Provides Middle Ground for
when, how and if to ask
Problem solving

13. To complete the full program
 For DBT fidelity, clients must:
 Be able to develop “behavioral” goals
 Participate in weekly individual therapy
 Attend group sessions for minimum of 6 months
 It is recommended that clients repeat and do two rounds for a year
of time
 Complete diary cards on a daily basis
 Commit to creating a “life worth living”

14. DBT for children
 Appropriate for children?
 DBT requires insight, impulse control and ability to notice and control one’s
thought patterns
 Children under 10-12 years old have not yet developed necessary skills
 No treatment manual with differing literacy levels
 Modified treatment manuals (those using images rather than text) have limited
evidence as to their use
 Perepletchikova, F. Axelrod, S.R., Kaufman, J., Rounsaville, B.J.,
Douglas, H., & Miller, A.L. (2011). Adapting dialectical behaviour
therapy for children: Toward a new research agenda for pediatric
suicidal and non-suicidal self-injurious behaviours. Child &
Adolescent Mental Health, 16,(2) 116-121.
 Beginning stages of creating treatment manual
 Very small sample
 Found that it may be more effective as parent training strategy than for the
children themselves

15. DBT for adolescents
 Miller, A.L., Rathus, J.H., Linehan, M.M., &
Swenson, C.R. (2007). Dialectical Behavioral
Therapy with suicidal adolescents. New York:
Guilford Press.
 Book about possibility of implementing DBT with
adolescents
 Not a treatment manual
 Suggests different components to treatment
 Suggests different dialectics

16. Differences from standard DBT
Treatment Manual Adolescent Dialectics
 Shorter modules
Excessive
 Less time in treatment Leniency
Force Normalize
 How groups are conducted
Pathological
Autonomy Behavior
 Implementation of a
“Graduate Group” Pathologize
Normal
Foster
Dependency
Behaviors
 Involvement of the parents Authoritarian
Control

17. Issues using DBT with adolescents
 No specific treatment manual
 Miller book primarily theory based, not like specific steps to
treatment like Linehan model
 Cannot diagnose adolescents with BPD
 Personality does not stabilize until after adolescence
 Most “typical” adolescent behavior could be considered BPD
 Recent concerns with using group treatment methods
with adolescents
 Can reinforce deviant/negative behaviors
 Many providers moving to Multi-Family Group, where parents are
involved
 Not evidence based
 No RCT’s

18. Recent publications in DBT-A
 Klein, D.A. & Miller, A.L. (2011). Dialectical behavior therapy
for suicidal adolescents. Child & Adolescent Psychiatry Clinics
of North America, 20(5), 205-216.
 “Although research to date on dialectical behavior therapy (DBT) for
adolescents has its limitations, growing evidence suggests that DBT is a
promising treatment for adolescents with a range of problematic
behaviors.”
 Backer, H.S., Miller, A.L., & van den Bosch, L.M. (2009).
Dialectical beahviour therapy for adolescents; a literature
review. Dutch Journal of Psychiatry, 51(1) 31-41.
 “There were no rct's involving dbt in adolescents, but we did find one
quasi-experimental design and several other studies with a pre-post
treatment design. However, the studies were difficult to compare. In
some cases it was doubtful whether the treatment could still be called
dbt.”

19. Recent publications in DBT-A
 Fleischhaker, et. al (2011). Dialectical Behavioral
Therapy for Adolescents (DBT-A): a clinical Trial for
patients with suicidal and self-injurious behavior
and borderline symptoms with a one-year Follow-up.
Child and Adolescent Mental Health, 28(1) 3-10.
 Pre-post with improvements directly related to suicide
attempts
 One year follow up with still no attempts
 Only 12 participants in study, no comparison group

20. So what does this all mean?
 DBT is effective in reducing suicide and self-injurious
behaviors in adults
 Must have fidelity to model to say using DBT
 DBT is not appropriate for children at this time
 Unlikely that it will be any time soon – work is too far out and not
appropriate developmentally
 It is unknown if DBT is effective with adolescent
population
 A “promising practice”
 Further evidence should be available in next few years, but to date,
no large scale studies done

21. Questions
 Further questions about DBT?