Is dialectical behavior therapy the right ‘fit’ for your patient?
4 steps can help you choose psychotherapies that are supported by the evidence
Additional priorities include skills deficits and secondary targets.1 Each week, the client monitors his or her behaviors, emotions, and actions using a diary card. The therapist uses this information to collaboratively prioritize the focus of each individual therapy session.
Skills training typically occurs weekly in group sessions of 1.5 to 2.5 hours with 1 or 2 therapists. This structured, psycho-educational training focuses on skills that persons with BPD often lack:
- mindfulness (paying attention to the experience of the present moment)
- emotion regulation (regulating or managing distressing emotions)
- distress tolerance (averting crises, tolerating or accepting distressing situations or emotions)
- interpersonal effectiveness (maintaining relationships and asserting needs or wishes).
Therapists often use the first half of group sessions to review each patient’s homework and to provide feedback and coaching on effective skill use. The remaining time is spent teaching new skills. The therapist then assigns homework to practice new skills and closes with a wind-down exercise, often involving relaxation training.
Step 2. Consider the evidence
Before you make a referral for DBT (or any psychological treatment), know what the research says about who is likely to benefit from it. For women with BPD, DBT is the only treatment that can be considered “well-established.”3,14 The literature on DBT includes 10 randomized controlled trials (as well as many uncontrolled trials), and the strongest research supports its use in women with BPD.2,4-13
Based on a detailed review of the literature on DBT, I recommend a basic, evidence-based priority list for referrals (Table 1).3,12,13 Patient groups at the top are most likely to benefit from DBT—according to the most solid, rigorous research—and deserve your strongest consideration for referral. Patient groups further down the list—with fewer rigorous studies of DBT—merit less consideration of DBT as the treatment of choice. Of course to use this list, an accurate diagnosis of your patient’s problems is essential.
DBT’s treatment strategies—exposure therapy, skills training, cognitive therapy, emotion regulation training, and mindfulness—can work for other types of patients. I have noticed, however, that some clinicians refer patients with depression, anxiety disorders, or even bipolar disorder for DBT. Despite DBT’s intuitive appeal, sufficient evidence does not yet support its use in patients with these disorders. Other evidence-based treatments may be more suitable for patients with uncomplicated mood and anxiety disorders (Table 2).3
Table 1
Candidates for DBT: An evidence-based referral priority list*
 | Women with BPD who are suicidal or who self-harm (without bipolar disorder, a psychotic disorder, or mental retardation). One randomized clinical trial with suicidal individuals with BPD included men. Two studies excluded participants with substance dependence, but the most recent, largest study13 did not. |
| Women with BPD and substance use problems (without bipolar disorder, a psychotic disorder, or cognitive impairment) | |
| Women with bulimia nervosa or binge-eating disorder (without substance abuse, psychotic disorder, or suicidal ideation). Other empirically supported treatments exist for these patients (Table 2). | |
| Depressed older adults (age ≥60, without bipolar disorder, a psychotic disorder, or cognitive impairment). Investigated treatments included group DBT skills training, telephone consultation, selective serotonin reuptake inhibitor medications, and psychiatric clinical management.12 | |
| Suicidal and nonsuicidal adolescentswith oppositional defiant disorder or bipolar disorder | |
| Incarcerated men and womenwith or without BPD, in high- and low-security forensic settings | |
| Couples and families where 1 member has BPDor where domestic violence occurs in an intimate relationship | |
| * Persons at the top of the list are the ones for whom the most solid, rigorous research has demonstrated the efficacy of DBT. Fewer rigorous studies of DBT have been conducted in persons further down the list. | |
| BPD: borderline personality disorder; DBT: dialectical behavior therapy | |
| Source: References 3,12,13 | |
Table 2
When not to refer a patient for DBT: Evidence is stronger for alternate treatments
| Diagnosis | Treatments with empirical support |
|---|---|
| Major depressive disorder | CBT, behavioral activation, interpersonal therapy, antidepressant medication, mindfulness-based cognitive therapy for depressive relapse |
| Panic disorder/panic disorder with agoraphobia | CBT involving cognitive therapy and exposure-based with agoraphobia interventions |
| Posttraumatic stress disorder | Prolonged exposure therapy, cognitive therapy, EMDR |
| Bulimia nervosa | CBT, interpersonal therapy |
| Primary substance use disorders | CBT, motivational enhancement/motivational interviewing, community reinforcement approach |
| Psychotic disorders | Medication management, social skills training, family-based interventions |
| CBT: cognitive-behavioral therapy; DBT: dialectical behavior therapy; EMDR: eye movement desensitization and reprocessing therapy | |
| Source: Reference 3 | |
Step 3: Would this patient benefit?
Would your patient, with unique struggles and characteristics, benefit from DBT? Consider to what degree DBT’s interventions would solve some of your patient’s problems and whether DBT fits your patient’s needs.
DBT’s target problems. In controlled trials, DBT’s pragmatic approach outperforms comparator treatments in reducing suicidal behaviors and self-injury, and DBT therapists monitor and target these behaviors. Thus, because few treatments reduce self-injury,15,16 you might consider DBT for patients who self-injure even if they do not have BPD.
