DBT in Real Life: Perspectives from DBT Experts
Meet the Experts
Cedar Koons, MSW, LISW — The Measure of Mindfulness
Melanie Harned, PhD, ABPP — DBT's Approach to Treating Individuals at High Risk for Suicide
Francheska Perepletchikova, PhD — DBT for Children
Seth Axelrod, PhD — DBT for Substance Use Disorders
Lucene Wisniewski, PhD — DBT and Eating Disorders
Yevgeny Botanov, PhD — Mental Healthcare Costs
Joel Beckstead, PhD — DBT with American Indian Youth
The Measure of Mindfulness
Cedar Koons, MSW, LISW, author of The Mindfulness Solution for Intense Emotions: Take Control of BPD with DBT (2016)
For the first years of this century, mindfulness-based interventions generated a lot of enthusiasm from the general public and researchers alike. Research on mindfulness treatments for education, health, and mental health increased exponentially (Farias & Wikholm 2016). Recently, however, reviews of mindfulness-based interventions have re-assessed the data, especially because of small effect sizes and a lack of real control conditions (Farias & Wikhom 2016). A serious, methodological problem common to most of the studies is the lack of a standard operational definition for mindfulness (Lutz 2015).
One of the most studied treatments, Mindfulness Based Stress Reduction (MBSR) includes formal meditation, body scan, and non-strenuous yoga, as well as listening to guided meditations (Kabat-Zinn 1990). Participants may do these practices for anywhere from ten to forty-five minutes each day (Kabat-Zinn 1990). MBSR has been shown to improve coping with stress and chronic pain, among other benefits (Praessman 2008). A similar treatment, Mindfulness Based Cognitive Therapy for Depression (MBCT), has been shown to be helpful with recurrent depression (Van Aalderen 2012). MBCT also employs mindfulness meditation and guided meditations (Segal et al 2013).
It is challenging to compare MBSR and MBCT to other treatments that include mindfulness but are structured differently, such as DBT. DBT does not teach mindfulness meditation but instead focuses on mindful awareness in daily life through use of the "what" and "how" skills (Linehan 2014). DBT does have certain traits in common with MBSR and MBCT, however, in that they all encourage the practice of unbiased, intentional observing (Linehan 2014, Kabat-Zinn 1990, Segal 2003). As of yet, there are no studies that specifically examine what role DBT mindfulness skills play in the treatment's overall effectiveness.
Self-report measures of mindfulness offer another framework for understanding how mindfulness research can inform our teaching. These measures look at specific characteristics ascribed to mindfulness such as awareness in the moment and acceptance of internal experiences. Because there are individual differences in the ability to be present and non-reactive, one client may look very different from another at the outset of treatment. Measuring these differences at baseline and during treatment may help us understand our clients better and improve our mindfulness teaching.
How is Mindfulness Measured?
There are two aspects of mindfulness we should recognize: state mindfulness and trait mindfulness. State mindfulness is the actual experience of being focused in the present moment, awake and aware, and not evaluating or reacting to our experience (Shapiro 2011). Trait mindfulness is how much a person tends to be mindful, even when they aren't really trying (Shapiro 2011). State mindfulness is what we hope clients will experience in the short exercises we lead in DBT skills group. Trait mindfulness is what we hope our clients will develop over time through skills generalization.
As early as 2012, there were eight validated measures of mindfulness for adults (Bergomi et al, 2012). While each measure is different, they do have some characteristics in common. I'd like to highlight three measures that relate to what we teach in DBT skills group.
The Five Factor Mindfulness Questionnaire (FFMQ), originally called the Kentucky Inventory of Mindfulness Skills (KIMS), is one of the oldest measures and was first developed to measure increases in mindfulness in DBT participants. As a result, it uses some terms quite familiar to DBT therapists (Baer 2004). The FFMQ includes five factors: observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience (Baer 2008). In DBT skills class, we teach each of these factors explicitly with the exception of the last one, which we target more in individual therapy. We know these states can be learned with lots of practice, even by highly dysregulated persons (Baer 2004, Linehan 2014).
A second measure of mindfulness, the Toronto Mindfulness Scale, asks people to participate in a meditation exercise and then answer ten questions about their experience (Lau 2006). Originally a measure of state mindfulness solely, the instrument measures two factors, curiosity about inner experiencing and "decentering," or the ability to step back from negative thoughts, emotions, and bodily sensations that arise during an exercise. Curiosity (in contrast to experiential avoidance) and decentering (in contrast to restructuring) are key concepts in cognitive therapy (Lau 2006). Curiosity has similarities to "mindfulness of current emotion" and decentering is similar to "Teflon mind" in DBT. When we are teaching these skills, we are actually building the experience of state mindfulness (Lau 2006). A later version of the Toronto Mindfulness Scale incorporated questions that measure trait mindfulness (Davis 2009).
Probably the simplest measure of mindfulness, the Mindful Attention Awareness Scale (MAAS), uses one factor called attention and awareness, which measures mindfulness over cognitive, emotional, physical, and general domains with 15 questions. Using the MAAS, one can measure a person's baseline "trait" mindfulness, such as how much they act on autopilot or how closely they pay attention to the present moment while undertaking daily tasks. High trait mindfulness, as measured using the MAAS, is associated with lower reactions to stressful situations (Weinstein 2009) and improved mental health outcomes (Shapiro 2011). Further, the practice of state mindfulness appears to increase trait mindfulness (Shapiro 2011).
Applying the Research on Mindfulness
Our clients who experience pervasive emotion dysregulation often exhibit low trait mindfulness at the outset of treatment (Baer 2004). However, as we teach observing and describing and entering into the moment nonjudgmentally, we are instructing clients in how to experience state mindfulness. The more they practice state mindfulness by observing, describing, or acting in awareness, the more they develop their trait mindfulness. In research measuring MAAS, high levels of trait mindfulness have been shown to help people cope better with stress, reduce depressive relapse, and improve well-being (Shapiro 2011).
Why mindfulness is associated with these outcomes is not fully understood. One hypothesis is that actually experiencing the present moment as it is, whether you are having your blood drawn or waiting to hear about a job application, is less stressful than ruminating, worrying, or trying to avoid your experience in the moment. What if it turns out that just accepting the moment over time can change your life for the better? I recommend you share this hypothesis with your clients. It just might build motivation to practice these skills daily until they become traits.
And what about our own practices? I like to consider how I am cultivating trait mindfulness by really listening with my full awareness in session and bringing my attention back again and again to present-moment awareness, even if I've been feeling bored, irritated, or distracted. Also, when I notice my inner experience non-judgmentally and do not react to it or push it away, I feel my mindfulness muscles getting stronger, whether I am seated on my cushion at home or coaching a client over the phone. Stronger mindfulness traits increase my appreciation of the moment, decrease my burnout, and make me a better therapist. And that means I enjoy my life more!
Download a PDF of article references.
DBT's Approach to Treating Individuals at High Risk for Suicide
Melanie Harned, PhD, ABPP
Mental health professionals play an important role in efforts to prevent suicide, as about one-third of individuals who die by suicide had contact with mental health services in the year before their death (Luoma, Martin, & Pearson, 2002). The U.S. National Strategy for Suicide Prevention emphasizes the importance of providing evidence-based psychotherapies (EBPs) that directly address suicide risk to high-risk clients, particularly those with a history of attempting suicide. Dialectical Behavior Therapy (DBT) is one of relatively few EBPs that has been found to be effective in reducing suicidal ideation and behaviors. For example, among recurrently suicidal individuals with borderline personality disorder, DBT has been found to reduce the rate of suicide attempts by 50% compared to non-behavioral therapy by community experts (Linehan et al., 2006). Within the larger DBT model, there are several important principles that guide treatment for clients at high risk for suicide.
- Target suicide directly. In contrast to approaches that attempt to reduce suicide risk indirectly by targeting underlying disorders (e.g., depression), DBT directly targets suicidal thoughts and behaviors as the key problem to be solved. This involves directly assessing the factors that are causing or maintaining specific episodes of suicidal thoughts and behaviors and generating solutions to address these factors.
- Thoroughly assess suicide risk. We cannot effectively intervene to reduce suicide risk unless we know that suicide risk is present. Therefore, it is critical that mental health professionals routinely conduct suicide risk assessments, ideally using an evidence-based approach such as the Linehan Risk Assessment and Management Protocol (LRAMP) that is used in DBT. A thorough suicide risk assessment should be conducted at intake with all new clients and when clinically indicated during ongoing treatment (e.g., when a client reports an increase in suicidal ideation). When conducting a suicide risk assessment, it is important to assess direct indicators of suicide risk (e.g., suicidal ideation, plans, and preparation), indirect indicators of suicide risk (e.g., severe hopelessness, access to lethal means), and protective factors (e.g., responsibility to family, belief that suicide is immoral).
- Routinely monitor suicidal thoughts and urges. For individuals at high risk for suicide, suicidal thoughts and urges may fluctuate weekly, daily, or even hourly. In addition, high-risk clients may experience weeks or months without any suicidal thoughts only to have those thoughts re-emerge at a later point. It is therefore important that mental health professionals routinely monitor suicidal thoughts and urges, particularly among clients with a history of suicidal behavior. This is done in DBT by having clients complete a diary card that includes daily ratings of urges to kill oneself. In addition, DBT therapists ask clients to provide a rating of current urges to kill themselves at the beginning of each therapy session. This kind of routine monitoring is critical to enable therapists to intervene when suicide urges are high, as well as to assess the factors that lead to increases and decreases in suicidal urges over time.
- Reduce the use of psychiatric hospitalization. DBT aims to provide treatment to high-risk clients in the least restrictive setting possible. This means that DBT therapists do not typically recommend or rely on psychiatric hospitalization when suicide risk is high. This approach is based on the lack of empirical evidence that psychiatric hospitalization reduces suicide risk, and concern that it may increase long-term risk. In addition, the DBT model assumes that people cannot have a reasonable quality of life if they are constantly going in and out of psychiatric hospitals, and that clients must learn how to reduce suicide risk while remaining in their natural living environments. Accordingly, many studies have shown that DBT greatly reduces the use of costly crisis services, such as psychiatric hospitalizations and emergency room visits, while simultaneously reducing suicidal behaviors.
- Provide skills-based solutions to reduce acute suicide risk. In DBT, suicide is viewed as the client's effort to solve a problem, typically intense emotional pain that the client feels unable to change or tolerate. To reduce immediate suicide risk, the therapist must help the client to identify and implement alternative solutions to the problem. DBT teaches clients four sets of behavioral skills to increase their ability to regulate emotions, tolerate distress, improve relationships, and live mindfully. The goal is for clients to use these skills to prevent suicide urges from increasing and to not act on suicide urges when they are present. Research has shown that use of DBT skills leads to reductions in suicidal and self-injurious behaviors (e.g., Neacsiu, Rizvi, & Linehan, 2010), indicating that learning and using skillful coping strategies is critical to reducing suicide risk.
- Identify and work towards long-term solutions to suicide. Although solutions to address acute risk are critical, it is equally important for therapists to help clients identify solutions that will reduce suicide risk in the long term. In DBT, the ultimate goal of treatment is to help clients build a life worth living. Simply put, we must help clients develop a life in which suicide is no longer viewed as a viable or necessary option. To do this, therapists must understand what exactly would need to be different for the person to want to be alive, and then tenaciously work with clients to achieve those life changes. Often this involves working on value-driven goals that may be slower to change, such as developing positive and lasting relationships, finding ways to make meaningful contributions to others, and achieving financial stability. Success stories of DBT clients provide hope that it is indeed possible for highly suicidal people to build lives worth living.
- Therapists must be available to clients between sessions. Individuals at high risk for suicide often require in-the-moment coaching to navigate difficult situations without resorting to suicide. In DBT, this is done by making therapists available to clients for phone coaching between sessions. Coaching calls are typically brief and focused on helping clients identify skills to effectively manage current and ongoing difficult situations. Importantly, DBT includes several strategies to reduce the likelihood that these between-session contacts may inadvertently reinforce suicidal behavior. For example, DBT uses the "24-hour rule" that makes therapists unavailable for between-session contact for 24 hours after any suicide attempt or non-suicidal self-injurious behavior. This rule is designed to make sure that these behaviors are not inadvertently reinforced by contact with a caring therapist immediately afterwards.
- Therapists require support and consultation. Mental health professionals working with high-risk clients need support. It can be scary and exhausting to live with the constant worry that one's clients may die by suicide. In addition, being available to high-risk clients between sessions means that therapists must be prepared to intervene in a suicidal crisis at any moment. When working with high-risk clients, it is also recommended that therapists seek consultation to determine the most effective way to intervene. To address this, DBT requires therapists to participate in a therapist consultation team consisting of a team of providers working together to deliver DBT to a community of clients. The primary functions of the therapist consultation team are to provide therapists with support, increase therapist motivation and reduce burnout, and increase therapist competence. Ideally, the therapist consultation team helps therapists feel ready and able to stay engaged in this challenging yet highly rewarding work.
Dialectical Behavior Therapy for Children
Francheska Perepletchikova, PhD
DBT for children (DBT-C) was developed to address treatment needs of pre-adolescent children with severe emotional dysregulation and corresponding behavioral discontrol. These children experience emotions on a different level, and much stronger than their peers. Little things irritate them, and emotions may be so overwhelming that verbal or physical aggression occurs. It may seem at times that these children are manipulative and are trying to push everyone's buttons. However, the child's volatile behaviors may indeed be the best way they know how to deal with their intense emotions. Further, these behaviors may continue because they are frequently reinforced (e.g., attention from adults and peers, getting their way when parents finally give in, reduction in the intensity of emotional arousal). The environment may not be ready to effectively manage the challenges such children present, and "good-enough parenting" may not be sufficient to meet these demands. As a child's needs cannot be adequately met by the environment, the environment frequently invalidates these needs, and destabilizes the child further. A more destabilized child continues to stretch an environment's ability to respond adequately, which leads to further invalidation, and so forth. This transaction over time may lead to the development of a psychopathology. Indeed, research shows that such children are at an increased risk to develop alcohol and substance use problems, suicidality and non-suicidal self-injury, depression, anxiety, and personality disorders in adolescence and adulthood (Althoff, Verhulst, Retlew, Hudziak, & Van der Ende, 2010; Okado & Bierman, 2014; Pickles et al., 2009). The main goals of DBT-C are to teach these children adaptive coping skills and effective problem-solving and to teach their parents how to create a validating and change-ready environment.
Adaptations to Standard DBT for Pre-adolescent Children
DBT-C retains the theoretical model, principles, and therapeutic strategies of standard DBT and incorporates almost all of the adult DBT skills and didactics into the curriculum. However, the presentation and packaging of the information are considerably different to accommodate for the developmental and cognitive levels of pre-adolescent children. Further, DBT-C adds an extensive parent training component to the model. DBT-C teaches parents everything their child learns (e.g., coping skills, problem-solving, didactics on emotions), plus effective contingency management techniques. DBT-C maintains that parental modeling of adaptive behaviors, reinforcement of a child's skills use, ignoring of maladaptive responses, validation, and acceptance are key to achieving lasting changes in a child's emotional and behavioral regulation.
DBT-C aims to stop the harmful transaction between a child and an environment and replace it with an adaptive pattern of responding to ameliorate presenting problems, as well as to reduce the risk of associated psychopathology in the future. In order to incorporate these goals, the hierarchy of treatment targets was greatly extended for DBT-C as compared to DBT for adults and adolescents. While the original DBT hierarchy includes four main categories (life-threatening behaviors, therapy-interfering behaviors, quality-of-life interfering behaviors, and skills training), DBT-C includes three main categories, subdivided into 10 subcategories:
I. Decrease risk of psychopathology in the future
- Life-threatening behaviors of a child
- Therapy-destroying behaviors of a child
- Therapy-interfering behaviors of parents
- Parental emotion regulation
- Effective parenting techniques
II. Target parent-child relationship
- Improve parent-child relationship
III. Target child's presenting problems
- Risky, unsafe, and aggressive behaviors
- Quality-of-life-interfering problems
- Skills training
- Therapy-interfering behaviors of a child
Research Progress for DBT-C
I have recently completed two randomized clinical trials on DBT-C (7-12 years of age) (Perepletchikova et al., manuscript in preparation). The outpatient setting trial targeted children with Disruptive Mood Dysregulation Disorder. Results of this trial indicated that DBT-C was acceptable to children and their parents and was significantly more effective in decreasing DMDD symptoms than Treatment-as-Usual (TAU). DBT-C had a significantly higher rate of attendance, treatment acceptability and satisfaction, and a significantly lower dropout rate as compared to TAU. Further, 90% of children in DBT-C responded to the intervention as compared to 45.5% in TAU, despite three times as many subjects in TAU as in DBT-C receiving additional psychopharmacological treatment. The residential care trial was completed with children (only males) with a range of psychiatric conditions, with ADHD, Disruptive Behavior Disorders and Anxiety Disorders being most prevalent. Significant differences were observed on the main measure of outcome — the Child Behavior Checklist (CBCL), milieu staff report. Children in the DBT-C condition as compared to TAU had significantly greater reduction in scores on both the CBCL Internalizing and Externalizing scales. Results of both trials were maintained at follow-up, and observed changes were clinically significant.
Disruptive Mood Dysregulation Disorder (DMDD) identifies children with severe impairment in self-regulation, who are also highly reactive and sensitive. DMDD is diagnosed if: 1) a child has three or more tempter outbursts per week that are grossly out of proportion to a situation (e.g., punching a sibling for taking his toy, 10 min of screaming "I hate you" when she is told "no") and are not commensurate with the developmental level of a child (e.g., a 7-year-old has a temper outburst that is more typical of a 3-year-old); 2) child exhibits an angry or irritable mood between outbursts for most of the week (e.g., snappy comments, cursing, mumbling under breath, stomping away, rolling eyes, sighing impatiently); 3) symptoms are present in at least two settings (e.g., at home, school, with peers); 4) symptoms started before 10 years of age, and 5) symptoms have lasted for at least one year.
There is some evidence (please see current research above) that DBT-C may be also helpful to children with other problems, such as depression, anxiety, and disruptive behavior disorders. Further research is needed; however, results obtained so far are encouraging.
Tips for Clinicians Working with Children
- Don't be afraid of temper tantrums during a session. They are going to happen anyway, and they can be quite informative and target-relevant. They allow a therapist to: 1) observe parent-child interactions; 2) model to parents how to respond to problematic situations; 3) coach parental responses in the moment; and 4) model effective conflict resolution, problem-solving and skills-use to parents and a child. Ignoring of problem behaviors in session also helps with extinction generalization (e.g., swearing is not attended to at home and in therapy).
- DBT-C is quite tolerant of a child's behaviors that may interfere with conducting a session. This stems from its ability to rely almost exclusively on parental learning, when necessary, which significantly relieves the pressure of ensuring the child's full engagement during a session. In DBT-C problematic behaviors (verbal aggression, threats, cursing, screaming, using threatening body language, devaluing treatment as a waste of time, running around, and other distracting behaviors) are just ignored with a plan to help a child re-regulate and re-focus attention when appropriate. If such behaviors occur consistently, they are targeted by a shaping program.
- A child's therapy-interfering behaviors are addressed primarily via 1) developing a strong therapist-child relationship; 2) reinforcing desired behaviors in the moment and shaping adaptive responding over time; 3) ignoring problematic behaviors (except if the behavior is dangerous); 4) relying on natural consequences (e.g., a child does not get a participation reward); 5) conducting a chain and solution analysis of a behavior in subsequent sessions; and 6) if child is not engaging, teaching material to parents with the goal for them to communicate this material to a child at home via modeling, discussions, and prompting, reinforcing and practicing the use of skills.
- Attempts to correct therapy-interfering behaviors as they are occurring during a session via discussions, behavior analysis, suppression of behaviors via punishment (except if dangerous), etc., can reinforce these behaviors with attention, interfere with addressing higher level targets (e.g., teaching skills to parents), lead to escalation, strain the therapist-child relationship, and decrease a child's willingness to attend further sessions.
- During an incident, caregiver's responses (i.e., remaining calm, validating, using skills, generating effective solutions, ignoring if needed) take precedence over the child's behavior. If a caregiver is modeling effective behaviors, even if a child has a total meltdown for two hours, the situation has been effectively resolved. In this case, the environment was no longer transacting with a child in a dysfunctional way. If applied consistently, parental adaptive responding over time may result in the creation of a validating environment, and the resulting transaction may help ameliorate the child's emotional and behavioral dysregulation. Conversely, in a situation when a child responded effectively to a stressor (e.g., used coping skills, walked away to prevent escalation), while parental responses were dysfunctional (e.g., used inappropriate punishment, resorted to screaming or threatening), the incident was not effectively resolved. Without environmental support, the observed child's adaptive behaviors are likely to remain isolated and sporadic incidents.
- Skills can be practiced with children in four main ways, such as during: 1) an actual problematic situation; 2) processing of a problematic response after an outburst has occurred and rehearsing alternative solutions; 3) the practice of skills in hypothetical problematic situations via role-plays; and 4) coping ahead of problematic situations that are likely to happen in a near future and deciding on how to respond. Advise parents to practice skills with their children as often as possible. Behavioral rehearsal increases chances of a child using a skill in an actual stressful situation. Further, it increases the frequency of reinforcement for skills use.
- Motivation is key. Therapists, not only caregivers, need to use tangible rewards. A positive therapist-child relationship is very important and serves as a source of motivation AND tangible rewards can get you further and faster. Use candy, small toys, etc. This will also help with shaping programs.
- Therapists also can engage in therapy-interfering behaviors. DBT for adults and adolescents highlight a whole range of such behaviors, including a failure to be dialectical (e.g., imbalance of reciprocal versus irreverent communication) and engaging in behaviors that are disrespectful to clients (e.g., coming in late, missing appointments, appearing disheveled). All of these issues apply to DBT-C therapists as well. However, a behavior that may be specifically problematic for a DBT-C therapist is an inability to tolerate intense emotional displays. A therapist's difficulties with tolerating children's temper outbursts and other behavioral escalations may lead to attempts to pacify a child in a moment and, thus, a reinforcement of dysfunctional behaviors, as well as modeling of ineffective problem resolution to parents.
Recommended Resources for DBT-C
Currently I have two books in preparation — DBT-C treatment manual and DBT-C treatment handouts and worksheets. The materials are not yet available for distribution to general public. However, Behavioral Tech is starting to conduct DBT-C training workshops. Participants will be provided with treatment handouts and other pertinent materials. There are also several publications on DBT-C that may be of interest:
- Perepletchikova F, Axelrod SR, Kaufman J, Rounsaville BJ, Douglas-Palumberi H, Miller AL. (2011). Adapting dialectical behavior therapy for children: Towards a new research agenda for paediatric suicidal and non-suicidal self-injurious behaviors. Child and Adolescent Mental Health, 16, 116-121
- Perepletchikova F, Goodman G (2014). Two approaches to treating pre-adolescent children with severe emotional and behavioral problems: Dialectical behavior therapy adapted for children and mentalization-based child therapy. Journal of Psychotherapy Integration, 24, 298-312.
- Perepletchikova, F. (in press). Dialectical Behavior Therapy for pre-adolescent children. In, In M.Swales (Ed). Handbook of Dialectical Behaviour Therapy. Oxford: OUP.
Dialectical Behavior Therapy for Substance Use Disorders
Seth Axelrod, PhD
Following the initial evidence supporting DBT for suicide and non-suicidal self-injury (NSSI) in the early 1990s, Marsha Linehan and colleagues introduced modifications to target substance use disorders (SUD) as one of the greatest risk factors for fatal outcomes. DBT-SUD developed by adding new principles, strategies, protocols, and modalities to address common problems and complications of addiction, while maintaining all of those from the original model for NSSI. For example, individuals with BPD and SUDs tend to demonstrate "butterfly attachment," characterized by limited treatment inclination, fleeting commitment, and minimal attachment to providers; whereas those with BPD without SUDS more often show an opposite attachment-seeking pattern. Therefore, a number of Attachment Strategies were added, such as assigning regular phone check-ins to build connection, orienting social networks to help reconnect with "lost" clients, and reinforcement of treatment participation. Some added DBT-SUD modalities include social networking meetings supporting attachment, urine toxicology screening, and pharmacotherapy to provide replacement medication for opioid addiction given its empirical support.
Is DBT-SUD really that different from standard DBT?
Before reviewing some of the specific modifications (for a more thorough review see McMain et al., 2007), it's important to note that the general strategies of DBT-SUD for helping individuals with addictions are much the same as the standard DBT approach to orientation and commitment, behavioral targeting, validation, and problem solving. As with NSSI and suicide, substance-related targets are understood as efforts to emotionally regulate in the face of challenging circumstances and experiences, with similar learning histories related to benefits such as emotional relief, numbness, or pleasant emotions — at least in the short term. As with standard DBT, clients are oriented to the option of developing new capabilities through DBT for responding to problems in ways that are consistent with their values and with moving towards lives that they would experience as worth living. Substance-related targets are monitored on diary cards, prioritized as the top quality of life-interfering behavior, explored through behavioral chain analysis, problem-solved using solution analysis, and coached with phone consultation (even after using if it is deemed that skills might be generalized).
The Dialectic of SUD Treatment
In dialectical fashion, DBT-SUD synthesizes the two polarized and dominant SUD treatment approaches, including abstinence models such as 12-step programs and harm-reduction models such as cognitive-behavioral relapse prevention. The middle position of dialectical abstinence recognizes the wisdom and strengths of each by establishing a solid commitment to abstinence that cuts off all known paths to use (the Burning Bridges skill), with a total acceptance of slips as part of learning to establish more secure pathways toward abstinence. This synthesis leaves out the main limitations of the two approaches, namely the shame and resignation that typically transform lapses into full relapses within the abstinence approach (i.e., the abstinence violation effect), and the continuing substance use (i.e., non-abstinence) that tends to match the treatment expectation communicated by the harm avoidance approach. While initially articulated for treating addictions, dialectical abstinence was already fully present in standard DBT in its approach to treating suicide and NSSI. With those examples in mind, its practice would likely already be quite familiar to DBT providers.
The Dialectic of Kicking the Habit
A dialectic of common substance use states of mind is also included among the DBT-SUD skills with an Addict Mind consumed by the rationales, physical cravings, and emotional benefits of using (e.g., "no one will know," "I deserve to," etc.), which often vacillates with a Clean Mind that pushes away from the physical, cognitive, and emotional consequences of using. Unfortunately, Clean Mind tends to push so hard against Addict Mind that it inevitably lands on overly simplistic solutions for remaining abstinent (e.g., "I've learned my lesson," "never again," etc.), setting the stage for further repetition. The Clear Mind synthesis is fully open to both sides, fully pursuing abstinence while accounting for the draw of using. For example, the Alternate Rebellion skill involves practicing new expressions of rebellious pleasures that do not harm oneself, goals, or others, such as wearing outrageous T-shirts or "going commando." Additional DBT-SUD skills include Community Reinforcement of abstinent behaviors, Building Bridges to new stimuli to condition abstinence, and Adaptive Denial of unbearable expectations of remaining abstinent. Over time, Linehan observed that the DBT-SUD skills are also very well-suited and relevant for targeting any habitual problematic behavior such as "addictions" to food, NSSI, social media, work, etc. (Linehan, 2014).
DBT-SUD Research Support
With five randomized controlled trials (RCTs) supporting it, DBT is the recognized treatment of choice for co-occurring BPD and SUD (Lee, Cameron, & Jenner, 2015). Three RCTs supported DBT-SUD for reducing substance use relative to treatment as usual (TAU; Linehan et al., 1999) or for reducing use over time in a way that was comparable to somewhat stronger than comparison manualized SUD treatments (Linehan et al., 2002; Linehan et al., 2009). Two RCTs found that standard DBT without SUD modifications outperformed TAU and treatment by experts in substance use outcomes (Harned et al., 2008; van den Bosch et al., 2002). Harned and colleagues (2008) found that 87.5% of those with substance dependence who received DBT achieved full remission for at least 4 weeks, as compared to only 33.3% of those who received comparison treatment by experts. DBT-SUD findings were recently generalized in three important ways within a large pre-post effectiveness trial of primary SUD (i.e., no BPD inclusion criterion), Native-American clients, and adolescents (Beckstead et al., 2015).
Some practice tips for responding to Lying:
A common obstacle in treating clients with SUD is patterns of lying about their use, which may be particularly challenging for DBT providers committed to acceptance and validation. The following are DBT-consistent recommendations for managing this.
- Be mindful of the Active-Passivity/Apparent Competence dialectical dilemma and the accompanying secondary target of inaccurate communication. These are individuals doing the best they can who learned that others are unavailable, uninterested, uncaring, and/or punitive of failings. As such, they've learned to protect themselves from disappointment or attack.
- Be ready to validate lying based on the wisdom from past learning and expectations (level-4 validation).
- If you find yourself feeling hurt or angry, seek the support of your team for getting back to a phenomenologically empathic formulation where "lying" can be descriptive and without judgment.
- State your desire to develop a different, supportive, honest, and collaborative relationship.
- Assess and validate any concerns that there could be actual consequences to their honesty with you (level-5 validation), such as information that could negatively affect legal decisions if shared including probation, disability status, child protective services, divorce proceedings, etc. Balance your commitment to being "on their side" with openness about the limitations of confidentiality.
- Remain committed to acceptance regardless of their honesty, as well as committed to following the data including tox-screen results as part of addictions best-practices.
- Be clear that although dishonesty may keep you at a distance and prevent treatment from working (and could ultimately necessitate a vacation from therapy if not surmounted), this is a shared problem you have together and it will not affect your experience of them as a person.
- Listen to your gut. If the self-report is superficially plausible but doesn't feel right, use level-three-validation mindreading such as, "As much as I would love to believe that what you're telling me is true, and perhaps it is, I'd like you to know that I'm also completely open to the possibility that you're not able to tell me what's really going on right now. In fact, given the way things have gone before, you have to admit that it would be foolish of me to act as if I assumed what you're saying is true."
- Continue to express availability, interest in understanding, regret for lost opportunities, and the desire to work together when possible.
- Do not ask if they are telling the truth, and avoid outright accusations of lying. Such actions will only serve to back them further away from the truth.
- The use of non-demanding mindreading opens the door toward more honest communication, if not in the moment, then over time.
- Beckstead, D. J., Lambert, M. J., DuBose, A. P., & Linehan, M. (2015). Dialectical behavior therapy with American Indian/Alaska Native adolescents diagnosed with substance use disorders: Combining an evidence based treatment with cultural, traditional, and spiritual beliefs. Addictive behaviors, 51, 84-87.
- Harned, M. S., Chapman, A. L., Dexter-Mazza, E. T., Murray, A., Comtois, K. A., & Linehan, M. M. (2008). Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. Journal of Consulting and Clinical Psychology, 76(6), 1068.
- Linehan, M. M., Lynch, T. R., Harned, M. S., Korslund, K. E., & Rosenthal, Z. M. (November, 2009). Preliminary outcomes of a randomized controlled trial of DBT vs. drug counseling for opiate-dependent BPD men and women. Presented at the 43rd Annual Convention of the Association for Behavior and Cognitive Therapies, New York, NY.
- Linehan, M. M. (2014). DBT skill training manual (2nd ed.). New York: Guilford.
- Lee, N. K., Cameron, J., & Jenner, L. (2015). A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug and alcohol review, 34(6), 663-672.
- McMain, S., Sayrs, J. H., Dimeff, L. A., & Linehan, M. M. (2007). Dialectical behavior therapy for individuals with borderline personality disorder and substance dependence. Dialectical behavior therapy in clinical practice: Applications across disorders and settings, 145-173.
- van den Bosch, L. M., Verheul, R., Schippers, G. M., & van den Brink, W. (2002). Dialectical behavior therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.
If you'd like to learn more about the DBT addiction skills that Dr. Axelrod describes, you may be interested in our video series titled DBT Addiction Skills with Dr. Marsha Linehan.
How DBT Can Help Treat Eating Disorders
Lucene Wisniewski, PhD, FAED
Therapy Models for Treating Eating Disorders
The rationale for applying DBT to the treatment of eating disorders (EDs) has been described comprehensively in the literature. The rationale proposed suggests that alternative approaches are necessary for eating disorders because current empirically founded treatments (e.g. cognitive behavioral therapy and interpersonal psychotheray) may only be partially effective or ineffective for a select number of patients. DBT can be considered a logical alternative because, unlike other approaches, it is based on an affect-regulation model of treating ED symptoms. Eating pathology (e.g. binge-eating, self-induced vomiting, restriction, etc.) may now be understood as mechanisms to cope with emotional vulnerability (Telch et al., 2000), as opposed to errors in cognition or faulty interpersonal relationships alone ( Fairburn et al., 1993).
DBT Applied to Clients Diagnosed with Eating Disorders: A Review
Those articles presenting efficacy data have consistently shown great promise for the adaptation of DBT theory and techniques to treat clients with eating disorders. For example, a case report published by Safer, Telch and Agras (2001a) applied a DBT approach to treat a previously unresponsive adult female with a long history of bulimia nervosa (BN) symptoms. This approach consisted of an abridged DBT skills training program to address ED symptoms, as well as consultation team meetings for the support of the clinician. This treatment did not include all the traditional elements of standard DBT: individual therapy sessions were seen as a proxy for group skills training, and the Interpersonal Effectiveness Skill module and telephone skills coaching were not included. Nonetheless, this patient experienced a rapid decline in both binge-eating and purging behaviors, showing drastic change at both post-treatment and at six-month follow-up. Safer and colleagues have also evaluated the effects of another DBT adaptation (20 weeks of skills training) for the treatment of bulimia nervosa (Safer, Telch & Agras, 2001b) and binge eating disorder (Safer, Robinson & Jo, 2010). In both studies, significant improvements on measures of binge-eating and related eating pathology were found post-treatment. A limitation of these studies, however, is that they primarily included individuals presenting with low to moderate levels of ED symptoms and excluded those suffering from anorexia nervosa (AN) and multiple treatment targets.
The treatment of clients with more significant ED symptoms and multiple problem behaviors requires more comprehensive treatment models (Ben-Porath, Wisniewski & Warren, 2009; Chen, Mathews, Allan, Kuo & Linehan, 2008; Kroeger et al. 2010). Our group has published detailed descriptions outlining the rationale and use of DBT for complex clients with comorbid Axis I and II disorders (Federici, Wisniewski & Ben-Porath, 2012; Wisniewski, Bhatnagar, & Warren, 2009; Wisniewski, Safer, & Chen, 2007). Although still considered preliminary, examinations of more comprehensive DBT programs (weekly consultation team and all four traditional DBT skills modules) appear to be effective in treating both eating disorder and self-harm behaviors (Bankoff et al., 2009; Chen, Matthews, Allen, Kuo, & Linehan, 2008; Kröger, Schweiger, Sipos, Kliem, Arnold, Schunert, & Reinecker, 2010; Palmer et al., 2003).
Anorexia nervosa (AN), the ED most resistant to treatment, has received considerably less attention in the DBT literature. In an effort to close this gap, one group explored the effectiveness of DBT in six adolescents diagnosed with AN and six adolescents diagnosed with BN (Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, & Miller, 2008). In their 25-week program, the six women diagnosed with anorexia demonstrated an appreciable weight gain post-treatment. Another group has been developing a model to use a DBT adaptation to treat the over-control that is a signature of individuals whose primary eating disorder symptom is restriction (Lynch, Gray, Hempel, Titley, Chen and O'Mahen (2013).
Continued research in the DBT and ED field is needed to develop a stronger base of studies evaluating the effectiveness of DBT for the treatment of EDs.
When is it appropriate to use DBT with clients diagnosed with an eating disorder?
Not all eating disorder clients are appropriate for comprehensive DBT and comprehensive DBT is not appropriate for all clients with eating disorder. DBT should be considered with eating disorder clients for whom standard, evidence-based treatments have not helped, for clients who have a co-morbid diagnosis, or for when emotion regulation issues are central to a client's illness.
Advice for clinicians
A common pitfall that DBT clinicians may experience when they begin treating eating disorders is they assume that the disorder is NOT about the food. Clinicians must understand that it is not about the food until it is! It is not about the food until you ask a client with restrictive behaviors to eat or one with binge eating to refrain from eating. More specifically, a patient may be using restrictive behaviors to "numb" emotions and to feel "in control," yet when faced with a granola bar that contains more than a predetermined number of calories, the anxiety and fear are really about THAT granola bar in THAT moment (not about being in control or numbing emotions).
Also, it is standard in ED treatment for the therapist to take the individual's weight at the start of each session. DBT therapists without ED experience may find this uncomfortable.
My advice to any clinician: if you are going to choose to see patients who suffer from an eating disorder, get trained! There is a heavy dose of cognitive behavioral treatment for EDs that is needed as part of the treatment. Training and supervision in EDs is necessary to successfully treat these clients.
If you are interested in learning more about DBT and eating disorders, Dr. Wisniewski has prepared a reading list for clinicians who would like to read more about the topic.
Dialectical Behavior Therapy and Mental Healthcare Costs
Yevgeny Botanov, PhD
The need for implementation of effective treatments for individuals at high-risk for suicide — and those diagnosed with borderline personality disorder (BPD) — is greater than ever. The most recent and highest quality epidemiological evidence indicates that the lifetime prevalence of BPD is between three and six percent in the U.S. population (Grant et al., 2008; Trull et al., 2010). Worldwide, nearly 1 million people die annually as a result of suicide (World Health Organization, 2016). Recently released data from the Centers for Disease Control and Prevention (CDC) indicates that rate of death by suicide has reached its highest level since 1991 (13.0 deaths per 100,000), making it the 10th leading cause of death for all ages (CDC, 2016). The rate of death by suicide has increased nearly uninterrupted since 1999, a 24 percent increase. And of great concern, over 40 percent of individuals who attempt suicide do not receive mental health care; half of those who do receive treatment report perceived unmet treatment need (Han, et al 2014). Subsequently, suicide results in an estimated $51 billion in combined medical and work loss costs in the U.S. (CDC, 2013).
Dialectical behavior therapy (DBT) is the gold standard treatment for multidiagnostic and suicidal individuals diagnosed with BPD. DBT is the most intensely studied psychological therapy for treating BPD and is effective in reducing suicide attempts, self-harm, and anger while improving general functioning (Stoffers et al., 2012). The intensity (e.g., time requirements, staffing, space) of providing DBT is greater than traditional standard-of-care within an individual, outpatient treatment setting. This is due to a requirement of four treatment modes in standard, outpatient DBT: (1) DBT individual therapy (1 hour/week), (2) DBT group skills training (2.5 hours/week), (3) therapist consultation team (1-1.5 hours/week), and (4) out-of-session coaching (as needed).
Due to the greater intensity of treatment and perceived increase in the costs of providing treatment, practitioners and organizations are often reluctant to implement DBT.
Is there empirical research on DBT and treatment costs?
While the research literature is not large, numerous studies have examined costs associated with providing DBT. Two published reviews of BPD-specific treatments have examined cost-effectiveness of DBT (Brazier et al., 2006; Brettschneider, Riedel-Heller, & König, 2014). However, these reviews have been inconclusive due to the scarcity of studies providing the necessary cost and clinical efficacy data.
The laboratory at the Behavioral Research and Therapy Clinics at the University of Washington is currently preparing a manuscript that systematically reviews studies on the reduction of mental healthcare costs associated with DBT (Botanov et al., in preparation). We have identified a total of 11 reports that have examined standard outpatient DBT. Five reports were controlled investigations; six studies were prospective cohort trials — it is these 11 reports that inform the following information.
Does DBT reduce the costs of providing mental healthcare treatment?
While reports varied in the healthcare costs calculated, all prospective cohort studies demonstrated a decrease in healthcare costs during treatment with standard outpatient DBT in comparison to prior standard-of-care treatment. Additionally, all but one report demonstrated lower healthcare costs during standard outpatient treatment with DBT in comparison to a control treatment. Standard outpatient DBT led to an average savings — in 2015 U.S. dollars — of nearly $20,000 per person compared to prior treatment and an average of $10,207 in lower costs compared to a control group.
How can DBT reduce costs despite the increase in intensity (i.e., modes of treatment)?
When examining costs related to DBT, it is crucial to calculate not only the costs for outpatient treatment but the associated medical, emergency room, and inpatient treatment costs. The majority of cost savings during DBT, in comparison to treatment before DBT, is accounted for by a decrease in inpatient costs. Emergency room costs, as assessed by six reports, were also lower during treatment with DBT.
What about long-term cost reductions?
Beyond comparison of treatment costs before and during DBT, longitudinal costs of treatment are also important. Three trials (Amner, 2012; Meyers et al., 2014; Wagner et al., 2014) compared mental healthcare costs prior to DBT with a follow-up, post-DBT period. All three demonstrated that treatment costs decreased after DBT in comparison to an equal treatment period before DBT. Therefore, it is reasonable to expect cost savings to increase over the years following treatment and provide additional net savings. The continued cost reductions are attributed to better long-term outcomes for individuals that are treated with DBT.
Is there research on DBT and costs in a residential setting?
DBT adapted to residential settings has also been examined in recent studies. In a randomized controlled trial examining a residential DBT program, Priebe and colleagues (2013) reported inpatient, outpatient, and psychotropic medication costs in the 12 months prior to admission to the program and the 12 months following completion of the program. Results demonstrate an average total cost of €18,100 per participant before the program and an average total cost of €7,233 per participant after the program. Steinbuck (2015) compared a similar residential DBT program to standard outpatient DBT and found that standard outpatient DBT was more cost-effective. These results suggest that while a residential DBT program may reduce overall healthcare costs, standard outpatient DBT may provide greater cost savings without sacrificing clinical efficacy.
Future research on DBT and mental healthcare costs.
It is difficult to synthesize mental healthcare economic data from studies spanning multiple countries with differing healthcare systems and nearly three decades of research. More studies are needed to examine DBT and costs in various treatment settings. Data examining healthcare costs is variable and somewhat limited, yet DBT is an evidence-based treatment that is likely to meet the objectives of funders, economists, accountants, administrators, providers, and consumers.
About Yevgeny Botanov
Yevgeny Botanov, PhD, is the Postdoctoral Fellow in Dissemination & Implementation (D&I) for Behavioral Tech, LLC. Concurrently, Dr. Botanov is a Research Associate at the University of Washington collaborating with Marsha Linehan, PhD at the Behavioral Research and Therapy Clinics. Broadly, his scholarly interests examine the neurological mechanisms underlying emotional regulation in healthy and clinical populations. His research examines the crossroads of clinical and affective neuroscience by elucidating neurobiological and behavioral mechanisms of mental illness and suicide as a consequence of environmental mutations. Dr. Botanov earned his PhD in clinical psychology at the University of Kansas and completed his predoctoral internship at Northwestern University Feinberg School of Medicine. Dr. Botanov will be joining the Department of Psychology at Millersville University in the fall of 2016 as an Assistant Professor.
DBT with American Indian Youth
Joel Beckstead, PhD, ABPP
NOTE: The opinions expressed by this trainer do not necessarily reflect the opinions of the US Department of Health and Human Services, The Public Health Service, the Indian Health Service, or the trainer's affiliated institutions.
Providing DBT within the Indian Health Service
The Indian Health Service (IHS), a component of the U.S. Department of Health and Human Services, operates two Youth Residential Treatment Centers (YRTC) in the Phoenix Area of the IHS. Desert Visions, located in Arizona on the Gila River Reservation, was established in 1994, and Nevada Skies, located on the Pyramid Lake Paiute Reservation in Nevada, was established in 2009.
Both facilities now enjoy significant support from the tribal governments, not only in the Southwest, but throughout the nation. Six years ago, Dr. Joel Beckstead, Clinical Director of both YRTC sites, and other members of the executive team embarked on a listening tour with the purpose of understanding how the facilities were meeting the needs of the American Indian adolescents and how the tribal partnerships might be further enhanced. During these visits in Arizona, Tribal leadership and Tribal health care providers voiced their frustration with the frequency in which adolescents were unsuccessfully discharged and did not complete the program. The Tribal Leaders questioned the efficacy of the treatment centers.
In addition to Tribal concerns, Dr. Beckstead also found that facility staff were increasingly discouraged and were experiencing burn-out because of the high acuity level of the adolescents who were admitted to the program. The high acuity was due to patients that were admitted with both substance abuse and behavioral health diagnoses.
Tribal concerns, the need for sustaining staff, and the multiplicity of treatment regimens resulted in Leadership seeking a therapeutic modality that would address these priorities. In consultation with executive leadership at Desert Visions/Nevada Skies, it was determined that Dialectical Behavior Therapy (DBT) would meet these three critical priorities.
Almost simultaneously, as Dr. Beckstead and the executive team were addressing these Tribal concerns, Congress was responding to testimony from Tribal leaders, the Indian Health Service, and public health experts concerning the alarming incidence of suicide attempts (some successful) and the prevalence of methamphetamine use in their communities. In 2009, Congress appropriated funding to support pilot projects using or adapting evidenced-based or practiced-based treatment, as well as projects developing promising practices. This allowed Tribal and IHS programs to address suicide or methamphetamine use, and in some cases, both issues.
At the request of Executive Leadership, Dr. Beckstead contacted the Behavioral Health Services Branch at the IHS Headquarters and was encouraged to apply for a new grant program, titled "the Methamphetamine and Suicide Prevention Initiative (MSPI)." Desert Visions was chosen to receive an MSPI grant to provide the funding necessary for the implementation of DBT.
In April, 2010, Desert Visions began the process of providing intensive training to counselors and staff in learning and implementing DBT. MSPI funds were used to send counselors to workshops, conferences, and training in the basics of DBT implementation. Eight providers were able to attend a two-week intensive training and had the opportunity to work with Dr. Marsha Linehan, the developer of DBT and a professor at the University of Washington. She provided invaluable feedback and direction regarding the implementation of DBT at both facilities. Over the past six years, this grant has resulted in a well-trained staff equipped to meet the demands of the adolescents, to fulfill the expectations of Tribal partners, and to begin to increase staff job-satisfaction.
Researching the Effectiveness of DBT with Native American Youth
In order to track the success of the implementation of this treatment modality, Dr. Beckstead implemented the use of the Youth Outcome Questionnaire (YOQ), an empirically validated tool. This instrument has been used in multiple behavioral health settings, both outpatient and inpatient. The primary purpose of the instrument is to track adolescents' progress in treatment. Additionally, the data from the YOQ is used by the clinical staff, in collaboration with the clients and their families, to modify treatment plans in order to address areas where the clients are experiencing stress to meet their individual treatment goals.
In November, 2013, a three-year program/statistical review of the YOQ data of 229 patients who had been enrolled in treatment at Desert Visions from 2010-2013 was conducted. The analysis of the outcome data showed that of the 229 patients admitted into the center that had received DBT treatment, 201 met the criteria for clinically significant change, i.e., "recovered" or "reliable change" or "improved" and ten (10) met criteria for no change. No patients deteriorated during this time. Eighteen (18) patients had only one YOQ score and were not included in the analysis. These results far exceeded the YRTC leadership's expectations. The results of this program review were published in the journal Addictive Behaviors in July 2015.
The Growth of DBT within Systems Treating Native Americans
In Indian Country, the good news spread fast. Desert Visions/Nevada Skies began to receive requests from Tribal Behavioral Health Programs to provide additional information about DBT. In addition, the Executive Leadership began to develop a plan to share the program with Tribal partners. Aftercare providers in Tribal communities expressed interest in learning about DBT and a desire reinforce the tools the adolescents had learned to help them remain sober and continue to make effective choices. In February of 2011, Desert Visions provided a four-day training in DBT to over 100 mental health professionals providing services to American Indian/Alaskan Native adults and adolescents.
In February and August of 2013, Desert Visions served as a training center by providing interested Tribal and IHS stakeholders the opportunity to complete a two-week intensive course in Dialectical Behavior Therapy in order to support treatment efforts in the aftercare setting. Behavioral health providers from six unique tribes participated in additional trainings at Desert Visions. Additionally, behavioral health providers from Phoenix Indian Medical Center (PIMC), the largest medical center in the Indian Health Service, attended previous training and subsequently completed a two-week intensive. Behavioral Health Services at PIMC now offers a DBT skills training group for adolescents.
Desert Visions and Nevada Skies represents an example of an implementation strategy that could serve as a template for implementation of DBT at other Tribal and IHS programs in the future.
If you would like to hear more about the work that Dr. Beckstead's team is doing at Desert Visions and Nevada Skies, you may be interested in a 1.5 hour webinar recording of Dr. Beckstead speaking about his experiences and research with using DBT to treat American-Indian and Alaska-Native youth.