In today’s podcast, I speak with Sabrina Heller, a social worker in Pittsburgh, Pennsylvania who has used Dialectical Behavior Therapy, (DBT) in a variety of clinical settings, including an inpatient eating disorders clinic and an outpatient substance abuse treatment program. In today's interview we spoke about the goal of DBT, clinical techniques, the role of the client and clinician, the skills training workshop, the three mind states: reasonable mind, emotion mind, and wise mind, and how Sabrina incorporates DBT into her work with clients.

  Listen to the Podcast [52:12]

DBT is an evidence-based cognitive-behavioral therapy developed by Marsha Linehan and her colleagues at the University of Washington in Seattle for suicidal clients who meet criteria for BPD. When I say it is an evidence-based treatment, I mean that as of 2007, DBT has more randomized trials demonstrating efficacy in the treatment of BPD and suicidal behaviors than any other approach, including psychodynamic or even other cognitive-behavioral treatments.

I saw Dr. Linehan speak at the American Association of Suicidology conference in Seattle, WA in June of 2006. During her presentation she said that if the name “CBT” had not already been taken, she would have called her approach CBT. She also said that, although DBT is an evidence-based approach for treating people with BPD, she initially sought to develop a more effective treatment for people with suicidal behaviors. During her research, she noticed that many of her clients met criteria for BPD. Because funding for research tends to favor projects that are tied to a diagnosis such as BPD rather than a set of behaviors such as suicide attempts, Linehan found that she could only get funding if she discussed her treatment in relation to the diagnosis, not the behaviors. So, even though DBT has become identified as a treatment for BPD, it was originally developed to treat people with self-harm behaviors, such as self-cutting, suicide thoughts, and suicide attempts.

There are five functions that are addressed by standard DBT: (1) increasing behavioral capabilities, (2) improving motivation for skillful behavior (through contingency management and reduction of interfering emotions and cognitions), (3) assuring generalization of gains to the natural environment, (4) structuring the treatment environment so that it reinforces functional rather than dysfunctional behaviors, and (5) enhancing therapist capabilities and motivation to treat patients effectively. These functions are divided among the following 4 modes of service delivery: (1) weekly individual psychotherapy (1 h/wk), (2) group skills training (2½ h/wk), (3) telephone consultation (as needed within the therapist’s limits to ensure generalization), and (4) weekly therapist consultation team meetings (to enhance therapist motivation and skills and to provide therapy for the therapists). (Linehan et al, 2006, p.759)

Since Linehan published her treatment manual in 1993, DBT has become one of the most empirically-validated approaches to treating BPD and self-harm behaviors. A 2006 study compared DBT to expert therapies and found that participants who received DBT had better outcomes. Linehan reported that subjects “were half as likely to make a suicide attempt (hazard ratio, 2.66; p=.005), required less hospitalization for suicide ideation (F1,92=7.3; p =.004), and had lower medical risk (F1,50=3.2; P=.04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; p <.001) and had fewer psychiatric hospitalizations (F1,92=6.0; p =.007) and psychiatric emergency department visits (F1,92=2.9; P=.04)” (Linehan et al, 2006, p. 757).

References

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006). Two-year randomized controlled trial and follow-up of Dialectical Behavior Therapy vs Therapy by Experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63, 757-766.

Behavioral Tech, LLC: [from the website] Behavioral Tech, LLC, founded by Dr. Linehan, trains mental health care providers and treatment teams who work with complex and severely disordered populations to use compassionate, scientifically valid treatments and to implement and evaluate these treatments in their practice setting.