Dialectical Behavior Therapy Skills Training Is Effective Intervention

Figure 1. The 4 treatment modes of standard dialectical behavior therapy

Figure 2 . DBT skills training: 4 sets of primary skills

Dialectical behavior therapy (DBT) is a comprehensive, modular, cognitive-behavioral treatment that was originally developed to treat chronically suicidal individuals with complex clinical presentations and is best known as a treatment for borderline personality disorder. Meta-analyses have identified standard DBT as the most studied treatment available for borderline personality disorder and suicidal behavior, and DBT is widely recommended as a front-line treatment for these problems in professional guidelines.^1-4

Standard DBT is typically delivered as a 1-year outpatient treatment modality with 4 modes (Figure 1). Standard DBT has primarily been evaluated as a treatment for individuals with borderline personality disorder. In this setting, it significantly decreases suicide-related outcomes (eg, suicide attempts, non-suicidal self-injury, suicide ideation), psychiatric hospitalization, use of emergency services, treatment discontinuation, depression, and substance use; it also increases social and global functioning.

DBT skills training

DBT skills training is typically delivered in a group format to target the enhancement of patient capabilities. Specifically, the primary focus is teaching patients a set of behavioral skills and strengthening their ability to use those skills in their everyday lives (Figure 2).

In standard DBT, it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year treatment program. Detailed descriptions of the skills and the structure of standard DBT skills training groups can be found in the recently revised DBT skills training manual and accompanying patient workbook.^5,6

DBT assumes that many of the problems exhibited by patients are caused by skills deficits. In particular, the failure to use effective behavior when it is needed is often a result of not knowing skillful behavior or when or how to use it. For example, deficits in emotion regulation skills are believed to be a core problem in individuals with borderline personality disorder, and these deficits result in maladaptive behaviors to regulate emotions (eg, suicide attempts, non-suicidal self-injury, substance use). Consistent with this skills deficit model, the use of DBT skills during standard DBT and DBT skills training has been found to fully or partially mediate improvements in suicidal behavior, non-suicidal self-injury, depression, anger control, emotion dysregulation, and anxiety.

A recent analysis evaluated the importance of the skills training component of DBT. Interventions that included skills training were found to be more effective in re­ducing non-suicidal self injury, depression, and anxiety.⁷ Taken together, these findings suggest that DBT skills are both a mechanism of change and a critical treatment component.

In clinical practice, DBT skills training has often been offered as a stand-alone or adjunctive intervention in settings where a comprehensive DBT program is not feasible or appropriate. Until recently, however, there was little research to support the use of DBT skills training separate from standard DBT or to guide clinicians in how to structure these interventions. DBT skills training interventions have now been evaluated in 13 published and peer-reviewed randomized clinical trials that have varied widely in the clinical population targeted, the duration of treatment, the specific skills taught, the degree to which skills were adapted, and the use of adjunctive treatment components. Emotion regulation and mindfulness are the most commonly taught skills modules, while interpersonal effectiveness is the most likely to be omitted. In addition, many studies included only a subset of skills within a larger module (see the DBT® Skills Training Manual,5 pages 110 to 122, for detailed skills curricula).

In these studies, DBT skills training interventions have improved a variety of conditions. (Monthly updates on the latest DBT research can be found on the Linehan Institute website: http://www.linehaninstitute.org/latestResearch.)

Disordered eating. Four trials have evaluated DBT skills training interventions for individuals with eating disorders, including binge eating disorder, chronic binging and purging, and subthreshold bulimia nervosa.^8-11 Participants who received DBT skills training had greater reductions in binge eating or binge/purge behaviors than wait list controls and those in an active therapy group. In addition, DBT skills training was superior to active and non-active control therapy in reducing other types of eating-related pathology, including weight-related concerns, urges to eat when angry, eating restraint, eating concerns, preoccupation with food, and appetite awareness.

Mood disorders. Three trials have examined the efficacy of DBT skills training for individuals with MDD or bipolar I or II disorder. Harley and colleagues¹² found significantly greater improvement among patients with treatment-resistant depression on stable antidepressant medication regimens who received DBT skills training compared with those on a wait list. A second study compared DBT skills training with antidepressant medication in a group of persons aged 60 years and older with MDD.¹³ The interventions were comparably effective in reducing depression at the end of treatment (28 weeks). Significant differences in favor of DBT skills training emerged at 6-month follow-up on clinician-rated depression remission rates. A third trial compared DBT skills training with a wait list for individuals with bipolar I or II disorder and found nonsignificant trends that favored DBT in reducing depression and mania.¹⁴

Several trials have also evaluated the effect of DBT skills training on depression severity in samples selected for other primary problems. Four studies found DBT skills training to be superior to active and non-active control therapy in reducing depression among individuals with borderline personality disorder, subthreshold bulimia nervosa, and childhood abuse histories.^7,8,15,16 Two trials did not find differences between DBT skills training and active treatment controls in reducing depression among persons with high levels of emotion dysregulation and binge eating disorder.^10,17

Anxiety. No studies have evaluated DBT skills training interventions for primary anxiety disorder. However, several studies have found DBT skills training to be more effective than active treatment controls in reducing anxiety severity among individuals with borderline personality disorder, high levels of emotion dysregulation, and a history of childhood abuse.^15-17 In addition, a component analysis found that DBT interventions that included a skills training component were more effective than those without skills training in reducing anxiety severity among suicidal and self-injuring individuals with borderline personality disorder.⁷

ADHD. Two studies that used active treatment controls demonstrated the effectiveness of DBT skills training for attentional difficulties. In the earlier trial, DBT skills training led to a greater reduction of ADHD symptoms than a semistructured discussion group for individuals who maintained a stable medication regimen and completed treatment.¹⁸ A recent study of college students compared skills training with self-study handouts.¹⁹ Symptoms of inattention were significantly reduced in the DBT group by the end of follow-up; mindfulness and quality of life improvements were evident at the end of treatment, and improvement in mindfulness persisted through the follow-up period.

Borderline personality disorder. Two trials have evaluated DBT skills training interventions among persons with borderline personality disorder. Soler and colleagues¹⁵ compared 3 months of a stand-alone DBT skills training group to standard group therapy for individuals with moderate to severe borderline personality disorder. The results demonstrated the superiority of DBT skills training in reducing treatment dropout, depression, anxiety, general psychiatric symptoms, anger, feelings of emptiness, and emotional instability. The 2 treatments did not differ in their effect on global borderline personality disorder severity, suicide attempts, non-suicidal self-injury, or emergency department visits.

A recent component analysis compared the efficacy of 1 year of standard DBT, DBT group skills training with individual case management, and DBT individual therapy with an activities group for suicidal and self-injuring women with borderline personality disorder.⁷ All 3 treatments resulted in similar improvements in suicide-related outcomes (attempts, ideation, use of crisis services due to suicidality, and reasons for living). The treatment conditions that included skills training (standard DBT and DBT group skills training plus case management) were superior to DBT individual therapy in reducing non-suicidal self-injury, depression, and anxiety. There were no significant differences between standard DBT and DBT group skills training plus case management conditions, although there were trends in favor of standard DBT for treatment retention and follow-up year suicide attempts and use of crisis services.

Summary

The available research suggests that DBT skills training is a critical component and mechanism of action in DBT and can be effective as a stand-alone or adjunctive intervention for a variety of conditions. The strongest evidence exists for brief DBT skills training as a stand-alone intervention for binge eating disorder and bulimia nervosa. In addition, moderate evidence exists for the efficacy of brief DBT skills training as an adjunctive intervention to antidepressant medication for individuals with MDD, as well as a stand-alone intervention for ADHD. Two trials have shown promising results for DBT skills training for borderline personality disorder, but the findings require replication because of the notable differences between trials in treatment length, the use of adjunctive treatment components, and the severity of illness.

Additional research with larger samples and consistent DBT skills training curricula is needed to draw firm conclusions. Nevertheless, the effectiveness of DBT skills training appears to be robust despite variations in treatment length and skills content, which suggests that such training in multiple forms is likely to be useful for different clinical populations.

Acknowledgment-We would like to acknowledge the work of Drs Marsha Linehan, Linda Dimeff, Erin Miga, and Kelly Koerner in compiling a list of DBT randomized controlled trials at Behavioral Tech, LLC.

Disclosures:

Dr Harned is Director of Research and Development and Dr Botanov is a Postdoctoral Fellow at Behavioral Tech LLC in Seattle, WA. Behavioral Tech LLC is a private company that provides training and consultation in dialectical behavioral therapy. Dr Harned reports that she receives federal grants to research dialectical behavior therapy.

References:

1. Stoffers JM, m BA, Rücker G, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;8: CD005652.

2. Tarrier N, Taylor K, Gooding P. Cognitive-behavioral interventions to reduce suicide behavior: a systematic review and meta-analysis. Behav Modif. 2008;32:77-108.

3. Klonsky ED. Borderline Personality Disorder. Society of Clinical Psychology; 2015. http://www.div12.org/psychological-treatments/disorders/borderline-personality-disorder/. Accessed January 11, 2016.

4. SAMHSA’s National Registry of Evidence-based Programs and Practices. Intervention Summary: Dialectical Behavior Therapy. 2015. http://legacy.nreppadmin.net/ViewIntervention.aspx?id=36. Accessed Janaury 13, 2016.

5. Linehan MM. DBT® Skills Training Manual. 2nd ed. New York: Guilford Press; 2015.

6. Linehan MM. DBT® Skills Training Handouts and Worksheets. 2nd ed. New York: Guilford Press; 2015.

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