A definitive new text for understanding and applying DialecticalBehavior Therapy (DBT). * Offers evidence-based yet flexible approaches to integratingDBT into practice * Goes beyond adherence to standard DBT and diagnosis-basedtreatment of individuals * Emphasizes positivity and the importance of the client'sown voice in assessing change * Discusses methods of monitoring outcomes in practice and makingthem clinically relevant * Lane Pederson is a leader in the drive to integrate DBT withother therapeutic approaches
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“Dr. Pederson’s clinical expertise shines as he takes DBT out of the hands of researchers and translates it into a practical, flexible, and powerful approach to human problems. This is your all-in-one source for understanding and practicing DBT and, beyond that, for doing good clinical work in tough client situations.”
Barry L. Duncan, Psy.D., author of On Becoming a Better Therapist: Evidence-Based Practice One Client at a Time
“Bridging research and practice, with this straightforward, accessible guide, Pederson delivers on his promise to place DBT philosophies and techniques all-squarely into the hands of us real-world clinicians working with our real-world clients who so desperately need it!”
Linda Curran, clinician, trainer, and author of Trauma Competency: A Clinician’s Guide and 101 Trauma-Informed Interventions
“Dialectical Behavior Therapy: A Contemporary Guide for Practitioners is a valuable resource for all levels of clinicians. There are several highlighted evidence-based interventions throughout the chapters that are well crystallized and easy to apply and that Dr. Pederson supports with a wealth of research and relevant background information. New and experienced practitioners who include DBT interventions in their practice will find a treasure chest of skills and ideas. The vast array of psychoeducational strategies offers a great `go to’ resource and will quickly become a clinician’s best friend!”
Judith Belmont, MS, author of the Tips and Tools For the Therapeutic Toolbox series
“Dr. Pederson’s book is so timely. I am ever so grateful for a book that is practical in its tone and still grounded in the DBT worldview. It is so important to present DBT to our clients in such a way that they can internalize and generalize the skills and techniques. This book is honest in its appraisal and tone of how to adapt the DBT principles in the `real world’ with real clients. It gives a practitioner the confidence to teach and dialogue about dialectical dilemmas and the concepts of DBT that have previously felt vague while simultaneously pedantic in tone. Having implemented many of Dr. Pederson’s approaches, I can verify that these techniques work to bring clients to a comprehensive understanding of how to live fully in a world that has judged them to be `untreatable’ and `lost causes.’ I recommend this book to any practitioner, be he or she a student or an extensively trained therapist tasked with working with individuals who suffer with a pervasive dysregulation of their emotions.”
Eboni Webb, Psy.D., HSP, owner, Kairos Mental Health Cooperative, LLC, and DBT trainer, PESI Mental Health
“In Dialectical Behavior Therapy: A Contemporary Guide for Practitioners, Lane Pederson has written a very comprehensive, readable guide to DBT in which he is able to bring clarity and understanding to complex concepts. Following a cogent discussion about the dialectics inherent in the ongoing controversy of adherence to DBT versus adapting DBT, Dr. Pederson develops a synthesis by focusing on helping practitioners to provide DBT in a way that will be most effective for their clients. He clearly and succinctly presents very thorough practical guidance about providing DBT, with relevant and helpful examples of skills, treatment, client behaviors and dialogue with clients, while always focusing on the importance of the therapeutic relationship. For practitioners who have been using DBT in their practices for many years, this book provides new insights and ideas that will increase effectiveness. For new practitioners who want to understand more about how to use DBT with their clients, this book is a must read. For any practitioner, this is an incredibly useful book about a very effective form of treatment.”
Pat Harvey, LCSW-C, DBT coach, trainer, and consultant and coauthor of Parenting a Child Who Has Intense Emotions and Dialectical Behavior Therapy for At-Risk Adolescents
“This book promises to be the most influential DBT publication to date, not only in its superb description of the approach but also in the way it builds a bridge between research and practice with a focus on what is most effective for clients. The future of our field rests on outcome-based modifications and customizations to evidence-based treatments, and Dr. Pederson provides an in-depth analysis of research that empowers DBT therapists to embrace the future now. This is a must read for all DBT therapists.”
Dr. Mark Carlson, DBT trainer for PESI Healthcare and author of CBT for Chronic Pain and Psychological Well-Being
“In reading Dialectical Behavior Therapy, I am reminded of the story of Siddhartha Gatauma, a dutiful student of the contemporary spiritual masters, who searched for The Way but ultimately rejected the dogmatic teachings of his time and attained enlightenment by questioning `truth’ while sitting under a Bodhi tree. Dr. Marsha Linehan brought this same spirit of `doing what works’ to the field of psychotherapy with suicidal clients over 30 years ago. Like her, Dr. Pederson challenges the status quo, asks us to look again at the evidence, and reminds us to make sure we are asking the right questions.”
Dr. Stephanie Vaughn, national DBT consultant and trainer, and founder of Vanderbilt University’s DBT Peer Consultation Team
“Dialectical Behavior Therapy: A Contemporary Guide for Practitioners is a clear, succinct, and readable guide for those who want to understand DBT. Dr. Pederson describes the components and techniques necessary to deliver the comprehensive treatment as well as some intriguing adaptations to standard DBT. Readers will find practical information that allows them to provide effective, evidence-based treatment with a sharp focus on the therapeutic relationship and, ultimately, outcomes. Anyone looking to improve his or her clinical skill and be a more effective clinician will find this book to be a useful resource.”
Britt H. Rathbone, co-author of Dialectical Behavior Therapy for At-Risk Adolescents
“New to DBT? Been using it for a while? Either way, this text will deepen your knowledge and strengthen your clinical skills. Dr. Pederson is an expert DBT clinician and trainer. He has created a comprehensive overview of DBT that has sufficient breadth and depth to empower readers to begin using DBT or improve their current practice. This text will be your go-to resource for all things DBT.”
Cathy Moonshine, author of Acquiring Competency and Achieving Proficiency with Dialectical Behavior Therapy, Volumes I and II
“In Dialectical Behavior Therapy: A Contemporary Guide for Practitioners, Lane Pederson takes DBT to the next level by demonstrating its efficacy with psychiatric illnesses other than borderline personality disorder (BPD), as well as the efficacy of adapted models versus the original model. In this book, Pederson helps clinicians learn how to provide the traditional DBT model for BPD as it was originally designed, while also encouraging us to take a more dialectical approach than has traditionally been taken with DBT: while it is innovative, it is also a therapy that derives many of its techniques from other tried and true therapies. In this respect, Pederson helps us continue to move in the direction of making DBT more accessible to therapists, and therefore also to individuals in need of a client-centered, nonjudgmental, skills-based model. This is a wonderful, thorough book that is a great introduction to DBT for newcomers and that will help seasoned therapists develop a more thorough understanding of the model and how to make it best suit their practice and, more importantly, their clients’ needs!”
Sheri Van Dijk, MSW, RSW, psychotherapist, international speaker, and author of The Dialectical Behavior Therapy Skills Workbook for Bipolar Disorder, Calming the Emotional Storm, and DBT Made Simple
Lane D. Pederson
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Library of Congress Cataloging-in-Publication Data
Pederson, Lane, author. Dialectical behavior therapy : a contemporary guide for practitioners / Lane D. Pederson. p. ; cm. Includes bibliographical references and index. ISBN 978-1-118-95792-9 (cloth) – ISBN 978-1-118-95791-2 (pbk.) I. Title. [DNLM: 1. Cognitive Therapy–methods. WM 425.5.C6] RC489.C63 616.89′1425–dc23
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To the Reader
1 Why Learn DBT?
2 Introduction to DBT
3 The Contextual Model and DBT
Comparisons of DBT with Other Therapies
Therapeutic Factors that Most Affect Outcomes
Adopting versus Adapting Standard DBT: The Question of Treatment Fidelity
The Answer to Fidelity: EBP
4 DBT: An Eclectic yet Distinctive Approach
5 Is It DBT?
6 Dialectical Philosophy
Dialectics in Practice
Validation versus Change
Acceptance of Experience versus Distraction from or Changing Experience
Doing One's Best versus Needing to Do Better
Noting the Adaptive in What Seems Maladaptive
Nurturance versus Accountability
Freedom versus Structure
Active Client versus Active Therapist
Consultation to the Client versus Doing for the Client
Dialectics and Evidence-Based Practice
to Be Dialectic: Dialectical Abstinence
Dialectics with Clients
7 The Biosocial Theory
The Role of Invalidation
How the Biosocial Theory Guides Practice
Being Flexible to the Client's Theory of Change
8 Client, Therapist, and Treatment Assumptions
9 The Five Functions of Comprehensive DBT
Generalize the Skills with Specificity
Motivate Therapists and Maximize Effective Therapist Responses
Structure the Environment
10 Treatment Structure
How Much Structure? Level-of-Care Considerations
Program Treatment Models
Individual Therapy Treatment Structure
Group Skills-Training Session Structure
Additional Treatments and Services
Expectations, Rules, and Agreements
11 DBT Treatment Stages and Hierarchies
Pretreatment and the “Butterfly” Client
Stage One: Stability and Behavioral Control
Stage Two: Treating PTSD, Significant Stress Reactions, and Experiencing Emotions More Fully
Stage Three: Solving Routine Problems of Living
Stage Four: Finding Freedom, Joy, and Spirituality
12 The DBT Therapeutic Factors Hierarchy
1. Develop and Maintain the Therapy Alliance
2. Develop Mutual Goals and Collaboration on Methods
3. Identify and Engage Client Strengths and Resources to Maximize Helpful Extratherapeutic Factors
4. Establish and Maintain the Treatment Structure
13 Self-Monitoring with the Diary Card
Levels of Validation
Validation versus Normalization
15 Commitment Strategies
16 Educating, Socializing, and Orienting
17 Communication Styles
19 Skills Training
20 Changing Behaviors
Behaviorism and the Therapist
The Most Effective Methods of Changing Behaviors
21 Behavioral Analysis
Behavioral Analysis Example
22 Dialectical Strategies
23 Cognitive Interventions
24 Telephone Coaching
25 Dealing with Safety Issues
Suicide Risk Factors
Creating the Safety Plan
Safety or No-Harm Contracts
From a Safety Plan to a Safety Commitment
26 Use of the Hospital
28 Evaluation of Clinical Outcomes
Appendix A Mindfulness Exercises
Appendix B Plans for Safety and Skills Implementation
Appendix C Professional Growth in DBT
End User License Agreement
Table of Contents
This book would not have been possible without the outstanding contributions of researchers, therapists, and thinkers Barry Duncan and Bruce Wampold, as well as the luminaries who influenced their works, such as Saul Rosenzweig, Jerome Frank, and Michael Lambert. Among this group, I give special thanks to Barry Duncan. Barry has a generous spirit and has provided me with his valuable time and support. Most importantly, he profoundly shaped my approach to therapy and considering how research evidence, and what research evidence, most impacts therapeutic outcomes.
I would like to thank Cathy Moonshine, an author and friend who is responsible for opening the door to my work as a speaker and trainer. Along with Thomas Marra, whom I also thank, she has contributed much to opening up the field of dialectical behavior therapy (DBT). Both Cathy and Tom have influenced my work with their innovations.
I acknowledge and I am grateful for the immense contributions of Marsha Linehan to the field of psychology. Her work is the genesis of mine, and my work is certainly a dialectical response to the rigidity promoted by some of her followers. Without them, I would only be me.
I owe debts of gratitude to my wife, Cortney, and my children, Sophie and Sawyer, who generously gave their support and tolerated my absences as I completed this book. I especially thank Cortney, who I am sure grew weary of hearing that “tomorrow I'm going to work on the book!”
In addition, I thank my friends and colleagues at Mental Health Systems, PC (MHS), PESI, and Tatra Allied Healthcare. At MHS, I thank Mark Carlson for his friendship and unwavering support, and Shelley Furer and Steve Girardeau for their support and contributions in my absence. I also thank Janice Haines-Ross, Lexi Schmidt, and Heather Anton for their time and care put into proofreading this book; your corrections and thoughtful suggestions greatly improved the readability and content. At PESI, my appreciation goes out to Claire Zelasko, Mike Olson, Mike Conner, and Teresa Kroll, all valued colleagues and friends of mine. At Tatra, I thank Hanna Norwicki, a colleague and friend who recruited me to spread practitioner-based DBT across Australia. I am lucky to be in such good company.
Last, my appreciation to Darren Reed and the team at Wiley Blackwell for giving me the opportunity to bring my DBT message to a larger audience, and special thanks to Hazel Harris for her excellent judgment, suggestions, and editing skill, which immeasurably improved this project.
My background is that of a practitioner, consultant, speaker, and trainer, not a researcher. That said, my education was grounded in the local clinical scientist model, and as such I am trained to bridge research and practice.
This book, consistent with evidence-based practice, considers broad-based research that informs clinical practice. Contemporary therapies such as DBT should not be learned and practiced in a vacuum but should instead be conceptualized and applied within a larger understanding of what is effective beyond a research laboratory, with actual clients in real-world settings.
This book is for real-world providers. Having trained over 7,000 professionals at the time of writing, I can say with confidence that the vast majority of therapists want to learn approaches that work in a manner that allows them to adapt, customize, and integrate those approaches rather than simply following a manual. Thankfully, the science supports that preference. Nonetheless, the politics of adopting Marsha Linehan's original DBT model versus adapting it to clinical practice sometimes creates heated, and occasionally unprofessional, debate. This book outlines the research that supports thoughtful DBT adaptations in order to educate readers on adopting versus adapting issues and to ground DBT in evidence-based practice. At times, that means critiquing and criticizing Linehan's and others' DBT research, which may seem counterintuitive or confusing in a text on DBT. However, challenging establishment thinking is a part of science and is what pushes innovation. Paradoxically, discussing the limitations of DBT research alongside emphasizing broad-based psychological research is what brings balance and practicality to its applications.
With any approach, I recommend that therapists seek out a variety of resources, and in the case of DBT I recommend reading and studying Marsha Linehan's (1993a, 1993b) source practitioner book and skills manual. Astute readers will notice, and hopefully appreciate, variations from and additions to her original DBT approach. Changes and expansions from Linehan's work stem from my 14 years of DBT practice, from my five years as a speaker and trainer, and from following research and practice in DBT and psychotherapy in general.
Dialectics are about synthesis, movement, and change. In this spirit I present a contemporary guide to DBT, and I hope readers find it understandable, accessible, and applicable.
The art of investigating the relative truth of opinions, principles, and guidelines.
Opinions, principles, and guidelines presented by authorities as incontrovertibly true.
evidence-based practice (EBP)
The process by which evidence is applied, evaluated, and adjusted in the context of the therapist's judgment and expertise in combination with a client's culture, characteristics, and preferences.
evidence-based treatment (EBT)
A treatment that meets a minimum standard of research evidence. Synonyms: empirically supported treatment (EST); empirically validated treatment (EVT).
When therapy models are compared, the consistent finding is that no one approach is superior to others, dialectical behavior therapy (DBT) included (Clarkin et al., 2007; McMain et al., 2009; Wampold, 2001). The virtual ties from hundreds of horserace therapy studies beg the question: Why learn DBT when you probably already know effective approaches?
The research is clear that therapy is contextual, not prescriptive, and as such successful therapists need to learn and become competent in a variety of treatments to find a goodness of fit between clients, therapists, and approaches. To paraphrase an amalgamation of experts who advocate a contextual approach to therapies and evidence-based practices (EBPs), to be effective, therapists ought to learn contemporary treatments sought by clients and payers, so long as therapists can coherently deliver them with belief, expectancy, and sufficient adaptation to clients' needs and preferences. And DBT fits the bill, as it is a highly sought contemporary approach for a number of reasons.
First, DBT's privileged status generates tremendous interest in its applications across settings and populations. Therapists gravitate to the approach, and they find that its philosophies and interventions fit nicely with their personalities and beliefs about what works with clients. Many therapists develop a natural allegiance to DBT, and DBT marketing has reached clients who tend to have significant buy-in with DBT therapists and programs. Therapists' and clients' belief and expectancy in DBT will enhance outcomes in many cases, as this therapeutic factor affects outcomes as much as or more than actual therapy models or techniques (Lambert, 1992; Wampold, 2001). As an example, DBT enhances the belief that difficult-to-treat populations such as those with chronic and severe suicidality and borderline personality disorder can be successfully treated, positively impacting the field and treatment results. Positive perceptions and successful outcomes contribute to DBT's credibility and popularity, increasing demand for the approach.
Second, there is a tremendous variety of interventions that comprise DBT, to the point that it can be argued that it approximates an eclectic therapy in practice. DBT interventions include mindfulness practice, skills training, relationship strategies, cognitive and behavioral techniques, and environmental interventions among others. Heard and Linehan (1994) point out that DBT has commonalities with client-centered, psychodynamic, gestalt, paradoxical, and strategic therapies. Marra (2005) also makes convincing comparisons between DBT and other approaches. Further, in a study of common therapeutic factors in empirically supported treatments for borderline personality disorder, 12 categories of interventions were rated from extremely important to proscribed, as indicated by each respective treatment manual. Of these categories, 11 of the 12 were rated extremely important in DBT with only one of the 12 being proscribed (making an interpretation) (Weinberg et al., 2010). This variety of interventions assists therapists in customizing the approach to clients, a hallmark of EBP.
Among its interventions, DBT places strong emphasis on acceptance and validation. Validation is perhaps the most fundamental method of building the therapeutic alliance and “represents a logical application of common factors research” (Duncan & Moynihan, 1994, p. 297). DBT also emphasizes active commitment to therapy and early agreement on goals, treatment targets, and methods of therapy, enhancing important elements that underlie the therapeutic alliance (DeFife & Hilsenroth, 2011; Linehan, 1993a).
Third, DBT is a teachable and practical treatment, making it accessible to therapists of all levels. Hawkins and Sinha (1998) evaluated the conceptual mastery of over 100 therapists following DBT training and found that therapists from diverse backgrounds were able to demonstrate understanding of the approach. Comtois et al. (2007) emphasize that DBT programs can be staffed with graduate therapy students who are often eager to learn the approach. This recommendation highlights that properly supervised therapists new to the field can effectively use DBT with clients. In my clinics, talented master- and doctoral-level students and interns successfully lead skills groups and conduct individual and group DBT after a few months of intensive training and mentoring by our team.
Last, DBT's dialectical philosophies fit with integrating research and practice, applying DBT with a formal consistency while customizing it to individuals, and balancing allegiance to a therapy, DBT, with allegiance to the therapeutic factors that transcend all therapies.
DBT was developed by Marsha Linehan in the late 1980s and early 1990s at the University of Washington. Interested in helping those with chronic suicidality and self-injury, Linehan specialized in the treatment of women diagnosed with borderline personality disorder.
Linehan's (1993a) initial work with this population used cognitive-behavioral therapy (CBT). However, she found that traditional CBT administered with too much problem and solution focus was ineffective and left her clients feeling misunderstood and invalidated. To compensate, Linehan began to incorporate acceptance strategies, but she found that too much acceptance focus was also ineffective, leaving her clients demoralized and thinking nothing would change. Linehan observed that her clients responded best to fluid combinations of acceptance and change strategies rather than the emphasis of one over the other. The balanced movement and flow between acceptance and change is a fundamental dialectic in DBT.
As DBT evolved, Linehan (1993a) searched for and integrated philosophies, relationship practices, and interventions that distinguished DBT from traditional CBT. Dialectical philosophies were used to bring balance and save clients and therapists from all-or-nothing concepts and behaviors. Treatment assumptions were drafted to orient clients and therapists to effective treatment. Mindfulness practices, taught from a secular perspective, emphasized nonjudgmental experiencing in the moment and effective rather than reactive behavioral responses in life. Systematic skills training bridged the gap between behavioral deficits and desired behavioral change. Treatment stages and a hierarchy to prioritize treatment targets decreased chaos and increased therapeutic focus. Functional behavioral analysis structured sessions with systematic pattern recognition aided by problem-solving with skills. And validation underpinned a strong relationship focus that included communication styles ranging from reciprocal to irreverent. Last, Linehan created a multimodal treatment-delivery framework to structure and administer DBT. Called the “standard model,” the treatment-delivery modes of standard DBT include weekly individual therapy, weekly group skills training, weekly therapist consultation, and individual therapists providing 24/7 telephone-coaching availability to their clients.
The prodigious changes from CBT seemed to better fit the needs and preferences of clients with borderline personality disorder, and therapists were inspired by this radically new yet highly derivative theoretical orientation. The therapy became in high demand, and Linehan with her associates founded a training company dedicated to teaching teams of therapists how to implement and deliver standard DBT as it was researched in Linehan's clinical trials.
The dedicated focus on one delivery of DBT, the standard model, makes historical sense given that DBT's initial development happened during the empirically supported treatment (EST) zeitgeist,1 when a major emphasis was placed on diagnosis-specific treatments, forever pairing DBT with borderline personality disorder. During this time period, therapists were compelled to adopt evidence-based treatments (EBTs) with fidelity to how the models were researched, with adherence2 to the specific ingredients prescribed by treatment manuals. In the case of DBT, treatment fidelity meant also following the researched treatment-delivery framework, the standard model.
With a paucity of evidence, the EBT movement created and perpetuated a myth that stubbornly persists today: that specific models of therapy and their interventions should be applied prescriptively to diagnoses vis-à-vis a medical model of treatment, as if clients, therapists, and other important mediating factors are irrelevant in psychological treatment.3
Despite the EBT movement and Linehan's efforts to promote fidelity to the standard model, DBT has been widely disseminated as a theoretical orientation for a broad variety of diagnoses in many adapted treatment frameworks (Andion et al., 2012; Apsche et al., 2006; Christensen et al., 2013; Chugani et al., 2013; Engle et al., 2013; Erb et al., 2013; Evershed et al., 2003; Federici et al., 2012; Goldstein et al., 2007; Harley et al., 2007; Hashim et al., 2013; Iverson et al., 2009; Keuthen et al., 2010; Klein et al., 2013; Kroger et al., 2005; Linehan et al., 1999; Low et al., 2001; Lynch & Cheavens, 2008; Rakfeldt, 2005; Ritschel et al., 2012; Roosen et al., 2012; Rosenfeld et al., 2007; Simpson et al., 1998; Sneed et al., 2003; Soler et al., 2009; Steil, 2011; Sunseri, 2004; Vitacco & Van Rybroek, 2006; Ward-Ciesielski, 2013; Wasser et al., 2008; Wolpow et al., 2000). In fact, research articles on adapting DBT to differing diagnoses and settings, frequently with changes from the standard model in service delivery, outnumber articles on standard DBT. As therapists continue to customize DBT to diverse populations in new settings, levels of adherence to the standard model differ, and, while DBT's reputation as a go-to treatment for borderline personality disorder and other difficult-to-treat issues has been enhanced by successful treatment adaptors, this has not happened without controversy.
A segment of self-described adherent therapists assert that only the standard model is “real” DBT, claiming a specious empirical high ground4 while ignoring a large body of research evidence and current guidelines on evidence-based practice (EBP). With varying applications and treatment frameworks, the natural question is: “Who is following the evidence?”
Standard DBT is an EBT for borderline personality disorder, but it may surprise many that adherence to an EBT is not necessarily EBP. Whereas adherence to an EBT meets a “minimum standard of empirical support,” EBP “is a process of applying research that involves clinical expertise and judgment in the context of client needs and preferences” (Duncan and Reese, 2012, p. 1009). EBP supersedes prescriptive therapy applications because it recognizes the important contextual roles played by therapists and clients in determining therapeutic outcomes, roles that have significantly greater impact than models and their techniques.
Movement to EBP is based on a larger view of the evidence, illuminating a cogent answer to the “who is following the evidence” question. We know therapy works, and its effect size is robust (Smith et al., 1980; Wampold, 2007), but the reasons why therapy is effective differ from those therapists and researchers often promote. The jury has been in for some time, and empirical evidence overwhelmingly supports the thesis that therapy works due to pan-theoretical therapeutic factors5 that operate within a contextual model. As noted in Chapter 1 and further explained in Chapter 3, this thesis rests on the fact that no therapy model, including DBT, has reliably demonstrated efficacy superior to that of other therapy models (Clarkin et al., 2007; Duncan et al., 2010; McMain et al., 2009; Wampold, 2001). The competing thesis—that the “specific ingredients” that comprise particular therapies such as DBT applied vis-à-vis a medical model account for change—has comparatively little empirical support (Wampold, 2001).
To compel therapists to attend to specific ingredients through high adherence to particular therapies is empirically misguided and narrows the scope and practice of therapy, both generally and with specific models such as DBT. Moreover, to adopt only certain therapies, in certain applications, with certain diagnoses, has moral and ethical implications when clients end up with limited and restricted options that neglect their needs and preferences.
Regardless, many adherent DBT providers continue to lobby that providers adopt only standard DBT, and they at times openly denigrate therapists who deliver DBT in differing treatment frameworks. The unfortunate result is that presumably well-intentioned policy-makers, payers, and providers end up “privileging”6 a narrow application of a robust theoretical orientation derived from other established orientations that have broad empirical bases. Even Linehan has acknowledged that the evidence may ultimately show that the effectiveness of DBT is due to its “standard cognitive-behavioral components” with differences being “not as sharp” as she suggested (Linehan, 1993a, p. 22).7
The split between those who adhere to the standard model and those who adapt from it begs for an appraisal of research evidence beyond DBT's important yet limited empirical base as well as a thorough understanding of current trends in EBP. In the foreword to Dialectical Behavior Therapy in Clinical Practice, Linehan offered a “word of wisdom” that DBT change in response to emerging DBT and CBT research to be “in sync with the empirical literature” (Dimeff & Koerner, 2007, p. xiii). I go further to recommend that DBT change to be in sync with decades of established yet often neglected research to bridge the dialectical split and to demonstrate that changes to standard DBT are legitimate, oftentimes necessary, and, importantly, also based in the empirical literature.
Constant change and responsiveness to it are fundamental to dialectics and should be for its namesake therapy. For Linehan to have the first and last word about DBT makes as much sense as saying psychodynamic therapy began and ended with Freud. A sea change is happening in psychology as the field wakes up to what the research has been telling us all along: that structured and credible treatment approaches will be effective when applied flexibly within the context of therapeutic factors.
To this end, a review of the contextual model of therapy, therapeutic factors, and EBP precedes an in-depth explanation of DBT. A broad-based analysis of this research and a true synthesis of research and practice will guide contemporary DBT practitioners.
Empirically supported treatments (ESTs), once called empirically validated treatments (EVTs), are now commonly called evidence-based treatments (EBTs). The most current term, evidence-based treatment, or EBT, will be used in the remainder of this text.
Adherence refers to the extent to which therapists apply the prescribed interventions (i.e., the specific ingredients) of a treatment manual or model, with interventions of different models being avoided or proscribed. DBT purists also expect adherence to the treatment framework, standard DBT.
Ironically, the factors shown to most affect change, such as the therapeutic alliance, are commonly referred to in clinical trials as “nonspecific factors,” with the assumption that they simply support the application of therapy ingredients, assumed to be the real drivers of change. The science shows quite the opposite.
Adherent DBT therapists rest primarily on Linehan's randomized clinical trials that compare DBT to treatment as usual. As discussed in Chapter 3, broader research and evidence-based practice would support adaptations. Ironically, when Linehan published her best-selling textbook (1993a) and skills manual (1993b), DBT was not classified as an EBT, and only one small randomized clinical trial had been conducted; in other words, DBT was popularized with extremely limited specific empirical support.
It was suggested in
The Heart and Soul of Change
(Duncan et al., 2010) that “therapeutic factors” could replace “common factors” to refer to the change agents that are shared across theoretical orientations and therapy models. This book adopts this suggested change for the remainder of the text.
A privileged therapy is one that is strongly advocated and is viewed as superior and therefore more legitimate than other approaches, even in the absence of any evidence for its superiority. These therapies are frequently encouraged or even mandated by policy-makers and those who pay for mental-health services. Cognitive-behavioral therapy is a prime example of a privileged approach. When was the last time a health maintenance organization recommended object relations or an existential approach?
Linehan's hypothesis is likely partially correct. The outcome variance accounted for by DBT ingredients would likely not differ significantly from the outcome variance accounted for by CBT ingredients. What she fails to acknowledge is that therapeutic factors account for significantly more variance in outcomes than do specific ingredients.
Every therapy approach is a contextual model therapy, and DBT is no exception. Nonetheless, proponents of treatments such as DBT often believe that high adherence to the techniques (i.e., the “specific ingredients”) that comprise approaches are of paramount importance to successful clinical results. Grounded in research evidence, this chapter explains the contextual model, comparisons of DBT with other therapies, the therapeutic factors that most affect outcomes, the relative importance of adherence to specific ingredients, and how DBT therapists can better align to the therapeutic factors that will improve positive outcomes.
The contextual model “emphasizes the contextual factors of the psychotherapy endeavor” (Wampold, 2001, p. 23). In other words, it acknowledges the significant overlap between therapy models and the therapeutic factors they share, knowing that therapists cannot apply the “specific ingredients” (Wampold, 2001, p. 23) of any therapy in the absence of these contextual factors. The contextual model also recognizes the ongoing and ever-changing dynamics that characterize the therapeutic alliance, going far beyond the medical-model perspective of applying specific manualized interventions believed to remedy specific disorders.
Early last century, an article titled “Some Implicit Common Factors in Diverse Methods of Psychotherapy”1 marked the birth of therapeutic factors (Rosenweig, 1936). Since then, the evidence that therapy works through shared therapeutic factors has accumulated to the point where it is not hyperbole but empirical fact. Perhaps the most compelling evidence that supports therapeutic factors is the Dodo Bird Verdict (DBV).2
The DBV refers to the fact that no therapy model has reliably shown superior efficacy to other therapy models, with the number of studies showing significant differences being less than what would be attributed to chance when examining the overall body of research (Duncan et al., 2010; Wampold, 2001). Extensive meta-analysis of the body of outcome research has shown that real therapies intended to be beneficial are so when applied coherently with belief and expectancy; CBT, interpersonal therapy, Rogerian therapy, psychodynamic therapy, and on and on all work, and equally well. DBT is no exception to the DBV. So what accounts for DBT's reputation as a superior treatment?
Many therapists do not know that DBT has never been shown to be more efficacious than other treatment models, only to comparison conditions that are not representative of bona fide therapy models. Linehan's and others' randomized clinical trials (Koons et al., 2001; Linehan et al., 1991, 1993, 1994, 1999; van den Bosch, 2002; Verheul et al., 2003) have primarily compared DBT to a control condition called “treatment as usual” (TAU),3 which can be thought of as unknown therapies by unknown therapists. TAU is not a bona fide therapy model, and virtually any structured therapy that is intended to be beneficial will outperform TAU. Indeed, it has been noted that one would almost have to create an iatrogenic “treatment” to fare worse than TAU. The results of TAU comparisons tend to be overvalued for several reasons.
First, large differences in therapist training and support between DBT and TAU can be expected to affect outcomes. Most of the therapists in Linehan's studies were highly trained and received intensive, ongoing consultation and support. As stated by Scheel (2000), “the comparison is not as simple as ‘DBT versus treatment as usual’ It is also ‘highly trained and supervised therapists versus therapists as usual’ ” (p. 77). In reference to the training and support that DBT research therapists received, Scheel stated, “it would be hard to beat this level of training and supervision in the field” (p. 77).
Second, allegiance effects significantly alter therapy outcomes (Wampold, 2001). Unlike double-blind medication studies, therapists and clients in randomized clinical trials are cognizant of what therapy condition is supposed to be more beneficial than the other, especially since informed consent requires that participants be told what treatment options they might be randomly assigned to. Allegiant therapists4 tend to be motivated to achieve desired outcomes, and their belief and expectancy in the approach are undoubtedly communicated to clients, who benefit from “enhanced” placebo (Luborsky et al., 1999; Wampold, 2001).
By comparison, TAU therapists, who typically work with greater caseloads and less training and support, may have had less belief and expectancy with the high-need and sometimes underfunded clients typical of studies like Linehan's. Moreover, clients referred to TAU conditions may have less enthusiasm to be in the “same old” therapy and not assigned to the “new and innovative” therapy, again affecting belief and expectancy and therefore outcomes. A person does not sign up for a medication trial if his or her current medications work, and he or she would not do so to get the placebo. Similarly, a client would not sign up for a therapy trial if “usual therapy” gets the desired results, and he or she would not do so with the hopes of being reassigned to what has already fallen short.
Third, TAU comparisons tend to be significantly different from manualized therapy models in terms of structure and oftentimes treatment dose, and they commonly do not have the formal consistency and stability that come with DBT or other structured therapies. Compared to one year of stable treatment in DBT, TAU clients are less likely to receive and continue therapy, and they can be involved in more intermittent and disjointed treatment efforts (Scheel, 2000). Structure and focus are central to therapeutic success with the lack of these qualities predicting negative outcomes (Mohl, 1995; Sachs, 1983). Further, Baskin et al. (2003) found through meta-analysis that, when control conditions approximated the treatment conditions in terms of structural equivalency, the differences between treatment and control conditions became nonsignificant. Considering treatment structure to be another therapeutic factor, Weinberg et al. (2011) found that a clear treatment framework was shared by EBTs for borderline personality disorder.
Recognizing the limitations that come with TAU comparisons, Linehan et al. (2006) compared DBT to treatment by community experts, finding that DBT resulted in fewer suicide attempts, ER visits, and hospitalizations (although it did not fare better than community experts in other measured outcomes such as suicidal thinking and depression). While the comparison condition of community experts seemed more credible than a typical TAU comparison, thereby lending more credence to the findings, a close look at the tables revealed questionable methods in calculating treatment dose, which likely influenced the results in favor of DBT. Duncan and Reese (2012) noted that 38 two-and-a-half-hour skills-training groups were tabulated as only 20 minutes of therapy each, “a somewhat curious way to record 95 hours of additional treatment” (p. 1009). Duncan and Reese also noted disparate levels of training, consultation, and support between the DBT therapists and community experts, mirroring concerns noted in the DBT versus TAU comparisons. These issues again highlight threats to validity.
When DBT has been compared to other bona fide treatments the results were consistent with the DBV. In 2007, Clarkin et al. compared DBT to transference-focused psychotherapy and supportive treatment. This study found no statistical differences in outcomes between the manualized approaches.5 The overall conclusion of this study was that “structured treatment works for clients with borderline personality disorder” (p. 922).
In 2009, McMain et al. conducted another randomized clinical trial that compared DBT to another bona fide therapy: general psychiatric management.6 This well-designed study had a large sample size and included adherence checks with DBT adherence comparable to standards established by Linehan. In spite of the hypothesis that DBT would outperform general psychiatric management, McMain et al. found no statistical differences between the approaches, again consistent with the DBV.
Practitioners should not be disheartened by this less-than-glowing summation of DBT research. The noted issues apply to virtually all randomized clinical trials that use TAU (and lesser, e.g., no-treatment) comparisons. In fact, the system for classifying EBTs that allows for unsatisfactory comparisons (especially no-treatment comparisons) has drawn criticism and calls for reform (Herbert, 2003). Since unfair comparisons provide expected results and comparisons between bona fide approaches most often result in no significant differences (Wampold, 2001), why continue these comparisons at all? Switching the focus from therapy comparisons to research on client and especially therapist effects would yield more useful information for practitioners, as will applying practice-based evidence as discussed in Chapter 28 and focusing on the therapeutic factors discussed next.7
Frank and Frank (1991)8 set the stage for therapeutic factors by describing commonalities between psychotherapies and other types of healing endeavors. They illuminated the importance of belief and expectation (i.e., placebo), the idea of common active components, and the importance of the larger healing context. In particular, Frank and Frank outlined the shared therapeutic factors of successful therapies. These factors include a confiding and emotional healing relationship (i.e., a therapy alliance), a healing setting, an acceptable explanation for the problems or symptoms with convincing methods and procedures to address those issues (i.e., a myth and ritual), and active participation by both client and healer in the competent delivery of those methods and procedures.
Frank and Frank further described theoretical commonalties shared by therapeutic interventions. They noted that effective therapists decrease alienation and demoralization as they cultivate hope and expectancy, that they attend to emotions, that they create learning experiences, and that they help clients develop mastery through engaging them in practicing this new learning. Taken together, these theoretical factors summarized the effective practice of virtually any therapy, including DBT, and set the foundation for future investigation. In time, studies that examined the relative importance of factors that impact clinical outcomes would validate the centrality of shared therapeutic factors.
Lambert (1986) extended Frank and Frank's work with the identification of four therapeutic factors along with an estimation of their respective percentages of outcome variance. Derived from analysis of outcome research, the estimated percentages of Lambert's factors are as follows: model/techniques 15%; placebo, hope, and expectancy 15%; relationship 30%; and extratherapeutic (client) variables 40%. As research on therapeutic factors evolved past Lambert's four factors, Hubble et al. (2010) noted that emerging research on therapist effects pointed to therapist variables being a fifth factor, and the research of Baskin et al. (2003), Weinberg et al. (2011), and others points to treatment structure as a sixth factor. Of note is the modest estimation of the impact of the model/technique on outcome in relation to the other factors, as validated by research on the DBV.
Duncan (2014) further extended therapeutic factors by thinking beyond static descriptions of them and instead emphasizing their interplay. According to Duncan, therapeutic factors are “interdependent, fluid, dynamic, and dependent on who the players are and what their interactions are like” (Duncan, 2014, pp. 19–20). This fluid interplay mirrors the application of dialectic philosophy to the therapy process and this book's emphasis on filtering DBT through therapeutic factors.
Based on recent research and meta-analysis, Duncan (2014) updated the contributions of therapeutic factors to include client-feedback effects. To start, 86% of outcome can be attributed to extratherapeutic, or client, factors (i.e., unique and specific client and circumstantial variables that have nothing to do with therapy), with the remaining 13% attributed to actual treatment effects. Of that 13%, the relative proportion of change attributed to what makes up treatment is characterized by substantial overlap, interdependence, and dialectical interplay. Duncan lists the relative importance of these highly interrelated treatment components in ascending order: model/technique 7%; feedback effects 21–42%; model/technique delivered,9 which includes the general effects of expectancy/allegiance and rationale/ritual, 28–?% alliance effects 36–50%; and therapist effects 36–57%. In reporting the relative importance of these treatment components, Duncan (2014) suggests that we take a “big-picture” view of therapy and “spend our time in therapy commensurate to each element's differential impact on outcome” (p. 19).
As examples, since the unique qualities of clients and their situations account for so much of the outcome, it makes sense to continuously rally their resources and enlist their engagement. Similarly, since the therapy alliance and the elements that underlie it are five to seven times more powerful than specific therapy models and their techniques (Martin et al., 2000; Wampold, 2001), therapists ought to continuously evaluate whether the therapy is serving the alliance or detracting from it. Of course, one of the surest methods of following these suggestions requires obtaining and integrating client feedback (Duncan, 2014), discussed further in Chapter 28.
The conceptualization, practice, and customization of DBT with the dialectic balance of therapeutic factors is called for by the evidence, and thoughtful adaptations and customizations in treatment manuals, models, and frameworks are acceptable and even necessary from a contextual perspective. As cited above, a large body of published research supports adapted DBT, and the success of these adaptations makes perfect sense as the science places primacy on the client, the therapist, and their shared participation in therapeutic factors, not on specific models or their interventions. Nonetheless, the ongoing prominence of the DBT adherence movement calls for further response to the questions regarding fidelity to standard DBT.
The dissemination of DBT from Linehan's clinical trials conducted in a university setting to community practice has created debate on best practices. DBT experts connected to Linehan (Dimeff & Koerner, 2007) have written on the dissemination of DBT into clinical practice with a strong focus on treatment fidelity. Fidelity to treatment refers to the extent that components theorized to impact the success of EBTs are transferred to community settings. The belief is that faithful implementations that have high therapist skill and adherence (i.e., therapists that are competent in the approach and closely administer the specific ingredients of it) and use a structure that is highly similar to the researched model will be more successful. Dimeff and Koerner's position will be summarized before the evidence on fidelity is presented.
Dimeff and Koerner (2007) argue that adoption of the standard model should be considered over adapting the standard model because a modification “may or may not retain the active ingredients required to get good clinical outcomes” (p. 19). While they admit that “little is known about the specific active ingredients of DBT (or, for that matter, about any psychosocial interactions)” (pp. 19–20), they caution that applying some DBT instead of all of the ingredients of standard DBT could lead to harm, citing a single study by Springer et al. (1996).10
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