Over a decade of research has now accumulated that generally supports the efficacy of stage I DBT for the problems it aims to treat. DBT has been evalu ated in seven well-controlled studies across four research groups, and in six additional nonrandomized controlled studies (for excellent, in-depth reviews, see Koerner & Dimeff, 2000; Koerner & Linehan 2000; Lieb, Zanarini, Schmahl, Linehan, & Bohus, 2004). Across studies, DBT has been found to significantly reduce the frequency of parasuicidal behavior, the lethality/medical risk of parasuicidal behavior, psychiatric inpatient days, and treatment dropout. These findings generally held when DBT was evaluated against a nonbehavioral treatment by "psychotherapy experts" in the community (Linehan et al., 2002a). Additionally, Linehan, Tutek, Heard, and Armstrong (1994) report improvements in social and functional adjustment and self-reported anger among those receiving DBT. Although most of these studies have included women diagnosed with BPD and chronic suicidal behavior, similar outcomes have been found for mixed samples of men and women (Turner, 2000).
Linehan and colleagues have developed and evaluated DBT for individuals dually diagnosed with BPD and substance abuse disorders (SUD), also known as DBT-SUD (see Dimeff, Rizvi, Brown, & Linehan, 2000). DBT-SUD differs from standard DBT primarily by expanding the targets of treatment to include substance use behaviors and including additional strategies for treatment retention; it retains the fundamental structure and strategies of DBT and is based on the same theoretical underpinnings. In two randomized controlled trials of women diagnosed with both BPD and substance use disorders, DBT-SUD resulted in significant reductions in drug use (Linehan et al., 1999; Linehan et al., 2002b). In a rigorous comparison of DBT-SUD to an intervention that combined a traditional 12-step program with the validation strategies of DBT, this reduction was comparable across groups; however, DBT-SUD participants continued to show improvement over the course of treatment, whereas those in the comparison group showed a slight increase in drug use at the end of treatment (Linehan et al., 2002b).
Additional adaptations of DBT have recently been developed and evaluated for a range of populations and diagnostic groups, including eating disorders (Palmer et al., 2003; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2000; Telch, Agras, & Linehan, 2001; Wisniewski & Kelly, 2003) incarcerated men (McCann, Ball, Ghanizadeh, Gallietta, & Froelich, 2002), suicidal adolescents (Miller, 1999; Miller, Wyman, Huppert, Glassman, & Rathus, 2000; Rathus & Miller, 2002), female juvenile offenders (Trupin, Stewart, Beach, & Boesky, 2002), and older adults with depression (Lynch, Morse, Mendelson, & Robins, 2003); preliminary data are encouraging. Although apparently disparate groups, each can be conceptualized according to the combined capability deficit and motivational model that underlies DBT. For example, Telch and colleagues view binge eating behavior as dysfunctional emotion regulation behavior that develops from inadequate emotion regulation skills and is maintained by the emotion regulation function of binge behavior; their application of DBT to binge eating disorders emphasizes teaching emotion regulation skills. In both an uncontrolled, prelimi nary study (Telch, Agras, & Linehan, 2000) and a larger-scale randomized controlled trial (Telch et al., 2001), DBT for binge eating was found to significantly reduce binge eating episodes. Lynch and colleagues propose a similar conceptualization of depression in older adults. Their adaptation of DBT teaches DBT skills and problem-solving strategies to decrease the behaviors maintaining depression in this population and increase more flexible and functional behaviors. In a randomized controlled pilot study of depressed older adults (Lynch et al., 2003), those who received DBT combined with antidepressant medication demonstrated greater reductions on several key measures of depression than individuals who received antidepressant medication alone.
This review is useful for considering possible applications of DBT to PTSD and related problems. First, a number of the diagnoses and problems mentioned above frequently co-occur with PTSD, such as suicidal behavior, substance use disorders, and eating disorders. Therefore, DBT may be useful for the treatment of these coexisting problems, prior to the instigation of exposure-based treatments for PTSD. DBT has, in fact, been proposed as a first stage of treatment for individuals with PTSD, toward the goal of stabilization prior to exposure (Becker & Zayfert, 2001; Melia & Wagner, 2000). This suggestion is supported by both theory and research that emphasize the ability to effectively regulate emotions (i.e., not engage in dysfunctional behavior in the presence of emotional cues) as requisite for exposure to be effective (see Wagner, 2003). Further, given that a sizable portion of individuals with BPD meet criteria for PTSD as well (up to 50% in the samples used by Linehan), the evidence suggests that these coexisting problems can be treated effectively in those with PTSD diagnoses. Second, many additional problems that are common among people with chronic and severe traumatic experiences can be similarly conceptualized according to the theories upon which DBT is based (e.g., dissociative behavior, shame, chronic depression, anxiety). As such, DBT strategies and skills may be useful for the treatment of these problems.
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