Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings


Buy It Now!

‘Practical’ book delivers valuable advice for clinicians
(February 2009 Issue)

“Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders
and Settings”
Edited by Linda A. Dimeff and Kelly Koerner
Guilford Press
New York, N.Y., 2007

By Paul Efthim, Ph.D.

Judging by recent press coverage, dialectical behavior therapy (DBT) has hit the big time. For example, Time Magazine devoted five pages of its Jan. 19 issue to borderline personality disorder and DBT. And in the recent scientific literature, psychotherapy research convincingly supports DBT as a cost-effective treatment for borderline personality disorder.

Despite all this good news, DBT could become a victim of its own success. Firstly, some practitioners may seize on it as a panacea. Although DBT was developed to treat the specific problems of persons with borderline personality disorder, increasingly, it is being adapted to other populations, such as those with eating disorders, substance abuse, social skill deficits, depression, and anxiety disorders. It is not surprising that such a powerful tool would spawn a diverse set of applications, but DBT cannot possibly be all things to all people.

Secondly, because of its manualized, behavioral flavor, DBT can promote a false sense of mastery when, in fact, its dialectical component - involving an understanding of deeply opposing existential dualities - requires much clinical sophistication. Less experienced clinicians in particular could be vulnerable to a paint-by-numbers fantasy, thereby underestimating their need for further training and support in delivering DBT or overestimating the degree to which DBT can be extended to other problem areas.

A recent book helps remedy this state of affairs. "Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings," assembles the collective wisdom of 36 expert clinicians, trainers and researchers, including Marsha Linehan, the founder of DBT. Edited by two of Linehan's closest collaborators, the volume extends Linehan's seminal treatment guidebooks by addressing how to implement and sustain the use of DBT in both programmatic and individual therapy settings.

The four elements of the standard DBT treatment package include individual therapy, a skills-training group, telephone coaching and a therapist consultation team. As the authors explain, DBT assumes that certain emotional deficits are central to borderline personality disorder and other severely disordered behaviors. The therapeutic frame and the skills training group are designed to help patients: regulate their emotions; tolerate distress; respond skillfully to interpersonal situations; observe, describe and participate without judging; and manage their own behavior with strategies other than self-punishment.

Several chapters in this pragmatic 363-page book discuss common obstacles and errors in implementing DBT in agency/clinic, private practice, inpatient, forensic and residential settings. Other sections offer step-by-step tips on strategies for financial arrangements and insurance reimbursement, designing inclusion and exclusion criteria for patient selection, program evaluation and preventing therapist burnout.

Of special interest are chapters on adapting DBT to address issues of substance dependence and eating disorders in patients with concurrent borderline personality disorder. The authors present innovative DBT strategies to treat these difficult impulse-control problems and then go further by showing how DBT can sit alongside and enhance other perspectives such as relapse prevention, motivational interviewing, 12-step programs and cognitive therapy.

The tone throughout this fine book is collegial, rigorous and practical. Relevant research is cited throughout the text. A number of reproducible forms and work-sheets add additional value for clinicians.

The contributors know their stuff and want to share their hard-won lessons with the larger DBT community. The editors open by saying: "This book is intended to save you grief." For readers involved in DBT service delivery or just thinking about it, this well-written guidebook will deliver its intended outcomes.

Paul Efthim, Ph.D. is a licensed psychologist in full-time practice in Brookline, Mass. He holds faculty appointments at the Massachusetts School of Professional Psychology and the Boston Institute for Psychotherapy.