In the second stage, the treatment goal is to replace "quiet desperation" with the ability to experience both positive and negative emotions without being traumatized by the experience. In the third stage, the goal is to achieve "ordinary" happiness and unhappiness, and reduce ongoing disorders and problems in living. The fourth and final stage focuses on resolving the patient's sense of incompleteness and achieving capacity for joy.
"In sum, the orientation of DBT is to first get action under control, then to help the patient feel better, to resolve problems in living and residual disorder, and to find joy and, for some, a sense of transcendence," explained Linehan. "All my research is at level one, but you can't stop treatment there. If you don't go to the next levels, [patients] will often move back to level one again."
Treatment at each level is very different. Level one is behavioral therapy that decreases behaviors that are life-threatening or interfere with therapy and quality of life, while increasing behavioral skills of mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance and self-management. Level two involves exposure-based procedures. Level three utilizes a range of interventions, and level four involves treatments such as spiritual counseling, existential analysis or "any work with a wise person," Linehan said.
The milieu for DBT is outpatient, and patients get group skills training and telephone consultation, said Linehan. "The comprehensiveness of the intervention addresses five basic functions: enhancement of patient capabilities, improvement of motivation, assurance of generalization of new skills and motivation to the natural environment, structuring the immediate environment to reinforce skillful functioning rather than problematic functioning, and enhancement of [the] therapists' capabilities and motivation to treat patients effectively," she explained.
Linehan emphasized that DBT therapy stresses acceptance, not judgment, of the patient. "Applying treatment strategies is a dance between acceptance and change," she said.
Regarding clinical research on DBT, Linehan said her first randomized clinical trial (Linehan et al., 1991) evaluated a comprehensive DBT package consisting of weekly individual therapy and group skills training. Compared to community-based treatment-as-usual (TAU), DBT subjects were less likely to attempt suicide during the treatment year, reported fewer suicide attempts at each assessment point, and had less medically severe suicide attempts over the year. DBT was also more effective at limiting treatment dropout and reducing inpatient psychiatric days. Also, at the end of treatment, DBT patients functioned better and were more improved on a number of characteristics associated with BPD, such as anger. DBT superiority was largely maintained during the one-year posttreatment follow-up period.
Since that first trial, three other groups have conducted their own trials to evaluate DBT compared to TAU. In a study of 20 patients (Koons et al., 1998), researchers at Duke University and the U.S. Department of Veteran's Affairs Hospital in Durham, N.C., found that women with BPD in the VA system who were assigned to DBT had greater reductions in deliberate self-injury and suicide attempts taken together, and in depression, than those assigned to TAU. Also, those assigned to DBT had significant improvements in suicide ideation, hopelessness, anger, hostility and disassociation.
In a study (Miller et al., 1997) that applied an adaptation of DBT for suicidal adolescents, researchers reported greater reductions in psychiatric inpatient days as well as treatment dropout for those receiving DBT versus TAU. At Columbia University, researchers (Stanley et al., 1998) looked at suicidal patients with BPD and found that those in DBT had greater reductions in self-mutilation acts, suicide ideation, suicidal urges and urges to self-mutilate than did matched subjects in TAU.