Dialectical Behavior Therapy (DBT): empirical evidence and clinical applications from a Christian perspective.

Wang, David C. ; Tan, Siang-Yang

Dialectical Behavior Therapy (DBT) is an evidence-based treatment originally developed and evaluated for individuals with borderline personality disorder (BPD), endorsing histories of multiple nonfatal suicidal behaviors (Linehan, 1993). DBT incorporates a broad array of behavioral (e.g., exposure, contingency management) and cognitive (e.g., cognitive restructuring, problem-solving skills training) techniques, along with contextual and experiential change strategies such as mindfulness and radical acceptance (Hayes, Follette, & Linehan, 2004; see also Brown, Creswell, & Ryan, 2015; Herbert & Forman, 2011; and the recent October 2015 special issue of the American Psychologist on "The Emergence of Mindfulness in Basic and Clinical Psychological Science"). Hayes, Luoma, Bond, Masuda, and Lillis' (2006) history of behavioral therapy delineated three generations (or waves) in the evolution of this particular line of psychotherapies, with the first wave of traditional behavioral therapy in the 1950s focusing on classical conditioning and operant conditioning, the second wave of cognitive behavioral therapy (CBT) incorporating cognitive interventions, and the third wave of behavioral therapies being characterized by the integration of themes such as metacognition, emotions, dialectics, and the therapeutic relationship (Kahl, Winter, & Schweiger, 2012), along with mindfulness and acceptance. Following this taxonomy, DBT can be categorized as a third wave treatment (Tan, 2011), along the likes of Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012; Hayes & Strosahl, 2004), Mindfulness Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2013), and Mindfulness Based Stress Reduction (MBSR; Kabat-Zinn, 1982; see also Alidina 2015). It should be noted that more recently, integrative books on ACT for clergy and pastoral counselors (Nieuwsma, Walser, & Hayes, 2016) and faith-based ACT specifically for Christian clients (Knabb, 2016) have also been published.

The standard DBT treatment program is comprehensive in scope, with patient care spread across a variety of treatment modalities, including: case management, skills training (which can be administered within the context of group or individual therapy), between-session skills coaching, and a therapist consultation team (Linehan, 2015b; see also Linehan 2015a); this standard treatment program can also be accompanied by pharmacotherapy as well as acute-inpatient psychiatric care. Due to limitations in available on-site resources, many mental health service providers (e.g., individual therapists operating out of a private practice context) have elected to provide DBT skills training as a stand-alone treatment. As will be outlined in more detail later, although the majority of research on the efficacy of DBT consists of clinical trials involving the full standard DBT treatment program, an emerging empirical literature is suggesting that skills training alone can also be effective in many situations as well (Linehan, 2015b).

Part of the original impetus for the development of DBT came from observations made by Linehan concerning the limitations inherent in conventional cognitive-behavioral therapy--as they specifically applied to the treatment of parasuicidal individuals diagnosed with borderline personality disorder. Of note, empirical evidence suggests that purely content-oriented cognitive interventions, such as the restructuring of maladaptive thought patterns, does not in fact significantly increase the effectiveness of cognitive therapy (Longmore & Worrell, 2007). Moreover, dismantling studies indicate that it may actually be the behavioral components (e.g., behavioral activation) of cognitive therapy that account for its efficacy (Dobson et al., 2008; Dimidjian et al., 2006). Alongside these potential limitations, Linehan (1993) added her observation that patients with borderline personality disorder tended to find conventional cognitive-behavioral therapy difficult to accept, as they often experienced the course of treatment (with its prominent emphasis on identifying and challenging beliefs that are understood to be irrational or problematic in some way) to be inherently emotionally invalidating. In contrast, DBT prominently emphasizes the importance of the therapeutic relationship as an integral ingredient for change, with special emphasis being placed on potential therapist-patient interpersonal dynamics that may interfere with the therapy process.

DBT treatment emphasizes the importance of balancing change with acceptance, moving a step beyond standard cognitive-behavioral therapy by retaining its change strategies while paradoxically maintaining a concurrent emphasis on teaching patients to accept themselves and their world as it is in the moment. This paradox of accepting patients just as they are within a context of helping them change represents the fundamental dialectic of DBT. Which is why in practice, DBT therapists often switch, potentially on a moment's notice, between supportive acceptance interventions and more confrontational (at times bordering on irreverent) change interventions. The term "dialectics," as it is applied to behavior therapy, refers to "the reconciliation of opposites in a continual process of synthesis" (Linehan, 1993, p. 19), which occurs within the context of a holistic view of reality--one that is highly contextual and stresses the interrelatedness of its various components (Rizvi, Steffel, & Carson-Wong, 2013). While more traditional approaches to mental health treatment might seek to identify, isolate, and then treat the pathology within an individual, the dialectical perspective of DBT affirms the presence of health and function even within the context of pathology and dysfunction. Part of the task of the DBT therapist, therefore, is to recognize and validate this "kernel of truth" inherent even in the client's most apparently maladaptive and destructive behavior. To illustrate, Linehan (1993) posits that individuals with borderline personality disorder may at times engage in parasuicidal behavior because such behavior is often what is required to elicit a helpful response from their social environment. The kernels of truth that a therapist can validate, from this example, might be the client's sense of genuine emotional desperation as well as their intention to elicit help from others to meet legitimate needs.

Linehan's (1993) biosocial theory, the primary tenets of which have recently received empirical support (Reeves, James, Pizzarello, & Taylor, 2010), forms the theoretical underpinnings of DBT's treatment approach. This theory is built on the premise that (similar to many other mental health problems) both suicidal behavior and borderline personality disorder are, at their core, disorders of emotion regulation (Linehan, 2015b)--which can potentially express itself broadly over the emotional, behavioral, cognitive, and interpersonal aspects of an individual (Crowell, Beauchaine, & Linehan, 2009). For individuals with borderline personality disorder, dysfunction of the emotional regulation system is understood to result from the combination and interaction of certain biological predispositions (e.g., for high emotional intensity, sensitivity to emotional stimuli, slow return to baseline following emotional reactions) and certain dysfunctional environments (i.e., chronically emotionally invalidating environments that do not allow individuals to learn how to label and regulate emotional arousal, tolerate distress, or trust their emotional responses as reflections of valid interpretations of events). The product of such a combination/interaction is an individual who is both emotionally vulnerable as well as deficient in emotion modulation skills (Linehan, 1993). Accordingly, DBT intervenes by teaching clients to validate their own emotional responses and giving them skills and strategies to regulate their emotions in an effective and safe manner.

DBT skills are organized into four skills modules: core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. The core mindfulness skills are titled accordingly because these skills are considered core/integral to the application of all other DBT skills. The core mindfulness module speaks of three states of mind--the reasonable mind (the state of mind that is analytical, rational, or logical), the emotion mind (the state of mind where emotions drive thinking and behavior), and the wise mind (the state of mind that integrates reasonable mind and emotion mind, guiding one to act thoughtfully and intuitively, with minimal internal conflict). Mindfulness skills are divided into two categories: "what" skills and "how" skills. "What" skills refer to what one can do to be mindful: observe, describe, and participate. "How" skills, on the other hand, refer to the posture or approach one is to follow as they practice the "what" skills: non-judgmentally, one-mindfully, and effectively. Interpersonal effectiveness skills help individuals assert themselves skillfully in situations that may require them to say "no" to others' requests or when they find themselves in need of asking others for something to achieve a goal. Emotion regulation skills provide tools that help people more accurately identify emotions (leveraging skills in part learned from the core mindfulness module), understand the function that emotions play, and decrease both emotional sensitivity (i.e., the frequency and likelihood of having negative emotions) as well as emotional intensity (i.e., the level and duration of emotional arousal). Last, distress tolerance skills are pragmatic, short-term skills designed to help individuals persevere through crisis situations without engaging in dysfunctional behavior (e.g., substance abuse, self-harm) that will make their situation worse. Among the strategies highlighted in this module are reality acceptance skills (e.g., radical acceptance), which guide clients towards accepting reality as it is when they find themselves in painful situations that cannot be changed.

Empirical Evidence for DBT

DBT is considered the most well researched treatment for borderline personality disorder--a condition that historically has been known to be difficult to treat, with low rates of client retention coupled with high rates of burnout among therapists working with this clinical population (ChoiKain & Gunderson, 2009). DBT meets Chambless et al.'s (1996) criteria as a well-established treatment, with at least two group-design experiments conducted in at least two independent research settings and by two independent investigatory teams, all finding that treatment was statistically significantly superior to either a psychosocial placebo or to another treatment. To date, DBT has at least fifteen randomized controlled trials (Neacsiu & Linehan, 2014), which have been conducted by independent research teams spanning North America (e.g., Linehan et al., 1991; McMain et al., 2009), Europe (e.g., Verheul et al., 2003), and Australia (Carter et al., 2010). In its initial randomized controlled trial, Linehan et al. (1991) investigated the effect of DBT on parasuicidal women with BPD; a series of follow up RCT studies by this same team examined the effect of DBT on samples of substance dependent women with BPD (Linehan et al., 1999), opiate-addicted women with BPD (Linehan et al., 2002), and then BPD women with a recent history of suicidal and self-injurious behavior (Linehan et al., 2006). Of note, empirical evidence across multiple studies thus far have established not only the efficacy of DBT for borderline personality disorder, but also its long-term effectiveness post-treatment (Kliem, Kroger, & Kosfelder, 2010).

In addition to borderline personality disorder, a growing literature attests to the efficacy and effectiveness of DBT in treating a host of additional conditions and disorders. For example, a recent meta-analysis of randomized controlled studies confirmed the efficacy of DBT in treating depression, with a large average observed effect size (pooled Hedges' g = -0.896; Panos, Jackson, Hasan, & Panos, 2014). Results from RCTs have also indicated that DBT significantly reduces anxiety (Bohus et al., 2004), hopelessness (Koons et al., 2001; Linehan et al., 1991), anger (Koons et al., 2001; Linehan, Tutek, Heard, & Armstrong, 1994), global psychopathology (Kliendienst et al., 2008; Bohus et al., 2004), eating disorders (Kliendienst et al., 2008), and impulsive behaviors (Verheul et al., 2003), while enhancing or increasing clients' general functioning (Stoffers et al., 2012), interpersonal functioning (Bohus et al., 2004), and reasons for living (Linehan et al., 1991).

Since its original development, the standard Dialectical Behavior Therapy treatment program has also been adapted for use with additional clinical populations and disorders, with positive results. DBT for borderline personality disorder with severe posttraumatic stress disorder after childhood sexual abuse (DBT-PTSD; Steil, Dyer, Priebe, Kleindienst, & Bohus, 2011), for example, was developed to meet the unique needs of individuals with comorbid BPD and post-traumatic stress disorder (PTSD) secondary to childhood sexual abuse. Its initial pilot study reported significant reductions in PTSD symptoms (Steil et al., 2011), with subsequent studies replicating these results with additional clinical samples (Bohus et al., 2013; Kruger et al., 2014). Another recent and promising adaptation of the standard DBT treatment program is Dialectical Behavior Therapy for school refusal (DBT-SR; Chu, Rizvi, Zendegui, & Bonavitacola, 2015), a multimodal intervention for severe emotional and behavioral dysregulation among adolescents exhibiting school refusal behavior.

Although DBT was originally developed as a treatment for adults, the literature supporting its application and adaptation for adolescent populations has grown significantly over the past few decades (Katz et al., 2004), with Miller (1999) among the first to propose and codify an adapted version of DBT for adolescents (DBT-A). Of special interest is Miller, Rathus, & Linehan's (2007) manual on DBT adapted for suicidal adolescents, which incorporates a modified treatment structure that better incorporates family members into the treatment process, modified skills handouts and worksheets, as well as an updated theoretical base with dialectical dilemmas that are better suited for adolescents (e.g., excessive leniency vs. authoritarian control, pathologizing normative behaviors vs. normalizing pathological behaviors). Empirical evidence, drawn largely from quasi-experimental studies, support the effectiveness of DBT-A for a range of emotional dysregulation problems among adolescents, including self-harm behavior (Fleischhaker et al., 2011; James et al., 2008), depression (Mehlum et al., 2014; Katz et al., 2004), dissociative symptoms (Woodberry & Popenoe, 2008), binge eating (Safer, Lock, Couturier, 2007), and impulse disorders (Shelton, Kesten, Zhang, & Trestman, 2011); these studies span multiple treatment contexts (e.g., inpatient, community and psychiatric outpatient settings). To date, adaptations of DBT also exist to treat adolescents with bipolar disorder (Goldstein et al., 2007), oppositional defiant disorder (Nelson-Gray et al., 2006), as well as anorexia and bulimia nervosa (Salbach-Andrae et al., 2008).

As noted earlier, due to the comprehensive scope of the standard DBT treatment program, which requires a team of practitioners providing care through multiple treatment modalities, many mental health service providers have elected to offer their clients DBT skills training as a standalone treatment due to limitations in available onsite resources. Although the majority of research on the efficacy of DBT consists of clinical trials on the standard DBT protocol, empirical evidence that speak to the effectiveness of DBT skills training alone is also well established. Clinical RCTs indicate that DBT skills training alone is effective in decreasing depression (Van Dijk, Jeffrey, & Katz, 2013), anxiety (Soler et al., 2009), binge eating (Safer & Jo, 2010), ADHD symptoms (Hirvikoski et al., 2011), intimate partner violence (Cavanaugh, Solomon, & Gelles, 2011), and aggression and impulsivity (Shelton, Sampl, Kesten, Zhang, & Trestman, 2009). Moreover, additional evidence from non-RCT studies suggest that DBT skills training can also be effective in significantly decreasing the frequency of seizures among patients diagnosed with conversion disorder (Bullock, Mirza, Forte, & Trockel, 2015), lessen perceived burden and emotional over-involvement among family members of individuals who have attempted suicide (Rajalin, Wickholm-Pethrus, Hursti, & Jokinen, 2009), facilitate grieving among relatives of individuals with BPD (Hoffman et al., 2005), and increase social adjustment among female survivors of domestic abuse (Iverson, Shenk, & Fruzzetti, 2009).

Clinical Applications: A Christian Perspective

The popularity of DBT and DBT skills training in various mental health treatment contexts (ranging from full-service inpatient psychiatric facilities to individual practitioners operating out of a private practice) is not surprising given its substantial empirical base, the comprehensive scope of its skills modules, the thoroughness of the treatment manual, and the applicability and adaptability of DBT interventions to treat a vast and growing number of conditions beyond borderline personality disorder. In addition to Linehan's published work, there are now several other books available on the practice of DBT that are particularly helpful to clinicians and practitioners (e.g., Dimeff & Koerner, 2007; Koerner, 2011; McKay, Wood, & Brantley, 2007; Pederson, 2012, 2015; Van Dijk, 2013). Indeed, even clinicians who do not primarily operate out of a behavioral or cognitive-behavioral theoretical orientation may still readily find occasion to integrate DBT skills training into their clinical work because many clients, despite their level of motivation and/or insight, may not actually possess all the requisite skills necessary for change. For instance, some clients may continue to struggle with saying no to other people not because they remain unconvinced of their need to do so or because they haven't come to terms with the many consequences resulting from not doing so in the past--but simply because they've rarely practiced or seen this behavior modeled by others and as a result, never had an opportunity to learn how to do it in real life. In such cases, the contents of the DBT training manual and corresponding DBT skills training handouts and worksheets booklet would be an excellent resource for clinicians to draw upon in providing the necessary scaffolding for their clients to build competence and remediate skills deficits. While many of the skills in the DBT repertoire may be readily applied by Christian therapists onto Christian clients with little or no interaction or tension raised in relation to matters of faith (in fact, Sandage et al. (2015) recently manualized a group forgiveness module within DBT, with promising empirical results), some aspects of the treatment model may warrant more thoughtful engagement (see Tan, 2011; see also Symington & Symington, 2012; cf. Hathaway & Tan, 2009). Below, we will highlight a few key areas of consideration, offering suggestions--whenever applicable--on how to possibly navigate potential challenges along the way.

First, it is noteworthy to point out that the Christian doctrines of justification and sanctification convey a certain paradoxical posture in the manner God relates to His people that is not unlike the fundamental dialectic of DBT--that is, of God loving, accepting, and redeeming individuals--declaring them as righteous just as they are, even while they were still sinners (cf. Romans 5:8) all the while inviting them into a lifelong journey of becoming increasingly set apart for His work (cf. Ephesians 2:10) and conformed into His likeness (cf. Romans 8:29). Indeed, DBT's emphasis on accepting individuals as they are within a context of helping them change should not at all be unfamiliar to Christians because this theme is central not only to the mission of the Church but also the testimony of Christ Himself. Bonhoeffer (1937/1995) explained, "the Word of God had become flesh, it had come to take sinners to itself, to forgive and to sanctify. It is this same Word which now makes its entry into the Church" (p. 250). Furthermore, this dialectic of acceptance and change is also a fundamental characteristic of lived Christian spirituality, which according to former archbishop of Canterbury Rowan Williams (1990), is in part grounded in the paradox of the incarnation: "God in flesh, 'raising up in power with himself the whole man,' leaves us with a 'restless spirituality,' always liable to...change" (p. 67).

The DBT concept of wise mind (i.e., the state of mind that integrates or synthesizes reasonable mind and emotion mind, guiding one to act thoughtfully and intuitively) can similarly be understood and conveyed from a Christian perspective. Indeed, Scripture affirms the rightful place of both rationality (cf. 1 Corinthians 13:11, Isaiah 1:18-20) and emotion (cf. Ecclesiastes 3:46, Proverbs 17:22, Mark 14:32-34) in the human constitution, both of which are grounded in our being created in the image of God (e.g., Augustine, 1991; Aquinas, 2006). Richard Rohr's (2013) distinction between the Christian's true self and false self may be a particularly helpful analogy to employ here as well. According to him, the embodiment of one's true self (i.e., who we are objectively in God) is understood to be foundational to the spiritual journey; it also implies a freedom from forms of internal conflict (between the mind and heart, rationality and emotion) that often arise out of our tendency to build, protect, or maintain fragile and idealized selfimages--many of which may turn out to be religiously-themed (e.g., seeing oneself as a good Christian, a spiritual leader, or as spiritually-mature). In step with this line of thought, David Benner (2011) conceptualized the process of authentic spiritual growth and maturity as "a journey from fragmentation to integration, from alienation to alignment, from part to whole.a journey towards being at one--at one within our self and at one with all that is" (p. 170). In contrast, Christian spiritualities that fall short of this journey may exhibit a tendency to equate faith with thoughts and beliefs, reducing it to mere mental processes; alternatively, they may be overly concerned with superficial behavioral change, cutting people off from their deep longings and desires because such longings may potentially seek an unacceptable outlet of expression and are often difficult to keep under control. Such false Christian spiritualities bear little resemblance to the restless soul of St. Augustine in Confessions, who modeled a robust Christian spirituality that was formed by both deep emotion and intellectual rigor.

The principle and practice of non-judgment is another foundational component of the DBT treatment model--for example, it comprises one of the "How" skills in the core mindfulness module and is foundational to the practice of the many reality acceptance skills presented in the distress tolerance module. Practicing non-judgment requires people to observe, describe, and participate in life without labeling or evaluating things as "good" or "bad," "positively" or "negatively", or through the lens of "should" and "shouldn't." It is common for facilitators of DBT skills groups to lead group members in rephrasing statements of judgment (e.g., "Chocolate is good," "That driver was a horrible person") into statements that are merely descriptive (e.g., "I like chocolate," "I was cut off and almost had an accident"). In doing so, clients learn to more thoughtfully and accurately distinguish the objective facts of their circumstances from the judgments that they impose on their experiences, which in turn can support more adaptive problem-focused coping behavior--to illustrate, thinking "I'm a terrible person" after putting one's family at risk due to substance abuse can trigger guilt and shame responses which in turn make it even more difficult for that individual to think about what's actually needed to change the situation.

Practicing non-judgment may turn out to be an especially difficult endeavor for some Christian clients, who (perhaps unknowingly) have been socialized at an early age in their religious upbringing to automatically apply moral judgments to their own behavior as well as the behavior of others. Although Scripture gives clear warning about judging others (cf. Matthew 7:1-2), clarifying that it is God who is the ultimate judge (cf. James 4:12). Elsewhere, Christians are instructed to not only judge sinful believers (cf. 1 Corinthians 5:12-13) but to do so with mercy (cf. James 2:12-13). Indeed, Christians cannot indefinitely suspend all forms of judgment, because doing so would be antithetical to their faith--for example, it would deny the reality of sin, the depravity of human nature, and the need for redemption in Christ Jesus. Nevertheless, we believe that Christians can still benefit from practicing non-judgment, with perhaps a few caveats in place. First, it may be helpful to speak of the importance and benefits of suspending judgment for a time, rather than removing all judgment (or alternatively, despairing over or denying the possibility or tenability of making any kind of judgment at all). Because judgments suspend meaning making and the emotional processing of experiences, the purpose of suspending judgment would be to create space to more clearly see and give proper context to the behavior or situation being judged. Anecdotally, we have found that when Christian clients practice non-judgment, especially in relation to observations or descriptions of their own suffering, the temporary suspension of guilt (e.g., "It was my fault") or shame-based judgments (e.g., "I should be doing better than I am") can in fact lead them to a breakthrough where they, perhaps for the first time, bear witness to the compassion that God has for them even as He sees their suffering.

Finally, the mindfulness component of DBT from a Christian perspective needs to be contextualized "within a Christian contemplative tradition of learning to be mindful of the sacrament or sacredness of the present moment, and surrendering to God and His will.... Clients can be encouraged to let their thoughts come and go, especially to Jesus so that every thought is brought captive to His control (cf. 2 Cor. 10:5) ... This also means that the content of one's thoughts is important because biblical truth is crucial in right thinking that still affects one's feelings and actions (cf. John 8:32; Romans 12:2; Phil. 4:8). Such truth includes having hope for the future because of eternal life in Christ" (Tan, 2011, p. 246). Therefore, while a Christian perspective on life will include focusing on the now or present moment (e.g., see Boyd, 2010), it will also anticipate the future with eschatological hope in Christ (Tan, 2011).

David C. Wang

Biola University

Siang-Yang Tan

Fuller Theological Seminary

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Correspondence concerning this article should be addressed to David C. Wang, Th.M., Ph.D. at Rosemead School of Psychology, 13800 Biola Avenue, La Mirada, CA 90639. david.wang@biola.edu

David C. Wang, ThM. (Regent College), Ph.D. (University of Houston) is Assistant Professor of Psychology at the Rosemead School of Psychology, Biola University in La Mirada, CA, and Associate Editor of the Journal of Psychology and Theology. His research focuses on trauma/traumatic stress, spiritual theology and spiritual development, mindfulness, and various topics related to multicultural psychology and social justice.

Siang-Yang Tan, Ph.D. (McGill University) is Professor of Psychology at the Graduate School of Psychology, Fuller Theological Seminary in Pasadena, CA, and Senior Pastor of First Evangelical Church Glendale in Glendale, CA. He has published numerous articles and thirteen books, the latest of which is Counseling and Psychotherapy: A Christian Perspective (Baker Academic, 2011).