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The State of the Science: Dialectical Behavior Therapy

Shireen L. Rizvi
Alma M. Bitran
Linda A. Oshin
Qingqing Yin
Rutgers University

Allison K. Ruork
Rutgers University and Evidence-Based Practice Institute

The first randomized clinical trial of dialectical behavior

et al., 2010). DBT’s popularity among mental
therapy (DBT) for women with borderline personality dis-
health clinicians was evident as early as the year
order was published in 1991. Over the past 30 years,
2000 (Swenson, 2000). In addition, DBT is well-
research on DBT has proliferated along with interest by
known by the public and often cited in popular
clinicians and the public. In this State of the Science review,
culture. However, despite the number of empirical
we provide a brief description of the treatment paradigm
studies and broad dissemination of DBT across
and its conceptual and theoretical underpinnings. We also
populations and settings, we argue that there is
briefly review the research conducted to date on DBT
still much to learn and improve about the treat-
across populations and settings, the vast majority of which
ment. In this State of the Science review (see
demonstrates that it is effective at treating the behaviors
Comer, this issue), we first provide a description
that it targets. We also argue that, although DBT has been
of the treatment paradigm and guiding theoretical
established as a “gold-standard” treatment for certain pop-
tenets. We then provide a brief review of the
ulations and behaviors, there is much more research needed
research conducted to date on DBT. We conclude
to answer critical questions and improve its efficacy.
by setting out an agenda for the future of scientific
study of DBT.

Keywords: Dialectical Behavior Therapy; borderline personality

Overview of Treatment
disorder; treatment efficacy The ultimate goal of DBT is to help clients develop
a life worth living. In its original form, DBT is a
comprehensive outpatient therapy with five func-
SINCE THE FIRST RANDOMIZED CONTROLLED TRIAL
tions designed to help a client reach this goal: (a)
(RCT) of dialectical behavior therapy (DBT) was
improving motivation of the client to change prob-
published (Linehan et al., 1991) more than 30
lem behaviors, (b) enhancing capabilities, (c) gen-
years ago, the treatment has become widely used
eralizing new adaptive behavior to relevant life
and known. There have since been dozens of RCTs
contexts, (d) structuring the client’s environment
using DBT for a range of disorders and popula-
to support new adaptive behavior, and (e) improv-
tions, including several systematic reviews and ing motivation and capabilities of therapists. The
meta-analyses (e.g., DeCou et al., 2019; Kliem modes of treatment in DBT, designed to explicitly
address these functions, include weekly individual
S.L.R. receives royalties from Guilford Press and YouTube for therapy, weekly skills training sessions, phone
DBT-related content. coaching as needed, and weekly therapist consulta-
Address correspondence to Shireen L. Rizvi, Ph.D., ABPP, Rutgers
University–GSAPP, 152 Frelinghuysen Road, Piscataway, NJ tion team. In Table 1, we show the link between
08854. e-mail: slrizvi@gsapp.rutgers.edu. modes of treatment and the primary function they
are meant to address. However, these are not
0005-7894/Ó 2024 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
mutually exclusive pairings. For example,

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2 rizvi et al.
Table 1
Overview of Components of Standard Comprehensive DBT for Adult Outpatient Populations
Mode Function(s) Structure Targets Clinicians
Individual therapy Improve Weekly 50- to 60-min ; Life-threatening behaviors Primary therapist
motivation sessions ;Therapy-interfering behaviors
;Quality-of-life-interfering behaviors
" Behavioral skills

Skills training Enhance Weekly, often in 2-houra ;Therapy-destroying behaviors Skills training leader,
capabilities groups, can be " Behavioral skills and for groups,
individual 60-min sessions ;Therapy-interfering behaviors coleader

Phone Skills As needed ;Suicide crisis behaviors Primary therapist

consultation generalization " Skill generalization to natural
environment
"Therapeutic alliance

Consultation Improve therapist Weekly "Therapist motivation All DBT clinicians

team motivation and "Therapist capabilities
capabilities ;Therapist burnout

Multiple Structure the As needed " Reinforcement of adaptive Variable

environment behavior
; Punishment of adaptive behavior
" Other effective contingencies of
behavior (e.g., shaping, extinction)
Note. DBT = dialectical behavior therapy.
a
In Linehan’s randomized clinical trials (RCTs) at the University of Washington, skills training groups were 2.5 hours. In our experience,
and in trials conducted by other investigators, group length is more likely to be 2 hours.

although the primary function of individual ther- behavioral science

apy is to improve motivation, an individual thera- Well-established behavioral theory and principles of
pist may address barriers to change that could learning are the backbone of DBT. All components
include enhancing capabilities (e.g., teaching a cli- of the treatment are consistent with a behavioral for-
ent a new skill) and/or structuring the environment mulation. DBT utilizes a scientific approach to
(e.g., working with family members to avoid rein- addressing problematic skills repertoires (e.g., defi-
forcing problematic behavior). Importantly, DBT cits in adaptive responses, overlearned ineffective
is considered a principle-based treatment, in con- responses). Problem behaviors are viewed primarily
trast to a protocol-driven treatment. Rather than as skills deficits that can be overcome with skills
a step-by-step session guide, a set of principles acquisition, strengthening, and generalization proce-
informs the content of individual sessions and dures. This behaviorally oriented, skills-deficit con-
therapists must be prepared to respond idiograph- ceptualization means that the targets of treatment
ically to each client based on their presentation are conceptualized as behaviors to increase or
and current context. Each mode of treatment has decrease, and behavioral specificity in defining these
corresponding hierarchical targets of intervention targets, as well as possible solutions, is required.
that inform priorities and requirements for all Individual instances of target behaviors are assessed
treatment activities (see Table 1). using a behavioral chain analysis (see Rizvi, 2019)
that identifies the specific target behavior, its antece-
Overview of Conceptual and Theoretical dents, and its consequences. This level of specificity
Underpinnings of DBT helps inform case conceptualization (see Rizvi &
At its core, DBT is a form of cognitive-behavioral Sayrs, 2020), provide more specific context for pro-
therapy (CBT). Yet, DBT developed as a result of gress or worsening, as well as work toward identify-
failures of traditional CBT for women with ing solutions for problem behaviors that are also
chronic suicidal behaviors and borderline person- behaviorally specific and functionally adaptive.
ality disorder (BPD; see Linehan & Wilks, 2015). A scientific approach also informs the treatment
The evolution led to three theoretical underpin- in that solutions and theorized functions of behav-
nings that inform DBT: behavioral science, ior are tested iteratively, and their relative effective-
acceptance, and dialectical philosophy. ness monitored. For example, if the function of

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 dialectical behavior therapy 3
nonsuicidal self-injury (NSSI) for a client is escape of their life so that they want to live more than
from painful affect, then some combination of skills they want to die.
for accepting and modulating affective experience
would be expected to be helpful. If an experiment biosocial model
using these skills is unsuccessful, then the therapist The biosocial model is a dialectical model used to
assesses potential reasons and adjusts accordingly. explain the etiology and maintenance of pervasive
If repeated experiments are unsuccessful, the thera- emotion dysregulation. It is dialectical in that it sug-
pist may begin reformulating hypotheses (e.g., NSSI gests that pervasive emotion dysregulation develops
is serving other functions, such as communication over time as a result of the transaction between a
to others). Principles of learning also inform inter- biological vulnerability and an invalidating environ-
ventions in that behaviors are formulated as occur- ment (Crowell et al., 2009; Linehan, 1993). This
ring likely because there has been a history of biological vulnerability is characterized by (a)
reinforcement. Thus, strategies such as contingency heightened emotional sensitivity, (b) inability to
management and shaping approximations of adap- regulate intense emotions, and (c) slow return to
tive behavior are used. emotional baseline that, combined, result in temper-
ament more vulnerable to emotion lability. A later
acceptance theoretical addition to the biosocial model also
Linehan reports that early attempts to apply posits that trait impulsivity potentiates across devel-
behaviorism to address chronic suicidal behaviors opment by transacting with environmental factors
were unsuccessful largely because the client felt leading to emotion dysregulation (Crowell et al.,
invalidated by the approach. This invalidation 2009). An invalidating environment is characterized
then led to dysregulation in session, which inter- by four primary features: inaccuracy (child is told
fered with treatment progress and caused strain they are wrong about their emotions), misattribu-
in the therapeutic relationship. The development tion (environment misattributes negative emotions
of strategies designed to help both therapist and to undesirable qualities in the child), discourage-
client accept one’s life and present moment thus ment (environment discourages child’s negative
became a focus of treatment. The embodiment of emotions), and oversimplification of problem solv-
acceptance in DBT comes via the adoption of ing (others minimize difficulty of emotional prob-
mindfulness principles, stemming from Zen prac- lem solving). Inaccurate emotional expression
tice, and the use of validation strategies becomes commonplace as the child learns to mis-
(Linehan, 1993, 1997). Mindfulness (i.e., attend- trust, minimize, or overstate their emotions and
ing to this one moment, with full awareness and does not learn adaptive emotion regulation skills,
without judgment) is taught as a skill to be learned leading to greater problems with emotion regula-
and practiced. Validation strategies are used to tion over time. An increasing amount of evidence
communicate that what the client is thinking, feel- supports both biological pathways and an invalidat-
ing, and doing makes complete sense given the ing environment in the development and mainte-
context and/or the client’s learning history. nance of severe emotion dysregulation, as
Through these acceptance practices, ultimately theorized by the biosocial model (see Crowell
the client learns to both self-validate as well as tol- et al., 2009, for a review).
erate their current experiences more effectively.
cultural considerations
dialectical philosophy Principles of behavioral science, acceptance, and
The dialectical philosophy that informs DBT dialectical philosophy are considered universal
includes many principles. Among them are “Peo- and therefore relevant and applicable for all peo-
ple and behaviors are holistic, connected, and in ple in all cultures and contexts. As a principle-
relationship”; “Tension and polarity are inevitable based treatment, DBT is well situated to be tai-
and a natural part of life”; and “Change is contin- lored to clients’ cultural contexts in application
ual and transactional.” The DBT therapist adopts while remaining adherent to the theories and val-
this dialectical worldview and aims to model it ues that are at the foundation of DBT. This flexi-
through words and actions in treatment. The ther- bility is consistent with the findings from a
apist also aims to balance acceptance and change systematic review of 18 studies on cultural adapta-
strategies and looks for a synthesis when polariza- tions of DBT, most of which have been tailored for
tion occurs. For example, the therapist can help communities of color in the United States (Haft
the client to accept that, at this moment, they both et al., 2022). The primary finding was that the
want to live and want to die. The therapist can adaptations mainly modified the treatment in
then work with the client to change the conditions terms of context, language/terminology, and meta-

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4 rizvi et al.
phor examples used within DBT to make them cul- reductions in NSSI and other self-destructive
turally specific. For example, multiple DBT adap- behaviors than TAU (Verheul et al., 2003). Fur-
tations modified the Interpersonal Effectiveness ther, by comparing DBT to control treatment
module by placing more emphasis on balancing administered by expert community therapists,
communication and incorporating cultural values, Linehan et al. (2006) showed that DBT-related
such as familismo or zhong-yong, and less empha- change in life-threatening behaviors was likely
sis on assertive communication in cultural contexts not attributable to clinician expertise but to active
that value social cohesion over individual needs ingredients in DBT treatment. Compared to TAU,
(Mercado & Hinojosa, 2017; Yang et al., 2020). DBT reduced suicide attempts, hospitalizations,
Additionally, some cultural adaptations have and attempt lethality, psychiatric hospitalizations,
made adjustments to the structure of DBT to make emergency room (ER) visits, and dropout. Since
it more accessible to contexts that have fewer these early trials, a large number of studies have
resources, such as condensing group skills training shown comprehensive DBT to be effective in
sessions to 1 hour (Kamody et al., 2020) or using reducing NSSI and suicidal behavior across a range
non-numeric ratings on diary cards (Ramaiya of populations (e.g., Goodman et al., 2016;
et al., 2018). One potential limitation of standard McMain et al., 2009; Pistorello et al., 2012).
DBT is that it does not explicitly address discrim- Though a comprehensive review of the litera-
ination, which is a known stressor in many com- ture is beyond the scope of this paper, various
munities and has been shown to contribute reviews and meta-analyses have summarized RCTs
directly and indirectly to suicide and self-harm of comprehensive DBT and concluded that DBT is
behaviors (Polanco-Roman et al., 2022). While effective in reducing life-threatening behaviors. In
DBT could be effective in helping clients to effec- a review of 31 RCTs rated on quality and assess-
tively manage their responses to discrimination, ment of treatment adherence, Miga et al. (2019)
further research is needed. concluded that there is solid research support for
comprehensive DBT’s reduction of suicidal and
Broad Summary of the Research Conducted to self-injurious behaviors. Furthermore, DeCou
Date et al. (2019) conducted a meta-analysis on 18
Dozens of RCTs have examined standard DBT, RCTs testing DBT for suicidal and self-injurious
adapted forms of DBT, skills training-“only” stud- behaviors across adult and adolescent populations
ies, and more. In addition to RCTs, there have been that received comprehensive or modified DBT
open pilot trials, nonrandomized trials, and quasi- delivered across inpatient and outpatient settings.
experimental designs. Given the number of existing Results showed that, compared to TAU, DBT
reviews and meta-analyses (e.g., DeCou et al., reduced self-directed violence (d = –0.324) and fre-
2019; Miga et al., 2019) and the ever-changing land- quency of psychiatric service use (d = –0.379),
scape of DBT research, we do not aim to provide a though there was no pooled effect of DBT on sui-
comprehensive review here. Instead, we provide a cidal ideation. However, this meta-analysis
summary of evidence for both comprehensive and excluded studies with an active comparison condi-
skills-only DBT, as well as for exemplary adapta- tion and thus only provides an estimate of DBT’s
tions across a number of populations and settings. efficacy compared to TAU. Evidence for BPD’s
Throughout, we summarize findings from existing superiority to other gold-standard treatments for
review papers (where available) and highlight speci- STBs is more mixed. One systematic review of psy-
fic studies that are of particular methodological chotherapies for BPD found no strong evidence of
strength and/or theoretical relevance. DBT’s superiority to other BPD-targeted modali-
ties in treating primary outcomes (i.e., BPD sever-
comprehensive dbt ity, self-harm, suicide-related outcomes, and
DBT was initially developed with the goal of psychosocial functioning), though DBT outper-
reducing life-threatening behaviors in adult formed TAU on these outcomes (Storebø et al.,
women struggling with emotion dysregulation, 2020). Thus, further work is needed to determine
particularly in the context of BPD. In the first pub- whether DBT outperforms other gold-standard
lished RCT studying the treatment, Linehan et al. treatments for managing suicide risk.
(1991) demonstrated that relative to treatment as
usual (TAU), DBT led to greater decreases in NSSI, skills only
greater retention in therapy, and fewer inpatient Studies have attempted to parse out the effective-
psychiatric visits in a sample of 44 women with ness of individual components of DBT, with evi-
BPD. Another early RCT published in the Nether- dence pointing toward skills training as a critical
lands also found that DBT led to greater mechanism of change (Neacsiu et al., 2010). One

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 dialectical behavior therapy 5
dismantling study of DBT randomized participants 1,081 participants, the racial and ethnic composi-
to 1 year of either standard DBT, skills-only DBT tion of existing research largely matches that of the
plus intensive case management, or individual U.S. population. Regarding sexual orientation,
DBT sessions only plus an activities group sexual minorities were found to be overrepre-
(Linehan et al., 2015). Results showed that condi- sented in DBT trials, though sexual identity was
tions that included skills training led to greater reported in only half of included studies. Gender
reductions in suicidal and self-injurious behaviors, minority identity was reported in only two studies,
demonstrating that skills use is a key active ingre- precluding conclusions about representativeness or
dient in DBT’s effectiveness for reducing life- efficacy in these populations.
threatening behaviors and paving the way for While DBT research may be largely representa-
research testing skills-only adaptations of DBT. tive, the actual number of racially minoritized par-
Skills training-“only” studies have exploded in ticipants in DBT research is still relatively small,
popularity, largely due in part to the perceived util- recent, and mostly among adolescent samples. Fur-
ity of the transdiagnostic coping skills that com- ther research should continue to test DBT in
prise the curriculum and relatively low resource diverse, well-defined samples, particularly gender
cost. Research has indicated that skills-only inter- minority populations, with the goal of identifying
ventions are effective as a standalone intervention whether identity factors influence treatment
for BPD, as well as a range of other disorders (see response. Few studies have examined minoritized
Delaquis et al., 2022; Valentine et al., 2020, for a identities as potential moderators for treatment
review). Individual studies of skill training have response. Some evidence suggests that there are
found that DBT skills are associated with greater not major disparities in treatment outcomes
reductions in symptom severity including depres- among ethnoracially or sexually minoritized popu-
sion, anxiety, irritability, anger, and affect instabil- lations (Adrian et al., 2019; Chang et al., 2023).
ity (Soler et al., 2009), and reductions in suicidal However, ethnoracially minoritized populations
and self-harm episodes, as well as ER and hospital may be disproportionately affected by systemic
visits at follow-up, although group differences barriers to treatment access (e.g., time, resources,
diminished over time (McMain et al., 2017). These lack of providers; Haft et al., 2022), underscoring
studies, along with several others (Gibson et al., the need for research examining potential lower-
2014; Uliaszek et al., 2016), provide preliminary dose, more accessible adaptations of DBT (see
evidence that skills training may be effective as an “The Future of DBT Research” section).
acute intervention for suicidal individuals. Other
Adolescents
studies have similarly found skills-only training to
DBT for adolescents (DBT-A) with suicidal behav-
be feasible and effective for a number of problems,
ior maintains the overall structure with two key
including binge eating (Safer & Jo, 2010; Telch
changes to target unique developmental considera-
et al., 2001), depression (Harley et al., 2008), and
tions (Miller et al., 2006). First, parents attend
global psychosocial functioning (Telch et al.,
skills training groups with adolescents. Second,
2001). While this growing body of evidence sug-
an additional skill module of “Walking the Middle
gests skills-only training to be a promising inter-
Path” is added, designed to provide additional psy-
vention for a variety of disorders, it remains to be
choeducation about dialectics, behaviorism, and
shown whether skills training outperforms other
validation (Rathus et al., 2015). DBT-A has been
manualized interventions (Valentine et al., 2020).
shown to be effective for reducing suicidal and
dbt with different populations and self-injurious behaviors and BPD symptom sever-
diagnoses ity across RCTs and controlled clinical trials (see
Whereas DBT was originally developed for a Kothgassner et al., 2021, for a review). In the lar-
specific target population, its popularity has led gest RCT to date (McCauley et al., 2018), suicidal
to wide proliferation in other populations and pre- adolescents (N = 173) received 6 months of either
senting problems. The following section broadly DBT or supportive individual and group therapy.
reviews the evidence for DBT in specific popula- DBT was found to be favorable across all out-
tions and presenting problems. comes (suicide attempts, NSSI) immediately post-
treatment, though groups no longer differed
Communities of Color and Other Underserved across outcomes at 1-year posttreatment. DBT
Communities also had higher treatment completion rates than
In their systematic review examining the represen- the comparison condition. Taken together, evi-
tativeness of comprehensive DBT trials, Harned dence supports the effectiveness of DBT-A as a
et al. (2022a) found that, across 16 RCTs and treatment for suicidal adolescents.

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6 rizvi et al.
Eating Disorders SUD to comprehensive validation therapy plus
In line with theoretical models of binge eating as a twelve-step (CVT+12S) in a sample of opioid-
maladaptive emotion regulation strategy (Leehr dependent women with BPD (N = 23) found both
et al., 2015), DBT has been specially adapted for conditions to be effective at reducing opioid use, as
the treatment of binge-eating disorder (BED) and measured through urinalysis (Linehan et al.,
bulimia nervosa (Safer et al., 2009). Evidence 2002). DBT was superior to CVT+12S in maintain-
shows DBT-BED to be effective in treating BED ing opioid use reduction through 12 months of ther-
and bulimia nervosa, although it has not been apy, although the DBT condition showed lower
shown to outperform other leading therapies, such retention (64% vs. 100%). The remaining evidence
as CBT for binge eating (CBT+; see Linardon for DBT-SUD comes from uncontrolled trials and
et al., 2017, for a review). One RCT comparing secondary data analysis of RCTs among individuals
DBT-BED to CBT+ found that in obese adults not specifically targeted for SUDs (e.g., Axelrod
(N = 77) with BED, the CBT+ condition had et al., 2011; Harned et al., 2008). These studies have
greater improvements in number of binges, global generally shown DBT to be effective in reducing
eating disorder pathology, and self-esteem SUD-related outcomes (Salsman, 2020). However,
(Lammers et al., 2020). However, both treatments the absence of larger RCTs with active comparison
led to comparable, clinically significant improve- conditions limits our ability to draw conclusions
ment, and the relative superiority of CBT+ may about DBT-SUD’s efficacy, particularly in compar-
have been due to its higher dosage relative to the ison to other evidence-based treatments.
less intensive DBT-BED. Other trials have also
Posttraumatic Stress Disorder (PTSD)
found similarly comparable improvements
Two primary adaptations of DBT for PTSD have
between DBT-BE and CBT+ (Chen et al., 2017;
been developed: DBT for PTSD (DBT-PTSD;
Lammers et al., 2022). In summary, DBT-BED is
Bohus et al., 2020), and DBT plus prolonged expo-
a promising treatment for binge-eating pathology
sure (DBT + DBT PE; Harned et al., 2014). DBT-
of comparable effectiveness to other leading
PTSD is a modular treatment adopting most com-
therapies.
ponents of standard DBT, supplemented with
Substance Use Disorders trauma-focused cognitive-behavioral techniques,
DBT has also been adapted for the treatment of as well as elements of compassion-focused therapy
substance use disorders (DBT-SUD; Dimeff & and acceptance and commitment therapy (Bohus
Linehan, 2008) and remains largely similar to et al., 2019). DBT + DBT PE adopts standard
standard DBT with some key differences. DBT- DBT with the addition of a PE protocol, derived
SUD includes some specific substance abuse- from PE for PTSD (Foa et al., 2019).
specific skills (e.g., dialectical abstinence, clear The strongest evidence for DBT-PTSD’s efficacy
mind, and urge surfing, among others). Accep- comes from an RCT conducted in Germany, com-
tance–change dialectics are used in DBT-SUD to paring 1 year of outpatient DBT-PTSD versus cog-
conceptualize both the importance of complete nitive processing therapy (CPT; Resick et al., this
substance use cessation (change), and of accepting issue), a gold-standard treatment for PTSD
the potential reality of a relapse (acceptance). (Bohus et al., 2020). Participants were women
DBT-SUD primarily addresses substance use as a with PTSD originating from child abuse who
feature of emotion dysregulation (Dimeff & showed at least three BPD symptoms (N = 193).
Linehan, 2008), thus DBT-SUD has primarily been Results showed a small but significant effect favor-
tested in individuals with comorbid BPD and SUD ing DBT-PTSD over CPT in terms of PTSD symp-
rather than as a standalone treatment for SUD. tom reduction, though both conditions improved
DBT-SUD shows promise as a treatment for during treatment. The DBT-PTSD condition also
comorbid BPD and SUD, but more rigorous tests showed lower dropout (25.5% vs. 39.0%) and
with active comparison conditions are lacking (see higher rates of remission and recovery. These find-
Salsman, 2020, for a review). To date, there have ings show strong early evidence for the efficacy of
been only two published RCTs with active compar- DBT-PTSD in reducing PTSD symptoms among
ison conditions testing DBT-SUD among samples populations with abuse-related traumatic stress
specifically recruited for SUD. The first found that and comorbid BPD features.
DBT-SUD outperformed community-based TAU Evidence for DBT PE is also favorable, though
in a sample of drug-dependent women with BPD preliminary. Research to date has included one
(N = 28), leading to greater reductions in pilot RCT (Harned et al., 2014), one open trial
urinalysis-screened positive drug tests (Linehan (Harned et al., 2012), and one pilot nonrandom-
et al., 1999). The second RCT, comparing DBT- ized effectiveness trial (Harned et al., 2021b).

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 dialectical behavior therapy 7
Across studies, DBT + DBT PE has been found to Comtois, 2019, for a review). Evidence is particu-
be superior to DBT alone for reducing PTSD larly strong for improvements in suicidal and
symptoms. The pilot RCT found that relative to self-injurious behaviors following DBT treatment
standard DBT, DBT + DBT PE, in addition to with minimal modifications (e.g., Berk et al.,
reducing PTSD symptoms, reduced suicide 2020). For instance, one randomized clinical trial
attempts and self-injury in women with comorbid (Santamarina-Perez et al., 2020) compared treat-
BPD and PTSD (N = 26). Taken together, these ment outcomes of DBT-A and TAU combined with
findings show promise for the added benefit of group therapy for adolescents with NSSI and/or
the PE protocol to standard DBT for individuals suicidal attempts in a community mental health
with comorbid BPD and PTSD, though larger tri- clinic in Barcelona, Spain. In this adapted DBT-A
als are needed to conclude effectiveness particu- program, the individual sessions were delivered
larly in comparison to other evidence-based weekly or every other week due to the therapist’s
treatments for PTSD. heavy clinical caseload, and youth and their family
attended skills training separately. The main find-
Other Conditions
ing was that the DBT-A program outperformed
DBT-based interventions have been adapted to treat
the comparison treatment in reducing NSSI and
emotion dysregulation associated with a wide vari-
antipsychotic medication use and improving global
ety of other conditions, including attention-
functioning. A recent study (Hiller & Hughes,
deficit/hyperactivity disorder (Halmøy et al., 2022;
2023) conducted in an urban community-based
Morgensterns et al., 2016), autism spectrum disor-
hospital in the northeastern United States corrobo-
der (Huntjens et al., 2020), bipolar disorder
rated the effectiveness of DBT-A in a community
(Goldstein et al., 2015), disruptive mood dysregula-
setting by demonstrating clinically significant
tion disorder in children (Perepletchikova et al.,
improvements in suicidal behavior, NSSI, BPD
2017), psychotic spectrum disorders (Lawlor et al.,
symptoms, depression, and service utilization
2022), and many more. As previously noted, DBT
(e.g., ER visit) among a sample of racially and eth-
primarily targets the transdiagnostic feature of emo-
nically diverse adolescents with BPD features.
tion dysregulation, making it a potentially effica-
Research involving adults receiving DBT in
cious intervention across a number of disorders.
community settings also shows similar trends of
Further research should continue to test DBT-
improvements. A sample of predominantly White,
based interventions where warranted (i.e., popula-
female adults with BPD who received comprehen-
tions in which emotion dysregulation presents a sig-
sive DBT in an outpatient community mental
nificant challenge). Adaptation of standard DBT is
health center reported improvement in medically
common as the comprehensive treatment is not
treated (suicidal or nonsuicidal) self-injuries and
always feasible or necessary across populations. In
crisis/emergency service engagements that were
this vein, research testing DBT-based interventions
comparable to outcomes in three prior clinical tri-
should follow best practice in reporting results by
als after 1 year of comprehensive DBT (Comtois
employing transparency regarding the structure
et al., 2007). This comprehensive DBT program
and content of interventions (e.g., which skills are
was adapted to include an explicit emphasis on
presented, in what order).
working toward employment and education goals
different settings and exiting the mental health services and a case
management component. In an Australian mental
DBT was originally developed as an outpatient
health service, a 6-month comprehensive DBT pro-
treatment in a university-based research clinic.
gram for BPD was found to be more effective than
However, the treatment has since been adapted
TAU for reducing suicidal attempt, NSSI, and ser-
for delivery across a variety of settings, including
vice utilization, as well as depression, anxiety, and
community mental health clinics, inpatient units,
general symptom severity among a predominantly
college counseling centers, schools, and correc-
female adult sample (Pasieczny & Connor, 2011).
tional settings. The following section presents a
There have also been efforts to implement DBT in
brief overview of, and research support for, DBT
community settings at national levels, which have
adaptations across treatment settings.
been shown to be feasible yet contingent on a mul-
Community Mental Health Clinics titude of nontreatment factors for long-term sus-
Research supports the feasibility and effectiveness tainability (Flynn et al., 2020; King et al., 2018).
of DBT among adolescents and adults in routine
community settings, though improvement is often Inpatient Units
smaller or more variable compared to DBT deliv- Inpatient delivery of DBT frequently occurs with
ered in controlled settings (see Walton & some modifications made to accommodate the

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https://doi.org/10.1016/j.beth.2024.02.006
8 rizvi et al.
unique constraints of the setting (see Bloom et al., ative to a matched comparison group, students
2012, for a review). The absence of a formalized (N = 72) participating in a yearlong STEPS-A
inpatient DBT protocol makes it difficult to mea- intervention showed reductions in internalizing
sure efficacy and adherence, as implementation symptoms, including depression, anxiety, and
varies across sites in terms of number of modes, social stress (Flynn et al., 2018). Another small
frequency of treatment sessions, and so on. One (N = 93) quasi-experimental study based in the
review of DBT for inpatients with BPD found that United States also found favorable effects of
treatment was generally effective across studies STEPS-A on emotion dysregulation relative to
(Bloom et al., 2012). However, very few studies class as usual (Martinez et al., 2022). However,
have tested inpatient DBT against a well-defined the largest trial to date (N = 1,071) found that an
comparison condition, and there are no RCTs to 8-week adaptation of STEPS-A (WISE teens), rela-
date testing DBT against other well-established tive to class as usual, led to increases in depression
treatments in an inpatient setting. Further, while and anxiety symptoms and deterioration of par-
flexibility in treatment delivery is needed given ent–child relationships, though most group differ-
substantial differences in the operation of different ences dissipated at follow-up (Harvey et al., 2023).
inpatient units and patient length of stay, future Post hoc analyses showed that students who prac-
work may work to manualize DBT for inpatient ticed skills at home had greater improvements,
settings in order to more rigorously test efficacy suggesting that negative outcomes may have been
and adherence across sites. driven by lack of engagement. Since evidence for
DBT skills as a universal intervention is mixed,
College Counseling Centers
more research is needed to determine whether uni-
DBT has been implemented in college counseling
versal, school-based DBT-based interventions can
centers (CCCs) in both standard and modified for-
be recommended.
mats to address rising concerns about suicidality in
college students. One RCT (Pistorello et al., 2012)
Correctional Settings
examined a 1-year standard DBT with minor mod-
There has been a long history of extending the use
ifications to better fit the college students’ sched-
of DBT in correctional and forensic settings given
ules and a skills module combining distress
the prevalence of emotion dysregulation and asso-
tolerance and validation skills. Results suggested
ciated problems that increase crises and costs of
that, as compared to optimized TAU (n = 32),
resources (see Ivanoff & Marotta, 2018;
the DBT treatment (n = 31) led to greater
Winicov, 2019). Common modifications of DBT
decreases in suicidality, depression, number of
in correctional settings include implementing skills
NSSI events, BPD symptoms, and psychotropic
training only, shortening session length, incorpo-
medication use, as well as greater improvements
rating treatment targets related to criminal behav-
in social adjustment. However, there are barriers
iors, and an emphasis on coping with stress in the
to implementing all modes of DBT treatment in
restricted setting (Frazier & Vela, 2014; Ivanoff &
counseling centers, including the added clinical
Marotta, 2018; Yang et al., 2023). According to a
demands (e.g., time for training, needing to extend
recent scoping review of DBT in juvenile correc-
limits for phone coaching) and a shortage of indi-
tional and detention facilities, DBT skills training,
vidual therapists and time for the consultation
with or without other DBT treatment modes, can
team, which explain the fact that a skills training
reduce problematic behaviors and rates of recidi-
group is the most commonly adopted mode of
vism among adjudicated or preadjudicated youth
DBT in CCCs (Chugani & Landes, 2016;
(Yang et al., 2023). For example, one study exam-
Kannan et al., 2021).
ined a 16-week DBT–corrections modified (DBT-
Schools CM) intervention that is based on DBT skills but
The most widely studied school-based DBT inter- involved simplified vocabulary, modified examples
vention, skills training for emotional problem solv- that are more relevant to situations incarcerated
ing for adolescents (STEPS-A; Mazza et al., 2016), youth face, and modified materials (e.g., binder)
is a universal intervention for social and emotional for safety and security (Shelton et al., 2011).
learning. It teaches DBT skills to improve emotion Reduction in physical aggression, distancing cop-
regulation skills in adolescents with or without ing, and disciplinary tickets for behaviors were
psychiatric issues and, theoretically, prevent found among a sample of racially diverse male
downstream psychological issues. STEPS-A con- youth after DBT-CM. Research based on recently
sists primarily of classroom-based skills training incarcerated female adults also found better out-
groups, with no individual sessions or phone comes in DBT-CM compared to a health promo-
coaching. One study out of Ireland found that, rel- tion program in reducing recidivism (Nyamathi

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https://doi.org/10.1016/j.beth.2024.02.006
 dialectical behavior therapy 9
et al., 2018). This DBT-CM program included six
group sessions that aimed to reduce substance use
and increase positive life experience, individual
sessions, and case management. Overall, favorable
outcomes have been found for adults and adoles-
cents in correctional settings.
Telehealth and Technology
The COVID-19 pandemic has facilitated a rapid
adoption of the telehealth format of psychothera-
pies, including DBT (Hyland et al., 2022;
Zalewski et al., 2021). Despite concerns about vir-
tual intervention for high-risk behaviors and treat-
ment adherence, no evidence to date has
demonstrated that DBT delivered via telehealth
platform is inferior to that delivered in person.
Additionally, emerging evidence exists for the util-
ity of computerized DBT skills training (Wilks
et al., 2018), smartphone-based DBT skills coach-
ing (Rizvi et al., 2011), and DBT skills taught
through animated videos (Rizvi et al., 2022).

The Future of DBT Research

The above section has documented the widespread
areas of research on DBT across populations and
settings over the past 30 years. However, a number
of critical questions remain that future research
must address. It is also important to note that
despite widespread interest and use of DBT, there
has been a dearth of funding for research to
improve access to, and efficacy of, DBT across
diverse populations and settings. For example, Fig-
ure 1 highlights the steady increase in published
research on DBT since the year 2000, which is FIGURE 1
contrasted against a relatively stagnant number
of new R-level awards on DBT funded by the
National Institute of Mental Health (NIMH). ever, beyond the original population, the question
Since 2000, there have only been 30 R-level grants remains as to for whom it is the best (i.e., most
studying DBT. To put this number into perspec- effective and efficient) treatment. Research is nec-
tive: the 14 R-level grants funded by NIMH since essary to determine whether DBT is equally effica-
2013 represents just 0.27% of the 5,199 total cious for all suicidal or self-injuring populations or
grants awarded by NIMH during this period. Such whether it is best for suicidal individuals with a
research is necessary to ensure that the evolution particular diagnostic or behavioral profile.
of DBT is informed by science. In the following Research is also needed to determine what behav-
section, we highlight how future DBT research iors and/or diagnoses DBT is best suited to treat as
can address the following questions: (a) For whom compared to other treatments. Studies have shown
is DBT most helpful?, (b) How much DBT is that for some populations, DBT does not outper-
needed?, (c) To what extent is fidelity to the form other, less costly interventions (e.g., stalking
DBT model important?, and (d) How can we offenders; Rosenfeld et al., 2019), suggesting that
improve efficacy and reduce barriers across popu- comprehensive DBT may be best reserved for pop-
lations and settings? ulations with severe emotion dysregulation that do
not respond to lighter-touch interventions. Fur-
for whom is dbt the best treatment ther, despite increasing interest in DBT among
option? general populations, the extent to which it is useful
DBT research and practice has extended far as a universal intervention or prevention approach
beyond the original target population of women for nonclinical populations is another unanswered
with BPD and chronic self-harm behaviors. How- empirical question, as some research with adapted,

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10 rizvi et al.
low-dose forms of DBT skills has found mixed or experience greater improvement in self-harm when
even iatrogenic effects (Harvey et al., 2023). receiving a 6-month, as opposed to a 12-month,
Moreover, although there are some data indicating course of DBT. In addition, stepped-care studies
that DBT is cost-effective in community settings could be designed such that everyone starts with
(e.g., Comtois et al., 2007; Pasieczny & Connor, a lower dose of DBT, like access to skills videos
2011), cost savings are typically due to reduction (Rizvi et al., 2022) and those who do not respond
in inpatient and crisis visits, not in the cost of are moved on to higher doses of treatment, like
the treatment itself. In order to determine for skills training groups and then to comprehensive
whom DBT is best, future studies evaluating DBT (Rizvi & Kleiman, 2023).
DBT to another treatment should also include cost
effectiveness data whenever possible. to what extent is fidelity to the dbt
Further, an important area for future DBT model important?
research is understanding the comparative effec- DBT is a complex treatment to learn and deliver as
tiveness and examining potential areas of dispari- a mental health clinician. The question about fide-
ties in the treatment of communities of color/ lity to the model can be examined from two differ-
underserved populations. This is particularly ent perspectives—namely, (a) How important is it
important to understand among Black; American to provide principle-consistent, full-model DBT,
Indian/Alaska Native; and lesbian, gay, bisexual, without additional non-DBT components, and
transgender, questioning or queer+ (LGBTQ+) (b) How important is therapist adherence?
groups, in which suicide rates have been increasing DBT was developed as a full, comprehensive
and DBT might be a particularly useful treatment treatment package. From the beginning of its dis-
(Haas et al., 2010; Meza & Bath, 2021). Future semination, however, modifications have been
research among communities of color must also made, often justified by constraints of the setting.
consider access to treatment, as many studies For example, phone coaching is the least utilized
examining the adaptation of DBT to different con- mode of treatment (Chugani & Landes, 2016), in
texts have described access as a main barrier to part due to limited time, resources, and policies
treatment (Haft et al., 2022). Potential modifica- to support clinicians’ use of phone coaching in
tions that would increase access among minori- their practice settings (Landes et al., 2021; Ruork
tized communities while balancing fidelity to the et al., 2022). Although some of these modifications
treatment are particularly worth attention. For are reasonable, we do not have sufficient research
example, some may wish to increase access by to tell us whether the removal of an aspect of DBT
dropping some modes of treatment (e.g., individ- impacts its potency. Similarly, research is needed
ual therapy, phone coaching), but these modifica- to inform decisions about how to deliver skills
tions should consider what is lost by removing training (e.g., groups vs. individually), and the rel-
these modes and consider ways to incorporate ative importance of a DBT consultation team. In
them so as not to reduce fidelity to the principles the absence of such research, clinicians and sys-
of DBT and potentially reduce effectiveness tems make non-research-supported decisions that
(Koerner et al., 2007). may, ultimately, dilute treatment effects.
Research on the effects of therapist adherence,
how much dbt is needed? or lack thereof, has been historically hampered
DBT was not originally designed with scalability by a complicated adherence measure, the DBT
in mind. Only more recently has attention been Adherence Coding Scale (DBT-ACS; Harned
paid to sustainability of DBT in nonresearch set- et al., 2021a), with few individuals reliable in its
tings. With a well-documented mental health crisis use. Further, the DBT-ACS is not free or publicly
and long waiting lists for services (American available, limiting access to the measure. Despite
Psychological Association, 2022; Mental Health these barriers to adherence coding, there is prelim-
America, 2023), more research is needed to deter- inary evidence to suggest therapist adherence in
mine who might benefit from smaller “doses” of DBT is worth considerable attention. One recent
DBT (McMain et al., 2022), or lighter-touch study pooled adherence ratings from six DBT clin-
DBT interventions, and for whom the full compre- ical trials for a total of 1,262 coded individual
hensive package is necessary. Such research could therapy sessions with 288 clients (Harned et al.,
take the form of moderator studies to examine 2022b). Using longitudinal data-analytical meth-
which individuals are more likely to respond to ods, the study found that higher therapist adher-
different forms or lengths of DBT delivery. A ence scores predicted fewer subsequent client
recent example by Traynor et al. (2023) found that suicide attempts and lower rates of dropout. More
individuals with impaired inhibitory control may recently, a more pragmatic, therapist self-report

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 dialectical behavior therapy 11
measure on DBT individual therapy adherence has Novice clinicians, including clinicians in graduate
been developed, the DBT Adherence Checklist for training, may be an important workforce with
Individual Therapy (DBT ACS-I; Harned et al., whom to dedicate time and resources in order to
2023). The DBT ACS-I, which is free and publicly improve access to DBT across systems.
available, shows high observer-rated interrater
reliability, and at least moderate concordance Conclusions
between therapist self-reported and observer- Marsha Linehan would often say, “DBT lives and
reported ratings. Though promising, the DBT dies by its data.” Her dedication to developing a
ACS-I has not yet been used in RCTs of DBT. treatment that was empirically based and rigor-
ously tested has led to a strong state of the science
how can we address barriers to for DBT. DBT has an ever-growing body of
treatment engagement and research to support its efficacy for a variety of dis-
utilization? orders, populations, and settings. However, there
Finally, with research designed to address any of remain a number of unanswered questions about
these questions, attention must also be paid to the use and practice of DBT. Future research is
reducing barriers to receiving DBT treatment. At necessary in order to address these questions in a
minimum, this includes barriers related to issues manner that improves the quality and access of
with treatment engagement, structural/systemic the treatment.
barriers, or the combination thereof, much of
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