Dialectical Behavior Therapy for the Treatment of Borderline Personality Disorder: An Evaluation of the Evidence

The International Journal of Psychosocial Rehabilitation

Dialectical Behavior Therapy for the Treatment of

Borderline Personality Disorder: An Evaluation of the Evidence

Jordan E. DeVylder, M.S.

School of Social Work
Columbia University

Citation:
DeVylder, JE (2010). Dialectical Behavior Therapy for the Treatment of Borderline Personality Disorder:
An Evaluation of the Evidence International Journal of Psychosocial Rehabilitation. Vol 15(1) 61-70

Correspondence:
Jordan DeVylder, M.S.
Columbia University School of Social Work
1255 Amsterdam Ave., New York, NY 10027
jed2147@columbia.edu

Abstract
Dialectical behavior therapy (DBT) is a treatment developed for borderline personality disorder (BPD) in which the clinician attempts to motivate the client towards change in behavior while simultaneously validating existing thoughts and feelings. The goal of DBT is to minimize maladaptive behaviors related to impulse control and emotion regulation, especially those that may result in self-injury or death. Eleven studies supporting the efficacy of DBT for BPD are reviewed and found to provide the highest level of evidence using previously established guidelines for the evaluation of evidence-based practice (Foa, Keane, & Friedman, 2000). Implications for current practice as well as for future research are discussed in the context of the presented studies.

Keywords: DBT, borderline personality disorder, evidence-based practice

Introduction:
Dialectical behavioral therapy (DBT) is a form of cognitive-behavioral therapy developed specifically for borderline personality disorder (BPD; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Tutek, Heard, & Armstrong, 1994). The word “dialectical” in DBT comes from its focus on providing motivation for change in behavior while simultaneously validating the client’s thoughts and feelings. Changes are enacted through the teaching of skills in core areas where people with BPD typically have difficulty. In order to improve treatment adherence and to reduce the risk of sudden drastic reactions to the introspection brought on by therapy, validation must be used to show acceptance of the individual even while the individual is being pushed towards restructuring deeply ingrained patterns of behavior.

Individual therapy
Individualized therapy sessions focus on the client’s progress over the past week in three key areas, organized in a hierarchy of importance. The therapist first focuses on reduction of parasuicide and life-threatening behaviors if these have been a problem over the past week. The term parasuicidal behavior refers to “intentional, acute self-injurious behavior with or without suicidal intent, including both suicide attempts and self-mutilative behaviors” (Linehan et al., 1991, p. 1060). If there have been no such self-injurious behaviors since the prior session, the therapist then shifts focus onto the reduction of behaviors and thought patterns that interfere with the process of therapy. Once these issues have successfully been addressed and the client is compliant with treatment, focus can shift to reduction of behaviors that seriously interfere with the client’s quality of life. The client must learn “radical acceptance” in order to accept his or her present situation as it is, and use that as the starting point for change rather than letting the emotions associated with that situation take over and leave the client feeling trapped and incapacitated.

Group sessions
Whereas individual sessions focus on the current events and personal progress, group sessions teach the core skills that facilitate change by improving the client’s view of his or herself while simultaneously improving the client’s ability to interact with others. These skills are taught in four areas; mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance (Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). Mindfulness skills address the tendency in BPD to make habitual defamatory self-judgments, while allowing the client to focus on the present moment without dwelling on past trauma or apprehension regarding the future (Robins, 2002). Interpersonal effectiveness skills teach clients how to negotiate and solve their problems with other people in their life, addressing the instability of interpersonal relationships that is a common feature in BPD. Emotion regulation skills allow the client to accept rather than become overwhelmed by emotions, allowing the person to process and act on emotions rather than to be made helpless by extreme all-encompassing feelings. Distress tolerance skills allow the client to build resiliency to be able to better cope with stressful situations (McKay, Wood, & Brantley, 2007; Linehan et al., 1991).

Additional therapeutic interventions and fidelity of treatment
In addition to individual therapy and group sessions, clients in DBT programs typically have emergency access to their therapist by telephone. The client can make brief phone calls to the therapist in moments of crisis, generally to prevent self-harm. Restrictions are placed on hours and frequency of telephone use, and are generally respected by clients regardless of the severity of the disorder (Lynch, Trost, Salsman, & Linehan, 2007).

DBT does not only include therapy for the client, but for the therapist as well. BPD can be considered a very difficult diagnosis to work with, and therapist burnout is a major risk. To address this, sessions are typically included to address therapist concerns and to insure treatment model fidelity, thereby allowing more consistent care with a relatively inconsistent population (Linehan, Schmidt III, Dimeff, Craft, Kanter, & Comtois, 1999).

DBT practice with good fidelity includes all four components just described. In most research studies, treatment lasts one year and consists of an hour of individualized therapy and 120-150 minutes per week of group sessions; however, this can be adjusted without major sacrifices in fidelity as clients generally respond to treatment well before one year (Linehan et al., 1991).

Strengths and limitations of DBT
The primary strength of DBT is that it has been shown through randomized control trials to be an efficacious treatment for BPD, a severe and persistent mental illness without prior evidence-based treatment. The treatment is well-received by clients and has a high rate of treatment adherence among this population (Lynch et al., 2007). DBT addresses core problematic behaviors (Linehan et al., 1991) and its effects continue to endure following termination (Linehan et al., 2006; Van den Bosch, Koeter, Stijnen, Verheul, & Van den Brink, 2004).

Some recent studies have provided evidence that alternative psychosocial therapies, or psychosocial therapies in conjunction with medication, may produce even better results. For example, one study compared DBT to transference-focused psychotherapy, a psychodynamic treatment, and found that transference-focused psychotherapy improved anger and impulsivity symptoms whereas DBT had no effect. However, the treatments had similar effects on other measures in this study (Clarkin, Levy, Lenzenweger, & Kernberg, 2007). Soler et al. (2005) showed that combining DBT with olanzapine, an atypical antipsychotic medication, improves treatment adherence as well as depression, anxiety, and impulsivity scores relative to DBT alone. However, this simply suggests that DBT may benefit from combination with psychopharmacological treatment and is not necessarily a weakness in DBT itself. Finally, Van den Bosch et al. (2005) showed that DBT effects, while still significant, are not as strong at 6 month post-treatment follow-up. It is therefore likely that some of the DBT effects may fade over time, and maintenance treatment may be a necessary adjunct in order to prevent relapse.

Goals and Targets of DBT
The desired outcome of DBT is a resolution of maladaptive behaviors related to impulse control and emotion regulation, especially those behaviors that may result in self-injury or death. It was originally developed to address suicidal and parasuicidal behaviors and this remains the highest priority in the hierarchy of treatment for the typical target population of BPD clients. The goals of DBT when treating BPD include a reduction or end of parasuicidal behaviors, the reduction of other associated self-injurious behaviors such as substance abuse and eating disorder traits, development of emotion regulation skills to allow clients to better process their feelings, and the development of social skills to help clients maintain healthy interpersonal relationships (Linehan et al., 1991; Linehan et al., 1994).
Progress in DBT is tracked through a variety of measures, depending on clinician preference and on the primary target behaviors for a particular client or group of clients. Self-report measures are typically used to measure progress in areas such as depression, anxiety, and suicide risk. These include the Reason for Living Scale (Linehan et al., 2006; Linehan 1991), Suicidal Behaviors Questionnaire (Linehan et al., 2006), Hamilton Anxiety Rating Scale (Soler et al., 2005), Hamilton Scale for Depression (Linehan et al., 2006; Soler et al., 2005), Beck Depression Inventory (Clarkin et al., 2007; Kroger et al., 2006, Linehan et al., 1991), Barrat Impulsiveness Scale (Clarkin et al., 2007), Social Adjustment Scale (Clarkin et al., 2007; Linehan et al., 1999; Linehan et al., 1994), DSM-IV GAF score (Clarkin et al., 2007; Kroger et al., 2006), and others. Semi-structured and structured interviews are also used to determine frequency of parasuicidal behaviors, impulsive behaviors, and substance use (Linehan et al., 2006; Kroger et al., 2006; Soler et al., 2005; Von den Bosch et al., 2005; Linehan et al., 2002; Linehan et al., 1999; Linehan et al., 1994; Linehan et al., 1991).

Supporting Evidence
Evidence supporting DBT as an efficacious treatment for BPD is substantial, with multiple replications and variations demonstrated to be successful in randomized control trials (see table I). The effectiveness of DBT for BPD has been well-established in outpatient settings (for review, see Lynch et al., 2006), expanded to include inpatient hospitalization (Kroger et al., 2006), and demonstrated to have lasting effects following treatment termination (Linehan et al., 2006; Van den Bosch et al., 2005). Studies have also addressed co-occurring disorders, which is vital for BPD research since BPD rarely occurs in isolation (Lynch, Trost, Salsman, & Linehan, 2007). In particular, it has been tested with co-occurring axis I mental illness (Kroger et al., 2006) and substance abuse (Verheul et al., 2003; Linehan et al., 2002; Linehan et al., 1999).

Table 1

Author, Date	Sample Characteristics	Design	Treatment Protocol	Structure & Duration	Outcome	Comment *
Clarkin et al., 2007	Diagnosis of borderline personality disorder	Randomized trial: DBT group vs. transference-focused psychotherapy group vs. dynamic supportive treatment; N of 90	Manualized DBT treatment including individual and group sessions	One year of weekly individual and group sessions plus telephone contact, with assessments every 4 months and at baseline	All Tx groups had improvements in depression, anxiety, global functioning, and social adjustment. DBT and transference-focused had showed declines in suicidality, transference-focused and dynamic showed declines in anger and impulsivity.	Level A Demonstrated effectiveness of DBT, but other methods were superior on some measures
Koons et al., 2001	Women veterans diagnosed with borderline personality disorder	Randomized trial: DBT group vs. treatment as usual; N of 20	Manualized DBT treatment with shortened sessions	Six months of weekly individual and group sessions, 90 minutes each	DBT group had greater decreases in suicidality, hopelessness, depression, anger, and parasuicidal behaviors.	Level A
Kroger et al., 2006	Inpatient population seeking 3-month treatment for BPD and co-morbid Axis I disorder, mean age 30.5 years	N of 50 (44 female, 6 male)	DBT treatment adjusted for 3-month treatment, with added emphasis on group therapy	Three month inpatient treatment including a one hour individual session and three 100 minute group sessions each week, with assessments at admission (baseline), discharge, and at 15-month follow-up.	With DBT treatment this group’s Beck Depression Inventory scores were reduced, symptom severity was reduced, and GAF scores were increased.	Level B Clinical evaluation, no control group or randomization
Linehan et al., 1991	Chronically parasuicidal borderline women, aged 18 to 45	Randomized trial: DBT group vs. “treatment as usual”; N of 44	Manualized DBT treatment, emphasis on management of emotional trauma	One year of weekly individual (1 hr) and group (2 ½ hr) sessions plus telephone contact, with assessments every 4 months and at baseline	Tx group had fewer parasuicide acts with lower medical risk but no fewer episodes, stayed in therapy longer, and had fewer days of hospitalization. No difference in Beck depression inventory score, number of episodes, likelihood of at 1< admissions in year	Level A
Linehan et al., 1994	Chronically suicidal borderline women, aged 18 to 45	Randomized trial: DBT group vs. “treatment as usual”; N of 26	Manualized DBT treatment, emphasis on management of emotional trauma	One year of weekly individual (1 hr) and group (2 ½ hr) sessions plus telephone contact, with assessments every 4 months and at baseline	Tx group had reduced trait anger, reduced use of psychotropic meds, improved global adjustment. No difference in global life satisfaction.	Level A
Linehan et al., 1999	Dual diagnosis BPD and drug-dependence women,	Randomized trial: DBT group vs. “treatment as usual”; N of 28	Manualized DBT treatment, with “attachment strategies,” and “dialectical abstinence” additions to address substance abuse	One year of weekly individual (1 hr) and group (2 hr) sessions plus telephone contact, with assessments every 4 months, at baseline, and at a 16 month follow-up	Tx group had reduced substance use measured by self-report and urine toxicology, improved social adjustment, global functioning at follow-up. No differences in amount and type of medical or psychiatric treatment needed	Level A
Linehan, et al., 2002	Opiate-dependent women meeting criteria for BPD	Randomized trial of DBT vs. comprehensive validation therapy plus 12-step; N of 23	Manualized DBT treatment, emphasis on management of emotional trauma	Opiate agonist therapy, plus DBT consisting of one year of weekly individual (1 hr) and group (2 hr) sessions plus telephone contact, with assessments every 4 months, at baseline, and at a 16 month follow-up	DBT group maintained reduced opiate use throughout treatment whereas CVT +12s group relapsed at 8 months but had a lower retention rate. DBT group was more accurate in self-report of opiate use.	Level A
Linehan et al., 2006	Chronically suicidal borderline women, aged 18 to 45	Randomized trial of DBT vs. therapy by experts; N of 100	Manualized DBT treatment, emphasis on management of emotional trauma	One year of weekly individual (1 hr) and group (2 hr) sessions plus telephone contact, with assessments at baseline and at every 4-months during treatment plus 1 year follow-up period	DBT group showed reduction in suicide attempts, hospitalization for suicide ideation, hospitalization overall, lower medical risk from parasuicidal behavior, and were more compliant with treatment during entire 2 year treatment and follow-up period	Level A
Soler et al., 2005	Borderline personality disorder of moderate to high severity, with substance use allowed but not dependence	Double-blind randomized trial of DBT with Olanzapine versus DBT with placebo; N of 60	DBT group therapy and phone contact (without individualized sessions) along with medication maintenance	One month baseline period plus 12-weeks of treatment of group sessions (2 ½ hours), telephone contact, medication management, and biweekly assessment	Clinical improvement in both groups, with additional improvement in depression scores, anxiety scores, impulsivity, and aggression in the Olanzapine group	Level A Clinical improvement with two group-only DBT treatments, with greater improvement in the Olanzapine group
Turner, 2000	Borderline personality disorder, age 18-27	Randomized trial of DBT vs. Client-centered therapy; N of 24 (5 males)	Manualized DBT treatment including individual and group sessions	One year with assessment at baseline, 6 months, and 12 months of treatment.	Greater reduction in number of hospitalizations and parasuicidal behaviors for DBT group	Level A
Verheul et al., 2003, Van den Bosch, 2005	Females with borderline personality disorder, with and without substance abuse, not required to have recent parasuicidal behaviors, age 18-65	Randomized trial of DBT vs. Treatment as Usual; N of 58	Manualized DBT treatment including individual and group sessions	One year of weekly individual (1 hr) and group (2 ½ hr) sessions plus telephone contact, with assessment after 12 months of treatment and at follow-up, 6 months after discontinuation of treatment	Clinical improvements in parasuicidal and impulsive behaviors and reductions in substance abuse were greater for DBT group at 6 month follow-up, with no return to baseline for any measure	Level A

* Agency of Health Care Policy’s Level of Evidence Coding System (Foa, Keane, & Friedman, 2000).

Marsha Linehan developed DBT and provided much of the evidence for its support. She first introduced her modified version of cognitive-behavioral therapy specifically as a method of addressing parasuicidal behavior in BPD. The first randomized control trial tested the effects of DBT versus “treatment as usual” (TAU) on 44 women aged 18 to 45, diagnosed with BPD with chronically parasuicidal behavior (Linehan et al., 1991). At the time, there was only a single published randomized-control trial for parasuicidal behavior and it did not include BPD (Liberman & Eckman, 1981). Therefore, there was not sufficient evidence in the literature for an alternative treatment that would allow it to be used as a control group. Instead, Linehan et al. compared DBT to TAU, the typical treatment that a client would receive in the community when diagnosed with BPD.

Linehan developed a year-long time-limited therapy which “emphasized the management of emotional trauma” and consisted of three components; one hour individual sessions addressing client progress and needs, 150 minute group sessions for skills training, and constant telephone access to the primary therapist by the client for emergency situations. The individual sessions addressed a hierarchy of needs that first addresses parasuicidal and life-threatening behaviors, followed by behaviors that interfere with treatment, and finally behaviors that interfere with the client’s quality of life. The individual therapist assessed the client’s life over the past week and would address the most pressing needs first. When a target behavior was identified, such as a suicidal act, than in response: “an exhaustive description of the moment-to-moment chain of environmental and behavioral events that preceded the suicidal behavior is elicited, alternate solutions that the individual could have used are explored, behavioral deficits as well as factors that interfere with more adaptive solutions are examined, and remedial procedures are applied as necessary” (Linehan et al., 1991, p. 1061). By addressing these personal issues, the therapist should be able to greatly reduce the client’s risk of self-harm while the group simultaneously teaches them skills needed to eliminate these behaviors over the long-term. The group sessions focused on training around the four core areas of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, as discussed above.

This initial study found no reduction in the number of parasuicidal episodes between the BPD groups but did find changes in the severity of episodes. Parasuicidal acts among the DBT group had lower medical risk and lower chances of lethality than the equivalent acts in the TAU group. While also hospitalized at a similar rate and with no fewer admissions over the course of the year, the duration of hospitalization was significantly shorter for the DBT group, with less time until recovery from the present episode. Furthermore, treatment adherence was improved by DBT, with DBT subjects staying in treatment longer than those receiving TAU.

These results demonstrating a significant effect of DBT on BPD prognosis were replicated in a subsequent study that utilized a similar procedure and population (Linehan et al., 1994). This study diverted from the concrete variables used in the prior study of number of hospitalizations and parasuicidal acts, and instead focused on global social adjustment, anger, and life satisfaction. Although no differences were found in global life satisfaction, the DBT treatment group was found to have reduced trait anger, improved social adjustment, and reduced use of psychotropic medications relative to the TAU group (Linehan et al., 1994). Additional randomized control trials by other research laboratories confirmed the reduction in suicidality, hopeless, depression, anger, and parasuicidal behaviors among clients receiving DBT relative to those receiving TAU in the community (Koons et al., 2001; Turner, 2000).

BPD with co-occurring substance abuse
Linehan’s lab next focused on subjects with BPD and co-occurring substance abuse, a condition that may actually be more common than BPD alone, occurring in as much as 2/3 of those with BPD (Dulit, Fyer, Haas, Sullivan, & Frances, 1990). This study (Linehan et al., 1999) used a similar procedure to the prior two studies but included additional “attachment strategies” and “dialectical abstinence” features intended to specifically address substance abuse. They also began including counseling for the therapists themselves as a part of DBT. This reduced therapist burnout with this difficult population and helped to ensure fidelity to the treatment model. Again, the DBT group exhibited improved social adjustment and global functioning at follow-up, even 4 months after termination of treatment. For this population, these changes were accompanied by self-reported decline in substance use, which was confirmed with urine toxicology tests. Since substance abuse and BPD frequently coexist in a single client, it is advantageous to have a single treatment that simultaneously and successfully facilitates recovery from both conditions.

One shortcoming of Linehan et al. (1999) is that it compared DBT to TAU for a population with co-occurring substance use and BPD. While the TAU control group could be justified for studies focusing exclusively on BPD, it could be seen as insufficient when substance abuse is included since commonly accepted practices for treating substance abuse do exist. Their next study therefore looked at women with BPD and opium dependence, comparing DBT to an accepted opium dependence treatment known as comprehensive validation therapy plus 12-step (CVT +12). Both treatment groups also received opiate agonist therapy to treat physiological symptoms of opium dependence. This study found that both treatment groups successfully reduced their opium use with treatment. However, the CVT +12 group began to relapse after an average of 8 months, whereas progress was maintained for the DBT group. Furthermore, the DBT subjects were more accurate in self-reporting their opium usage, suggesting greater awareness or insight into the condition.

Using DBT to treat BPD in an inpatient setting
BPD also frequently co-occurs with axis I mental illness and may often be treated in an inpatient setting. It is therefore important to extend the findings of Linehan to an inpatient environment and to ensure that DBT is still effective when a client has a primary axis I diagnosis. Kroger et al. (2006) studied a group of 50 patients with BPD in an inpatient unit, the vast majority of whom also had an Axis I diagnosis. In their adjusted 3-month variation on the Linehan DBT model which included an added emphasis on the group therapy component, they found a reduction in Beck depression scores and symptom severity and an increase in Global Assessment of Functioning (GAF). Unfortunately, this experiment was a clinical evaluation with no control group or randomization, so potential interpretation of these data is limited. A study by Soler et al. (2005) considered the effect of combining DBT with an atypical antipsychotic, another likely scenario for hospitalized BPD clients. They found that both the DBT and the DBT + Olanzapine groups showed significant clinical improvement, but that the group that included medication had additional improvements in depression and anxiety scores, as well as reductions in impulsivity and aggression. Based on this study, we must continue to consider the possibility of combining DBT with medication, despite the efficacy of DBT as a psychosocial treatment on its own and despite evidence that DBT reduces a client’s need for psychotropic medication (Linehan et al., 1994).

Long-term efficacy of DBT for BPD
Having established the efficacy of DBT as at treatment for BPD, the Linehan lab then attempted to demonstrate long-term effects of this time-limited therapy. They conducted a similar study as their earlier DBT work, but with an additional year of follow-up assessments. This two-year study revealed that DBT reduces suicide attempts, hospitalization for suicide ideation, overall hospitalization, medical risk for parasuicidal behavior, and increases treatment compliance. Furthermore, these effects persisted throughout the entire one-year treatment phase and the one-year follow-up phase, demonstrating a continuing effect of DBT for a substantial period following termination (Linehan et al., 2006). A set of studies by Verheul et al. (2003) and van der Bosch et al. (2005) confirmed this effect, demonstrating lasting efficacy of DBT over a 6-month post-treatment period. Their studies did exhibit a slight decline in progress, but there was no return to baseline on any measure and the follow-up prognosis was significantly better than that of the TAU group.

DBT as an evidence-based practice for BPD
Foa, Keane, & Friedman (2000) published a set of guidelines for determining the level of evidence supporting treatment for post-traumatic stress disorder. These same guidelines can be generalized to other treatments and disorders, and can be useful in concisely explaining the level of evidence supporting a particular treatment. DBT for BPD is supported by ten studies presented in this paper at a Level A degree of evidence, and in one additional study with Level B evidence. DBT has been shown to be an effective treatment for BPD and this finding has been consistently replicated in a series of randomized control trials. Based on this review, DBT can be ranked as a Level A treatment for BPD, the highest level of evidence based on this coding system.

Recent developments in DBT research
Now that DBT is established as an evidence-based practice for BPD, researchers are attempting to push the method into new directions. DBT has significantly outperformed anti-depressant medication in the reduction of depression symptoms among geriatric clients with major depression, both with (Lynch et al., 2007) and without a co-occurring personality disorder (Lynch, Morse, Mendelson, & Robins, 2003). Research into DBT as a treatment for eating disorders is expanding as well, with recent case studies providing evidence of its efficacy among adolescents with anorexia, bulimia nervosa, and binge eating disorder (Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, & Miller 2008; Safer, Lock, & Couturier, 2007). DBT had previously been shown to reduce eating disorder symptoms among BPD adolescents (Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2000). Another case study has produced somewhat unexpected results, showing strong effects and promise for future research in the use of DBT for the more “perfectionistic” and “risk-averse” personality disorders, considered in many ways to be the opposite of the emotion dysregulation and impulse control problems seen in BPD. Nonetheless, a client with co-morbid obsessive-compulsive personality disorder and paranoid personality disorder showed full remission from symptoms of both personality disorders as well as depression, and these effects lasted for two years after treatment termination (Lynch & Cheavens, 2008).

One final recent direction in DBT research comes from neuroscience, where researchers are now beginning to identify biological changes that result from behavioral treatments. A pilot study (BPD n = 6) demonstrated that DBT leads to reduction in activity in the limbic system, the emotional center of the brain, in response to highly valenced negative images, and that those who respond to treatment show greater reduction in the amygdala, a subcortical region implicated in the processing of emotional stimuli, especially those that are fearful or threatening. (Schnell & Herpertz, 2007). The demonstration of biological changes not only adds further evidence for the effectiveness of the treatment, but also may add legitimacy to a behavioral method in a field that is dominated by the medical and psychopharmacological model of treatment.

Implications of Research and Future Directions
Support for DBT as an evidence-based practice for BPD is substantial, far exceeding the two randomized control trials required by the American Psychological Association. With many randomized control trials, several case studies, modifications for different treatment settings and procedures, and adjustments for other related mental health and substance abuse conditions, DBT has been shown to be a consistently and broadly efficacious treatment.
DBT can address chronic reoccurring mental health problems that are not currently well handled in acute medicine-based care. Rapid shifts in mood seen with BPD can make chronically suicidal BPD clients seem recovered at the hospital, who may then relapse very soon after discharge. However, even a three-month inpatient DBT treatment can be effective, regardless of co-occurring axis I disorders (Kroger et al., 2006). Based on evidence for DBT, clinical practice can be improved by training psychologists and social workers in DBT skills. Psychiatrists can benefit from DBT training as well, although it may be more effective to educate acute care psychiatrists in hospital emergency rooms and inpatient units regarding the benefits of DBT, so that they may make appropriate referrals and not rely primarily on medication for treatment of BPD. Although this treatment modality is efficacious, it may still be difficult to engage clients and to have them initiate treatment. Programming can be improved through the development and implementation of effective intake procedures, psychoeducation for BPD clients regarding the need and efficacy of treatment, and outreach to the community providing information on how to access services. Mental health policy can benefit from DBT research as well. BPD accounts for much of mental health spending, as it may be responsible for approximately 20% of psychiatric hospitalizations in the United States (NIMH, 2001). DBT treatment for BPD may lead to widespread reductions in health care costs over the long term by training clients to better control their emotions and impulses, thereby preventing hospitalizations and emergency room visits.

Future research for DBT should focus on simultaneously addressing BPD and the frequently co-morbid conditions of Axis I disorders, eating disorder, and substance abuse. Some progress has been made in these areas, but more research is needed to ensure efficacy in these sub-populations, all of which may be as common as or more common than BPD in isolation. Initial research combining DBT with antipsychotic medication (Soler et al., 2005) and in modifying DBT to include specific substance abuse components (Linehan et al., 1999) have been successful thus far.

Another area in which DBT research is thoroughly lacking is in its applications to diverse populations. Demographic data related to race and ethnicity is lacking in many of the DBT studies. However, there have been no studies that specifically look at DBT as a multicultural treatment modality. There is especially little evidence for use of DBT with male subjects, as BPD is a very disproportionately diagnosed in females (Simmons, 1992). However, males still account for approximately 25-30% of the population diagnosed with BPD, and therefore form a significant minority that should not be excluded from evidence-based treatment (Linehan et al., 1994). Furthermore, this diagnosis may be underrepresented among males due to bias in clinicians which may lead them to give females a diagnosis of BPD and to give similarly presenting males a diagnosis of anti-social personality disorder (Simmons, 1992). Many DBT studies, including those by the Linehan lab, which developed the treatment, exclude male subjects from their subject pool (Linehan et al., 2006; Van Den Bosch et al., 2004; Koons et al., 2001; Linehan et al., 1999; Linehan et al., 1994; Linehan et al., 1991). The studies that do include subjects from both genders are still so disproportionately female that it is conceivable for them to show an effect even if all male subjects are unresponsive to treatment (Clarkin et al., 2007; Kroger et al., 2006; Soler et al., 2005). BPD presents differently to some extent in male clients and is also approached differently by clinicians with female clients (Nehls, 1998); it is therefore likely that some adaptations may be needed in DBT protocol to make it applicable to this substantial minority. Although there is now sufficient evidence to support DBT as an evidence-based practice, there has not yet been ample research towards addressing generalizing this treatment across culture and gender.

Despite the evidence and support, current challenges faced in implementing DBT are still numerous. For one, the BPD population is notoriously difficult to engage and non-adherent to treatment. Many of the studies presented above showed improved treatment adherence for the DBT group, but that still leaves us with the difficulty of initially engaging clients and beginning treatment. Even once engaged, this population is considered difficult to work with by many clinicians, and even necessitated a special counseling session for the therapists in a number of the studies presented in this paper. Compounding problems with the clients themselves are the systemic difficulties in obtaining insurance reimbursement for behavioral and psychosocial treatments, and in implementing such programs in facilities and agencies that retain a primarily medical model of mental health, such as hospitals and many community treatment centers.

Conclusion
DBT has been repeatedly shown to be a highly efficacious treatment for BPD and is likely beneficial to a substantial portion of the mental health population. However, some gaps in the research remain. DBT findings must be expanded to and multi-cultural and multi-gender population, they must be expanded to cover frequently co-morbid conditions, and ideally they should be extended into related areas of mental health, including other personality disorders and other mental illness and substance abuse conditions that involve emotion dysregulation and poor impulse control. Once these issues are sufficiently addressed, DBT can truly be considered an effective treatment for a variety of mental health conditions across a diverse and representative population.

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