Behavioral Assessment in DBT: Commentary on the Special Series

Behavioral assessment is woven into the fabric of DBT. The articles of this special series beautifully illustrate this point by describing the relevance and application of behavioral assessment principles in several DBT contexts: creating a case formulation; assessing suicidal behavior; client use of DBT skills; and within family or couple interventions. This commentary highlights themes common to the papers and discusses assessment as it relates to several core concepts in DBT: behaviorism, acceptance, dialectics, and the assumptions about treatment. We identify several dialectical tensions that practitioners must balance when using behavioral assessment strategies. Suggestions for clinical practice are provided.     

Behavioral Assessment in DBT

Dialectical behavior therapy is a widely popular treatment that has been demonstrated to be efficacious with individuals with severe emotion dysregulation problems. DBT is a highly flexible treatment that relies heavily on assessment throughout all phases of treatment to generate idiographic interventions that closely match each client’s varied needs. This series describes a set of principles for utilizing assessment to enhance both one’s adherence to the DBT manual and one’s treatment outcomes. The four articles and commentary illustrate how assessment can facilitate the development of a case formulation; improve skills acquisition, strengthening, and generalization; reduce suicide risk; and make interventions with couples, parents, and other family members more effective. They discuss what pitfalls may occur if providers drift from careful, ongoing assessment, and how best to utilize assessment to work well within DBT’s flexible structure.     

Treatment of a Case Example With PTSD and Chronic Pain

This commentary reviews the case of GH, a survivor of a road traffic collision, who has chronic pain and posttraumatic stress disorder (PTSD). The case formulation, assessment strategy, and treatment plan are informed by the relevant experimental literature and empirically supported treatments using a cognitive behavioral perspective. Given this framework, the commentary includes a focus on the treatment of PTSD with an eye toward generalizing the therapeutic strategies to chronic pain problems. Psychoeducation, imaginal exposure to the traumatic event, in vivo exposure to avoided activities, and cognitive interventions including coping self-statements, correction of logical errors, decatastrophizing and developing alternative explanations are all included in the recommendations as part of a standard cognitive behavioral treatment for PTSD. Added to this standard PTSD protocol is the suggested use of interoceptive exposure to address GH’s feared bodily sensations. In the assessment domain, standard measures for pain and PTSD assessment are suggested along with tracking of depression and anxiety sensitivity. Some recognition of more recent approaches to cognitive behavioral therapy (e.g., Acceptance and Commitment Therapy) is given in considering potential obstacles to treatment.     

Clinical Guidelines for Improving Dialectical Thinking in DBT

Cognitive dysregulation, often characterized by extreme, nondialectical thinking, is a core problem area identified in dialectical behavior therapy (DBT) and is posited to contribute to pervasive emotional and behavioral dysregulation. However, cognitive flexibility is understudied and rarely considered a direct treatment target in DBT. This paper provides clinical guidelines for increasing dialectical thinking with patients in DBT. We review the historical context of dialectical thinking in DBT and present the results of a survey examining DBT therapists’ perspectives on nondialectical thinking as a treatment focus. We describe cognitive restructuring strategies from cognitive therapy models, and compare these with techniques targeting cognitive dysregulation in DBT. We highlight the rationale for incorporating dialectical thinking as a direct treatment focus in DBT, and offer strategies derived from cognitive restructuring to incorporate directly targeting dialectical thinking in conceptualization, treatment planning, and in session. These strategies are demonstrated with clinical vignettes and examples.     

Enhancing the Responsiveness of Family-Based CBT Through Culturally Informed Case Conceptualization and Treatment Planning

Family-based CBT has been shown to be effective in controlled settings for an array of youth mental health difficulties, yet disparities in treatment engagement and outcomes across culturally diverse groups remain. In practice, cultural minority families are less likely to reap the demonstrated benefits of supported programs. Although there have been tremendous advances in case conceptualization, leading models have largely ignored cultural factors, contributing to observed disparities. The present paper reviews recent advances in science-informed case conceptualization and highlights how such advances nonetheless have failed to provide guidance on systematically incorporating cultural formulation into assessment and treatment planning. We then build upon Christon et al. (2015) useful 5-stage model of science-based case conceptualization in an effort to move the field toward culturally informed case conceptualization. We highlight how leveraging cultural assessment—such as with the use of the Cultural Formulation Interview (CFI)—can facilitate the incorporation of cultural factors into each of the five stages of science-based case conceptualization. A case example is utilized to illustrate key opportunities for strategically incorporating relevant information gleaned from the CFI into culturally responsive care with youth and families.     

Changes in personality in pre‐ and post‐dialectical behaviour therapy borderline personality disorder groups: A question of self‐control

Dialectical behaviour therapy (DBT) is an evidence‐based therapy for people with borderline personality disorder (BPD). Past research has identified behavioural changes indicating improved functioning for people who undergo DBT. To date, however, there has been little research investigating the underlying mechanism of change. The present study utilised a between‐subjects design and self‐report questionnaires of Self‐Control and the five factor model of personality and drew participants from a metropolitan DBT program. We found that pre‐treatment participants were significantly lower on Self‐Control, Agreeableness and Conscientiousness when compared to both the post‐treatment assessment and the norms for each questionnaire. Neuroticism was significantly higher both before and after treatment when compared to the norms. These findings suggest that Self‐Control may play a role in both the presentation of this disorder and the effect of DBT. High levels of Neuroticism lend weight to the Linehan biosocial model of BPD development.     

A Functional Approach to the Assessment and Treatment of Non-Suicidal Self-Injury in Veterans: A Dialectical Behavior Therapy–Informed Perspective

Given that non-suicidal self-injury (NSSI) is related to increased odds of suicidal ideation and suicide attempts, treating NSSI in veterans is a key treatment priority to help reduce suicide risk and increase quality of life. Treating NSSI can be difficult for clinicians and training in addressing NSSI can enhance therapist empathy and decrease negative attitudes. The current paper describes prevalence of and risk factors for NSSI in veterans and presents a Dialectical Behavior Therapy (DBT)-informed approach for arriving at a functional understanding of NSSI in order to inform assessment and treatment. This DBT-informed approach is demonstrated with two case examples of veteran clients. While in many circumstances treatment of NSSI may be most effective in the context of full model DBT (i.e., individual therapy, group skills training, phone coaching, and therapist consultation team), many aspects of the functional approach discussed herein are not specific to DBT and could therefore be integrated into behavioral analyses and case formulations conducted within non-DBT therapeutic approaches.     

Treatment of Comorbid Pica and Generalized Anxiety Disorder: A Case Study

This case report describes the assessment and treatment of a treatment-naïve 36-year-old Hispanic/Latina female with comorbid pica and generalized anxiety disorder (GAD), and iron-deficiency anemia. At the onset of treatment, the client consumed chalkboard chalk and vermiculite from potting soil approximately three times per week and presented with moderate-severity GAD. Assessment and treatment occurred over 24 weekly outpatient individual sessions. Treatment was delivered in concert with medical intervention to address anemia. A cognitive-behavioral case formulation was developed from multiple assessment sources. A process-based cognitive-behavioral therapy (CBT) intervention approach was used to target GAD and pica simultaneously, which included psychoeducation, self-monitoring, arousal reduction skills, cognitive training (reappraisal, distancing), and behavior modification/stimulus control techniques. Barriers to treatment and their solutions are discussed. At the end of treatment, the client demonstrated increased insight and understanding of her worry symptoms and pica behavior, acquired cognitive skills and arousal reduction strategies for managing GAD, and reported less than one episode of pica per week. The identified assessment and treatment approach is worthy of future investigation to inform empirically based treatment development efforts, especially for pica.     

Dialectical Behavior Therapy for Adolescents: Theory, Treatment Adaptations, and Empirical Outcomes

Dialectical behavior therapy (DBT) was originally developed for chronically suicidal adults with borderline personality disorder (BPD) and emotion dysregulation. Randomized controlled trials (RCTs) indicate DBT is associated with improvements in problem behaviors, including suicide ideation and behavior, non-suicidal self-injury (NSSI), attrition, and hospitalization. Positive outcomes with adults have prompted researchers to adapt DBT for adolescents. Given this interest in DBT for adolescents, it is important to review the theoretical rationale and the evidence base for this treatment and its adaptations. A solid theoretical foundation allows for adequate evaluation of content, structural, and developmental adaptations and provides a framework for understanding which symptoms or behaviors are expected to improve with treatment and why. We first summarize the adult DBT literature, including theory, treatment structure and content, and outcome research. Then, we review theoretical underpinnings, adaptations, and outcomes of DBT for adolescents. DBT has been adapted for adolescents with various psychiatric disorders (i.e., BPD, mood disorders, externalizing disorders, eating disorders, trichotillomania) and problem behaviors (i.e., suicide ideation and behavior, NSSI) across several settings (i.e., outpatient, day program, inpatient, residential, correctional facility). The rationale for using DBT with these adolescents rests in the common underlying dysfunction in emotion regulation among the aforementioned disorders and problem behaviors. Thus, the theoretical underpinnings of DBT suggest that this treatment is likely to be beneficial for adolescents with a broad array of emotion regulation difficulties, particularly underregulation of emotion resulting in behavioral excess. Results from open and quasi-experimental adolescent studies are promising; however, RCTs are sorely needed.     

Principles of Behavioral Assessment and Management of “Life-Threatening Behavior” in Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) in its initial iteration was developed for the treatment of suicidal and self-injuring adults. As a result, the assessment and management of suicidal and nonsuicidal self-injurious (NSSI) behavior was and is central to the conduct of standard DBT. In this paper the authors describe the DBT approach to suicide risk assessment including discussion of both comprehensive and targeted suicide risk assessment and the associated documentation. In addition, it describes when and when not to conduct such assessment. Finally, this article describes management of both imminent and distant suicide risk and the application of DBT treatment strategies that can be applied in session.     

Efficacy of dialectical behaviour therapy for adolescents

The current review provides a qualitative assessment of the efficacy of dialectical behaviour therapy (DBT) as adapted for adolescents. The aim was to assess the efficacy of DBT compared to usual methods in the treatment of adolescent mental health symptoms, inclusive of suicidal ideation and self‐harm. Computerised databases including Medline and PsycINFO were accessed and knowledgeable informants in the area of DBT were contacted. Inclusion criteria required the studies to be clinical trials on DBT provided to adolescents. Due to the requirements on research design only three studies were appropriate for review. The review focused on quality assessment of the current data, including investigation into the effects of selection bias, confounding variables, outcome measures and measurement errors. The data suggest that there is some evidence for DBT being effective in reducing symptoms of mental health, especially those consistent with borderline personality disorder. The resultant data, however, are of very poor quality, and as such the review addresses ways to improve the quality of research and offers suggestions for future research.     

Mastering the Art of Chain Analysis in Dialectical Behavior Therapy

Behavioral chain analyses, which are common in behavioral and cognitive-behavioral treatments more broadly, are the primary assessment tool in Dialectical Behavior Therapy (DBT). As such, they are conducted in nearly every DBT session. Despite their importance in the treatment, very little has been written about the “how-tos” of chain analyses in DBT or how to improve therapist skill in this area. This article describes the rationale and proposed functions of chain analyses, provides details about the various components of the chain analysis, and includes common problems that arise in conducting chain analyses. A case example of a detailed chain analysis is provided.     

Interoceptive Exposure: An Overlooked Modality in the Cognitive-Behavioral Treatment of OCD

Accumulated research implicates anxiety sensitivity (AS) as a transdiagnostic construct important to the maintenance of OCD. Yet despite the clinical implications of targeting fears of body-related sensations during treatment, interoceptive exposure (IE) is an often-overlooked therapeutic procedure in the cognitive-behavioral treatment of OCD. In this article, we discuss the rationale for—and procedures of—addressing AS during treatment for OCD. We provide two case examples, illustrating how a clinician might approach clinical assessment, case formulation, and treatment planning with each of these patients. We conclude by discussing future research directions to better understand if (and how) targeting AS during therapy might enhance OCD treatment outcome.     

Assessment of Parents,Couples, and Families in Dialectical Behavior Therapy

Family intervention in Dialectical Behavior Therapy (DBT) is a core part of multiple required functions of DBT, providing opportunities for skill training (including relationship-specific skills that are not covered in individual DBT), skill generalization, and direct intervention into the social and family environment. In order to intervene with parents, partners and other family members efficiently and effectively, therapists must first conduct a careful assessment. The core relationship transaction of emotion vulnerability/dysregulation and inaccurate expression leading to invalidating responses (and vice versa) is highlighted, as are the treatment targets in DBT with families, which inform assessment targets. Then, two core assessment procedures are explored, with clinical examples: (a) conducting “double chain” analyses, demonstrating how one person’s social or relationship responses affect the other’s emotional arousal (and vice versa); and (b) direct behavior observation of family interactions, which allow treatment targets to be identified efficiently. These two assessment strategies may also be combined. Implications for family interventions are discussed.     

Dialectical Behavior Therapy: An Emotion-Focused Treatment for Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment for borderline personality disorder (BPD) that is based on the theory that emotion dysregulation is the core feature of BPD. This article focuses on aspects of DBT theory and techniques that specifically address emotion. The dialectical and biosocial theories that underlie DBT are reviewed with an emphasis on how each relates to emotional experiencing in BPD. Selected treatment strategies that address emotion dysregulation and their hypothesized mechanisms of change are also described. Relevant research findings are incorporated throughout to provide an empirical foundation for the DBT theories and strategies that are discussed.     

Addressing Shared Vulnerability for Comorbid PTSD and Chronic Pain: A Cognitive-Behavioral Perspective

Posttraumatic stress disorder (PTSD) frequently co-occurs with other conditions and symptoms that can complicate assessment and treatment. Of these, chronic musculoskeletal pain and related avoidance behaviors are amongst the most common and, unfortunately, the most often overlooked. In this paper we discuss issues that warrant consideration in developing and implementing a treatment plan that may maximize chances of successful outcome for GH, a patient with PTSD and chronic pain. Assessment strategies used in arriving at a case formulation are presented and, based on the emerging state-of-the-art, a tentative cognitive-behavioral treatment program targeting shared vulnerability for PTSD and chronic musculoskeletal pain is presented. Issues pertinent to anticipated treatment outcome are also discussed.     

Testing Case Formulation Hypotheses in Psychotherapy: Two Case Examples

We describe two cases that illustrate and demonstrate the effectiveness of a case formulation–driven approach to psychotherapy in which the therapist, in collaboration with the patient, develops a hypothesis (formulation) about the psychological mechanisms that cause and maintain the patient’s difficulties, uses the formulation to guide intervention, and collects data to test the formulation and evaluate the effectiveness of the intervention plan. As shown by the cases reported here, a key strength of this collaborative empirical process is that it enables the patient and therapist to quickly determine when a treatment is failing and take action to rescue it.     

Dialectical behavior therapy adapted for suicidal adolescents

We report a quasi-experimental investigation of an adaptation of Dialectical Behavior Therapy (DBT) with a group of suicidal adolescents with borderline personality features. The DBT group (n = 29) received 12 weeks of twice weekly therapy consisting of individual therapy and a multifamily skills training group. The treatment as usual (TAU) group (n = 82) received 12 weeks of twice weekly supportive-psychodynamic individual therapy plus weekly family therapy. Despite more severe pre-treatment symptomatology in the DBT group, at post-treatment this group had significantly fewer psychiatric hospitalizations during treatment, and a significantly higher rate of treatment completion than the TAU group. There were no significant differences in the number of suicide attempts made during treatment. Examining pre-post change within the DBT group, there were significant reductions in suicidal ideation, general psychiatric symptoms, and symptoms of borderline personality. DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics.