3

DIALECTICAL BEHAVIOR THERAPY

CLIVE J. ROBINS, M. ZACHARY ROSENTHAL,
AND PRUDENCE F. CUPER

Dialectical behavior therapy (DBT) grew out of Marsha Linehan’s

attempts in the 1970s and 1980s to apply the standard behavior therapy of
that time, which had already demonstrated efficacy with a range of disorders,
to chronically suicidal individuals (Linehan, 1987). The assumption was that
suicidal behaviors are usually attempts to escape a life perceived to be not
worth living, and therefore these individuals need to develop skills not only
to better tolerate emotional distress but also to create a life that they view as
worth living. Helping clients learn these skills would involve direct skills
training through instruction, modeling, rehearsal, and coaching as well as the
use of principles of reinforcement and exposure. However, clients who have
made multiple suicide attempts tend to be sensitive to criticism and prone to
emotion dysregulation, and a strong focus only on change strategies can lead
them to feel that their level of distress is not understood, or even that they
are being blamed for their problems. They may respond with anger at the
therapist or withdrawal from treatment. On the other hand, letting go of an
emphasis on change can lead the client to feel that the therapist is not tak-
ing his or her pain seriously, which in turn may generate hopelessness or
anger. This observation led Linehan to develop a treatment that attempts to
balance and integrate acceptance and change through a dialectical process.

49
Because most of the chronically suicidal individuals treated with this approach
met criteria for borderline personality disorder (BPD), the treatment manu-
als were developed for that disorder (Linehan, 1993a, 1993b).
The most fundamental dialectic addressed by DBT is that of acceptance
and change. The difficulties Linehan encountered with a more purely change-
oriented treatment led to attempts to balance the therapist’s focus on helping
the client change with communicating acceptance of the client as he or she is.
The difficulties BPD clients commonly have in tolerating distress, and in accept-
ing themselves and others, led to attempts to help them develop acceptance-
oriented skills as well as change-oriented skills. In addition to change-oriented
treatment strategies that draw primarily on standard cognitive behavior ther-
apy and from basic principles from psychological science, DBT includes strate-
gies for the therapist to communicate his or her acceptance of the client that
draw primarily on client-centered and emotion-focused therapies. Finally,
DBT includes treatment strategies to help the client develop greater accept-
ance of the self, of others, and of life in general that draw primarily on Zen
principles and mindfulness practice (Robins, 2002).

THEORETICAL FOUNDATION

In this section, we describe DBT’s conceptual model for understanding

the development and maintenance of BPD, principles of change derived from
basic psychological science that are the foundation of DBT treatment strate-
gies, a conceptual framework for understanding the nature of the difficulties
experienced and expressed by the individual with DBT, and the structural
elements of DBT.

Biosocial Theory

The development and maintenance of BPD behaviors are viewed in

DBT as resulting from a transaction of a biological component, dysfunction of
the emotion regulation system, with a social–environmental component, an
invalidating environment (Linehan, 1993a). BPD may involve a dysfunction
of parts of the central nervous system involved in regulating emotions. There
is evidence for genetic influences on emotion dysregulation and on BPD, and
early life trauma can have enduring structural effects on the developing lim-
bic system, which is central to emotion regulation (Sapolsky, 1996). In an
invalidating environment, the individual’s communications about his or her
private experiences are frequently met with responses that suggest they are
invalid or inappropriate or that oversimplify the ease of problem solving. As
a consequence, the individual may come to self-invalidate and not learn how

50 ROBINS, ROSENTHAL, AND CUPER

to accurately label, communicate about, or regulate his or her emotions. Com-
munication of negative emotions may be ignored or punished, but extreme
communications are taken more seriously so that the individual is reinforced
for either inhibiting emotional expression or responding to distress with
extreme behaviors.
Over time, as the individual’s behavior becomes more extreme, in attempts
to regulate emotion or to communicate, he or she is increasingly likely to
experience invalidation from the environment (often including the mental
health system), and in response the sensitive individual is likely to feel even
more emotionally vulnerable and react more intensely, thereby generating
further invalidation. Thus, in this transactional model the individual and
those in his or her interpersonal environment continuously influence one
another. The individual comes to experience frequent and pervasive emotion
dysregulation and has poor emotion regulation skills, often relying on ulti-
mately maladaptive coping behaviors.

Principles of Change

DBT assumes that the BPD clients’ difficulties are a result of both inher-
ent biological tendencies and their individual learning histories that have led
to skills deficits and to deficits in motivation to use whatever skills they do
have. Skillful use of the therapeutic relationship, which we discuss later in this
chapter, is one avenue through which motivational problems are addressed.
DBT assumes that many maladaptive behaviors have been learned by the
three primary ways in which organisms learn: (a) respondent (classical) condi-
tioning, (b) operant (instrumental) conditioning, and (c) modeling. The same
methods can also be used to help the client develop more adaptive behaviors.
In respondent conditioning, two or more stimuli co-occur closely in time,
thereby becoming associated, so that the natural response to one becomes a
learned response to the other; this was famously illustrated by the salivation
of Pavlov’s dogs in response to a tone previously paired with food. Involun-
tary responses, such as emotional reactions, both negative and positive, are
often learned through classical conditioning. For example, if a person is raped
in a dark alley, being near a dark alley may elicit fear. After many instances
of drug use, the sight of drug paraphernalia may come to elicit drug cravings.
In treatment, maladaptive emotional reactions may be reduced by removing
relevant stimuli or by developing new associations with them.
In operant conditioning, when positively valued consequences follow a
behavior they may lead to a subsequent increase in that behavior, and nega-
tively valued consequences lead to a decrease, processes referred to as rein-
forcement and punishment, respectively. When previously reinforced behavior
no longer is reinforced, the behavior will decrease, a process called extinction.

DIALECTICAL BEHAVIOR THERAPY 51

When desired or adaptive behavior does not occur, and so cannot be rein-
forced, reinforcement of successively closer approximations of the behavior
can lead to the desired behavior, a process referred to as shaping. DBT, like
many other behavioral therapies, pays considerable attention to behavior–
consequence contingencies.
Modeling refers to the process by which humans and other organisms
learn both emotional responses and overt behaviors by observing the responses
of others and the consequences of those responses. Maladaptive behaviors
may have been learned through modeling by parents, siblings, other clients,
and other individuals in the client’s environment. In the context of a strong
therapeutic alliance, therapists can serve as effective models of more skillful
behavior.

Domains of Operation

DBT organizes the nine Diagnostic and Statistical Manual of Mental Dis-
orders (4th ed., text revision; DSM–IV–TR; American Psychiatric Associa-
tion, 2000) criteria for BPD into five broad areas of dysregulation, described
in the following sections, because this clarifies what skills the client needs to
learn and practice. Dysregulation in any one area can have effects on each of
the others, but in DBT emotion dysregulation is viewed as the most central
problem. All components of DBT are used to address these five domains.
After describing each of these domains, we identify and highlight the role of
the four sets of skills that are taught to clients.

Emotion Dysregulation
In addition to high reactivity and instability of mood, the baseline mood
in a person with BPD often is one of chronic dysphoria. Although DSM–IV
specifies intense, inappropriate expressions of anger as a separate criterion,
many BPD clients are at least as likely to be underexpressive of anger, and
they typically have as much difficulty regulating sadness, anxiety, guilt, and
shame as they do regulating anger. In DBT, clients are taught and practice
specific emotion regulation strategies.

Relationship Dysregulation
Unstable, intense relationships may result from the interpersonal impact
of clients’ intense emotions and accompanying behaviors, such as anger out-
bursts or self-injury, or from their own difficulty in being assertive about rela-
tionship problems. Frantic efforts to avoid abandonment may reflect this
relationship history and/or rejection, neglect, or abandonment in childhood.

52 ROBINS, ROSENTHAL, AND CUPER

DBT targets interpersonal problems, in part, through training and practice of
interpersonal skills.

Self-Dysregulation
The experience of intense, frequently changing emotions and behaviors
makes it difficult to predict one’s own behavior, which probably is an impor-
tant component of developing a coherent sense of self. In addition, BPD
clients’ repeated experience of invalidation usually leads to self-invalidation
of their own preferences, goals, perceptions, and so on, which therefore do not
become well developed or stable. Mindfulness skills taught in DBT can help
clients to observe their own experiences and behavior without judgment and
are one means through which DBT helps clients develop a clearer sense of self.

Behavior Dysregulation
DSM–IV criteria include suicidal and other self-injurious behaviors
specifically, and other impulsive and potentially harmful behaviors, such as
substance abuse or binge eating, generally. These behaviors may serve a vari-
ety of functions, including interpersonal communication, but their most com-
mon function seems to be to escape or decrease aversive emotions. In DBT,
skills are taught that can help clients to better tolerate strong distress with-
out resorting to maladaptive escape behaviors.

Cognitive Dysregulation
Some BPD clients experience transient paranoia, dissociation, or hallu-
cinations when under stress. These biased or distorted perceptions and beliefs
may reflect the influence of strong emotions on cognitive processes. Mindful-
ness skills can help clients attend carefully to external reality in the present
moment and thereby counteract paranoid ideas and dissociation.

Process of Therapy

Stages of treatment and treatment targets

One of the challenges in working with clients with BPD is the sheer
number of problems with which they often present and the fact that the prob-
lem viewed as most urgent by the client and/or therapist often changes from
session to session. A loss of focus and continuity can easily result. This is
addressed in DBT, in part, by establishing a clear list of therapy targets and
arranging these in a hierarchical order of priority that depends on their sever-
ity and impact on long-term functioning rather than on a short-term sense of

DIALECTICAL BEHAVIOR THERAPY 53

urgency. Treatment of DBT is generally grouped into four stages, according
to the client’s level of dysfunction.
Clients who have severe behavioral dyscontrol, such as repeated self-
injury, hospitalization, or a severe eating disorder or substance abuse, are con-
sidered to have the highest level of severity and to require Stage 1 treatment,
in which the primary focus is simply on getting those behaviors under con-
trol. Within Stage 1, the highest priority is given to life-threatening behav-
iors, including not only suicide attempts but also any deliberate self-injury,
regardless of intent or severity, as well as major changes in suicidal ideation
and behaviors related to harming others. When one of these has occurred
since the last therapy session, understanding the incident and problem solv-
ing for similar circumstances in the future become the primary session foci.
The second highest priority is therapy-interfering behavior, because insuffi-
cient attention to this can lead to the therapist losing motivation to work
with the client or the client prematurely dropping out of treatment. The third
priority is severe quality-of-life–interfering behaviors, such as serious sub-
stance abuse, major depression, or other mental health or social problems.
Stage 2 focuses on some of the sources of the client’s misery, which he
or she is likely to still experience even after behaviors are more under con-
trol. This might include exposure to trauma-related cues and other trauma-
focused work and on helping the client to be more willing and able to tolerate
experiencing a full range of emotions that he or she may have been avoiding
and escaping from through self-injurious or other problematic behaviors. The
most important thing is to not embark on this until there is evidence that the
client is sufficiently equipped to handle the strong emotions such exposure
may elicit without resorting to extreme behaviors.
If the client no longer has serious difficulties with severe behavioral
dyscontrol or posttraumatic stress disorder–related phenomena, Stage 3 treat-
ment, in which the goal is to help the person solve the ordinary problems in
living that bring most people to psychotherapy, such as relationship problems,
self-esteem, and dysthymia, can proceed.
To complete the continuum from extreme mental illness to optimal
mental health, Linehan (1999) added a Stage 4 to her treatment model. In
this stage, the goal is to help the individual develop a greater capacity for joy
and freedom.
DBT explicitly includes a pretreatment stage, in which therapist and
client reach agreements about the most important treatment targets and the
treatment structure, among other things. We discuss these agreements further
in the section titled Alliance Factors Related to Process and Outcome.
Treatment Modes. Comprehensive treatment for clients with BPD needs
to address four functions: (a) help the client develop new skills, (b) address
motivational obstacles to skills use, (c) help the client generalize to daily life

54 ROBINS, ROSENTHAL, AND CUPER

what he or she learns; and (d) keep therapists motivated and skilled. In stan-
dard outpatient DBT these four functions are addressed primarily through
four modes of treatment: (a) group skills training, (b) individual psychother-
apy, (c) telephone coaching, and (d) a therapist consultation team meeting,
respectively.
Linehan (1993a) found that it was extremely difficult for the therapist
to focus on long-term skills acquisition in individual therapy because of the
need simultaneously to respond to current crises, dysregulated emotions,
and recent instances of behavioral dyscontrol; thus, she separated these two
treatment functions into different treatment modes. Skills are taught in four
modules: (a) mindfulness, (b) distress tolerance, (c) emotion regulation,
and (d) interpersonal effectiveness. During each skills group session, home-
work practice from the previous session is reviewed for each participant, fol-
lowed by the teaching of new material and assignment of new homework
practice.
In individual therapy, the therapist helps the client use whatever skills
he or she has to more effectively navigate crises and reduce problem behav-
iors. This frequently occurs in the context of a behavioral analysis of a recent
incident of problem behavior, which we discuss and illustrate in detail later in
this chapter. Problems in motivation to use the skills that the client actually
has need to be addressed in individual therapy; these can include environmen-
tal punishment of adaptive behaviors or reinforcement of maladaptive ones,
hopelessness, fear, or other cognitive and emotional inhibiting factors.
Clients are instructed to call their individual therapist for skills coaching
when they are in crisis or having difficulty controlling urges to self-injure, drink
alcohol, leave work, or engage in other problem behaviors. Clients are expected
to call before, rather than after, engaging in high-priority target behaviors, and
specifically not to call within 24 hours of self-injury (to avoid reinforcing the
behavior). If the client does call in that circumstance, the therapist only assesses
and responds to possible medical risk. Other than the 24-hour rule, therapists
determine their own limits regarding out-of-session contacts.
Most experts in treatment of clients with BPD agree that, because of
the difficulty in treating these clients, including the stress often experienced
by therapists, obtaining regular consultation is essential. A consultation
team that meets regularly is therefore a required component of DBT. The
purpose is to keep therapists motivated and to provide guidance in conduct-
ing the treatment. Team members agree to accept a dialectical philosophy
in which useful truths are seen as emerging from the transactions between
opposing ideas. The team members use with each other the same DBT strate-
gies used with clients, including balancing validation and problem solving,
and help each therapist find an optimal balance of acceptance and change
strategies.

DIALECTICAL BEHAVIOR THERAPY 55

 RELATIONAL CONSIDERATIONS

There currently is little empirical evidence regarding which client char-

acteristics, therapist characteristics, and therapeutic alliance characteristics
influence the process or outcomes of DBT. However, this treatment model
assigns high priority to monitoring and attempting to resolve any problems in
these relational domains that interfere with clinical progress. We describe
here the therapist behaviors and attitudes and therapeutic relationship qual-
ities that are encouraged or required in DBT.

Alliance Factors Related to Process and Outcome

Three elements of a therapist–client relationship constitute the thera-

peutic alliance: (a) the collaborative nature of the relationship, (b) the affec-
tive bond between therapist and client, and (c) the dyad’s ability to agree on
treatment goals and tasks (Martin, Garske, & Davis, 2000). The therapeutic
alliance is often viewed as one of the common factors that underlies client
improvement regardless of the practitioner’s theoretical orientation or the type
of intervention used. A recent meta-analysis of 79 studies yielded a moderate
correlation (r = .22) between quality of alliance and treatment outcomes, with
no evidence that this relation differs by type of treatment (Martin et al., 2000).
Given that interpersonal difficulties are a hallmark of many personality
disorders, forging a strong therapeutic alliance with clients with Axis II dis-
orders is both important and challenging (J. S. Beck, 1995; Bender, 2005).
We discussed earlier the emphasis in DBT on targeting treatment-interfering
behaviors in order to develop a collaborative relationship. Similarly, devel-
opers of other cognitive–behavioral approaches to treatment of personality
disorders, such as cognitive therapy (A. T. Beck, Freeman, & Associates,
2004), emphasize the importance of understanding the causes of noncollab-
orative behavior and approaching those causes in an objective and nonjudg-
mental manner. They suggest numerous potential causes of noncollaborative
behavior from the client, many arising from skills deficits of the client or ther-
apist, interfering beliefs on the part of the client or therapist, or contingen-
cies or environmental variables that impede compliance. Therapists are
advised to adopt a stance of “friendly advisor” instead of “expert helper,” to
examine their own emotions that arise in session, and to expect more non-
collaboration than in clients with only an Axis I disorder.
In DBT, alliance issues are targeted, in part, by orientation sessions and
strategies designed to elicit commitment to therapy. During pretreatment ori-
entation, the therapist educates the client about DBT, and the client makes
an informed decision about whether to proceed. Both client and therapist
make specific agreements regarding treatment goals, targets, and structure, and

56 ROBINS, ROSENTHAL, AND CUPER

they discuss at the outset the possibility of difficulties in the relationship and
how they might best be handled. The client agrees to remain in treatment for
one year; attend all scheduled sessions; work on reducing suicidal, self-injurious,
and therapy-interfering behaviors; attend skills group; and pay all fees. The
therapist agrees to make all efforts to practice competent psychotherapy, obey
ethical and professional codes, attend scheduled sessions, provide phone
coaching and back-up therapists as needed, respect the integrity of the client,
adhere to confidentiality guidelines, and obtain consultation as needed. The
therapist provides an explicit definition of dropping out of therapy: A client may
miss up to three sessions, but upon missing the fourth he or she will be consid-
ered to have dropped out and may not return until the end of the treatment
year. This policy, designed to prevent clients from drifting out of therapy, may
be responsible for superior attendance rates of DBT in some trials (e.g., Line-
han, Armstrong, Suarez, Allmon, & Heard, 1991).
Both cognitive therapy and DBT emphasize respect for the client and
the need for therapists to examine their own contributions to the relation-
ship, by means such as eliciting verbal and/or written feedback from clients,
observing in-session therapist behaviors and emotions, and participating in a
consultation team or obtaining supervision. Working with clients who have
more severe dysfunction will inevitably lead to the making of some mistakes;
the mistakes themselves are less important than how the therapist recovers
from them and works to mend the relationship. A study of cognitive therapy
for clients with depression plus avoidant personality disorder (AVPD) or
obsessive–compulsive personality disorder (OCPD) recently provided support
for this principle; in it, the presence of alliance rupture–repair episodes, as well
as strength of early alliance, predicted reductions in personality disorder
symptoms, reductions in depression symptoms, and better therapy attendance
(Strauss et al., 2006).

Client Characteristics Related to Process and Outcome

In an early review of 166 studies, Luborsky, Chandler, Auerbach, Cohen,

and Bachrach (1971) examined a wide range of client characteristics and
their associations with treatment success. Factors predicting success included
general personality functioning, less severe diagnoses, high motivation and
expectation of change, high initial anxiety, higher intelligence, and greater
social achievements. In short, higher functioning clients fared better. However,
Luborsky et al. excluded from their review all studies of behavior therapy.
Sloane, Staples, Cristol, Yorkston, and Whipple (1976) looked at the relation-
ship between client characteristics and outcomes in two treatment conditions:
(a) psychotherapy (psychoanalytically oriented) and (b) behavior therapy. As
in Luborsky et al.’s meta-analysis, the authors found that variables associated

DIALECTICAL BEHAVIOR THERAPY 57

with higher general functioning predicted success in psychotherapy. High
scores on the Mania and Hysteria scales of the Minnesota Multiphasic Person-
ality Inventory, which Sloane et al. described as reflecting acting-out behav-
iors, predicted poorer outcomes. In contrast, fewer factors predicted success
in behavior therapy and, in fact, the clients who did exceptionally well in
behavior therapy were those who scored highest on the “acting-out” scales.
This study suggests that clients with severe personality symptoms, in partic-
ular the impulsive and dramatic behaviors of Cluster B disorders, may be best
served by behavior therapies.
Sloane et al.’s (1976) results are consistent with those from studies of
newer behavior therapies, such as DBT. In a controlled trial of DBT conducted
in the Netherlands, investigators found that DBT was more effective than
treatment as usual for clients who had the most severe symptoms (i.e., those
who reported more frequent episodes of self-mutilation) at intake (Verheul
et al., 2003). As in the first DBT outcome study conducted by Linehan et al.
(1991), Verheul et al. (2003) found that although DBT provided superior
results for reducing parasuicidal acts, it showed no advantage over treatment
as usual in treating depression, hopelessness, or the BPD symptoms of empti-
ness and boredom (van den Bosch, Verheul, Schippers, & van den Brink,
2002). Because the presence of Axis II symptoms predicts poorer outcomes for
treatment of Axis I disorders (Reich & Vasile, 1993), DBT may be an optimal
intervention for early treatment of severe personality symptoms, which need
to be controlled before interventions for an Axis I disorder can be useful.
Client characteristics certainly are one factor that predict treatment
outcomes, but therapists’ beliefs or assumptions about such characteristics
may be equally important. DBT recommends a number of assumptions about
clients that are believed to facilitate therapy, the adoption of which requires
a dialectical stance, because some of them might appear at first glance to be
in opposition to one another. These seven assumptions, described in detail by
Linehan (1993a) are as follows: that (a) clients are doing the best they can;
(b) clients want to improve; (c) clients need to do better, be more motivated,
and try harder in their lives; (d) clients have to solve their own problems,
regardless of who caused them; (e) the lives of suicidal BPD clients are cur-
rently unbearable; (f) failures in therapy are not failures of the client; and
(g) clients need to learn behaviors across many contexts, and in particular
they need to practice new behaviors in times of stress.

Therapist Characteristics Related to Process and Outcome

Successful therapists generally have more experience and a higher level

of skill, and they display warmth, genuineness, and empathy (Luborsky et al.,
1971). In cognitive and behavioral therapies, such as DBT, skill can be oper-

58 ROBINS, ROSENTHAL, AND CUPER

ationalized as adherence to the treatment manual and guidelines. In one con-
trolled trial of DBT in the treatment of BPD and co-occurring substance use
disorder (Linehan et al., 1999), clients whose DBT therapists were judged by
expert raters to be treatment adherent had better outcomes than those whose
therapists were less adherent.
Therapists range in their natural levels of warmth, genuineness, and
empathy, but cognitive and behavioral approaches provide strategies that can
enhance these assets within the therapeutic relationship. For example, DBT
therapists use a variety of validation strategies with the aim of helping the
client see that they are actively listening; can take the client’s perspective; and
understand why a particular maladaptive behavior made sense for the client,
given his or her developmental history and the current context in which the
behavior occurred. Validation strategies work so well that, in a study of clients
with BPD and comorbid substance use disorders, a treatment condition that
included only DBT’s validation strategies (and a 12-step program) had zero
dropouts, a retention rate that was significantly higher than in the DBT group,
which had already fared well in terms of retention compared with most stud-
ies of substance abuse treatment (Linehan et al., 2002). Within DBT, such
strategies are balanced with change procedures and irreverent communication
style strategies. Irreverent strategies, such as calling the client’s bluff and
“going where angels fear to tread” can help the client to see the therapist as
genuine, someone who is going to call it as he or she sees it and who is able to
tolerate the higher levels of distress that might result from such conversations.
Overall, DBT is well suited for therapists who can model a nonjudgmen-
tal attitude and those who are comfortable with ambiguity. The dialectical
stance and strategies require the acceptance of apparent paradoxes such as the
one mentioned earlier in this section, the concurrent beliefs that a client is
doing the best that she can and that he or she needs to try harder and be more
motivated to change. Therapists need to flex between the two poles on sev-
eral dimensions: change and acceptance, centeredness and flexibility, and
nurturance and benevolent demandingness. This flexibility, along with the
concurrent use of reciprocal and irreverent strategies, helps create an atmo-
sphere that is both challenging and accepting, one that optimally keeps the
client slightly off balance, making it difficult for him or her to fall back into
rigid or overlearned patterns of behavior, cognition, and emotion.

TECHNIQUES AND METHODS OF TREATMENT

A variety of strategies, which we detail in this section, are used to help

clients to do four things: (a) be more motivated to change maladaptive behav-
iors (which in DBT refers not only to overt behaviors but also to thoughts and

DIALECTICAL BEHAVIOR THERAPY 59

emotional responses); (b) accept the current state of their own behaviors,
other people, and their environments without judgment; (c) learn new skill-
ful behaviors, strengthen them, and generalize their use outside the therapy
setting; and (d) adopt a more flexible, dialectical stance toward life.

Description of Methods Used

There are four primary sets of DBT strategies used to support therapists
and strengthen their skills, each of which includes both acceptance-oriented and
change-oriented strategies. Core strategies include validation (acceptance) and
problem solving (change). Dialectical strategies present or highlight extreme
positions that tend to elicit their antithesis. Communication style strategies
include a reciprocal style (acceptance) and an irreverent one (change).
Case management strategies include intervening in the environment for the
client (acceptance), being a consultant to the client (change), and obtaining
consultation from the team (balancing acceptance and change).

Compendium of Techniques That Are Consistent With the Dialectical

Behavior Therapy Approach

Commitment Strategies
In discussing alliance factors in DBT, we have described a number of
agreements that clients and therapists are expected to make before therapy
proceeds (and that may need to be revisited at times). To facilitate those
agreements, as well as to increase motivation to try new behaviors during
treatment, Linehan (1993a) suggested several commitment strategies that
have been found effective in research in social psychology, marketing, and
motivational interviewing:
䡲 evaluating the pros and cons of changing and of not changing;
䡲 foot-in-the-door techniques, in which eliciting agreement to a
small request increases the probability of subsequent agreement
to a larger one;
䡲 door-in-the-face techniques, in which refusal of a large request
increases the probability of subsequent agreement to a smaller one;
䡲 devil’s advocate, in which the therapist tries to strengthen a
weak commitment by noting the difficulty of, or obstacles to,
change;
䡲 connecting the present commitment to previous commitments
the client has made; and
䡲 highlighting the client’s freedom to choose whether to commit,
while acknowledging the consequences of the choice (e.g., the

60 ROBINS, ROSENTHAL, AND CUPER

 client may continue to get hospitalized; the therapist can choose
not to treat the client).

Validation Strategies
Validation means to communicate to the client that his or her response
is valid, that is, that it makes sense or is reasonable. Although some instances
of a behavior would almost universally be considered either valid or invalid,
in many situations a behavior can be valid in some ways but not in others. For
example, self-injury may be invalid in that it usually has some negative conse-
quences and interferes with the client’s longer term goals, but it may also be valid
insofar as it reduces emotional pain in the short term. Whether or not to vali-
date a behavior therefore is often a strategic choice on the part of the therapist.
The therapist would be more likely to acknowledge or highlight the valid aspects
of ultimately maladaptive behaviors when the therapeutic alliance is weak
or when the client is currently emotionally dysregulated or self-judgmental.
Validation may be accomplished through a variety of techniques:
䡲 unbiased listening and observing, which communicates to the
client that he or she is important;
䡲 accurate reflection, which communicates to the client that he
or she has been understood;
䡲 articulating emotions, thoughts, and behavior patterns that the
client has not yet put into words, which, when accurate, may
help the client to feel deeply understood;
䡲 validation in terms of past learning history or biological dys-
function, which communicates to the client that, even if a
behavior currently is maladaptive, its occurrence nonetheless
makes sense;
䡲 validation in terms of the present context or normative func-
tioning, which lets the client know that that is how most peo-
ple would respond in that situation; and
䡲 Radical genuineness on the part of the therapist, who does not
treat the client as overly fragile, which validates the client’s
capability.

Problem-Solving Strategies
The principal approach to helping the client change a problem behav-
ior pattern is, first, to repeatedly examine particular instances of it, that is, to
attempt to understand the variables that maintain the behavior by examining
its antecedents and its consequences. A helpful behavioral analysis will point
to one or more solutions, that is, changes that would lead to more desired out-
comes. To facilitate those changes, the therapist uses standard cognitive

DIALECTICAL BEHAVIOR THERAPY 61

behavior therapy procedures, which can be usefully classified into four groups:
(a) skills training, if the client does not know how to behave more skillfully;
(b) contingency management, if the client’s maladaptive behavior is being
reinforced, or adaptive behavior is being punished or not reinforced; (c) expo-
sure, if conditioned emotional reactions to particular stimuli interfere with
adaptive behavior; and (d) cognitive modification, if the client’s beliefs, atti-
tudes, and thoughts interfere with adaptive behavior.

Example of a Clinical Process Highlighting Technique

In the following dialogue, the therapist is conducting a chain analysis on

problem behavior and, while doing so, is weaving in validation, irreverence,
and skill rehearsal and is modeling nonjudgmental and dialectical thinking.
Therapist (T): So, let’s talk a bit about what happened earlier in the
week when you cut yourself with a razor. (Chain analysis
begins)
Client (C): OK.
T: It was yesterday, right?
C: Yeah, it was yesterday.
T: OK, so let’s do what we do now and take a closer look at
what happened just before, during, and after you harmed
yourself.
C: Fine.
T: What was it that prompted you to eventually cut your-
self? What started the chain?
C: [Pauses, head begins to look down, eyes averted] Well, you
know how my mom just makes me so mad sometimes?
She can just downright piss me off, you know? And I
don’t know why she does it. It’s like she just can’t help
herself but say mean things sometimes.
T: I know. She hasn’t exactly been the warmest and kind-
est person in your life. From everything you have ever
told me it sounds like she has said and done a lot of
things that have really hurt you, deeply, over the years.
And we know that when the two of you have an argu-
ment, the outcome is not exactly good for you. So it
sounds like maybe something happened with her yester-
day that may have eventually led to you harming your-
self. But I may be jumping to conclusions here, because
you haven’t told me anything specific yet. So tell me,

62 ROBINS, ROSENTHAL, AND CUPER

 what exactly was it that happened that led to you harm-
ing yourself? (Validation)
C: It was my mom. She called and left a message. And I was
sleeping. And she kept going on and on over the answer-
ing machine. And that thing is loud! You know how
when you’re just trying to sleep and that’s the only thing
you really want in the world, and someone or something
wont let you?
T: Oh yeah, I know that feeling well. (Validation)
C: That’s what happened. So I’m sitting there and she’s
carrying on about how she knows I am in bed, and I need
to wake up and take her call, and she’s going to keep
talking until I get up and pick up the phone . . . It was
driving me insane, and I just kept getting more and more
angry.
T: Yeah, I imagine. That sounds like it could be a really
aggravating situation for anyone. So there you are, lis-
tening, getting more and more angry, and when did you
start to think about hurting yourself? (Validation)
C: [Looking down, shaking her head back and forth restlessly
now] I don’t know. I just got up out of the bed, picked up
the phone, and told her to stop calling me.
T: You told her?
C: No, I screamed it in her ear so she would know where I
was coming from.
T: Did she seem to know where you were coming from
when you screamed at her? (Irreverence)
C: I don’t think so, because she kept on calling me names
and telling me I was lazy.
T: So screaming didn’t exactly work to get her to know
where you were coming from? (Irreverence)
C: No, I guess not. But she’s not just gonna get away with
callin’ me and bein’ nasty!
T: I totally agree that this is a problem. But I want to be sure
that we both agree that the solution to her calling you
and interrupting your sleep is not you screaming at her.
(Irreverence)
C: I know you’re right. But what am I supposed to do? Just
sit there and take it?

DIALECTICAL BEHAVIOR THERAPY 63

 T: That’s one option. But [it’s] a hard thing to do. If some-
one is talking that way to me, I have a hard time simply
sitting and taking it too. Sitting and taking it is kind of
an extreme thing to do, just like screaming back is kind
of an extreme thing to do. (Validation)
C: So you’re saying I shouldn’t do either?
T: I’m saying there may be more solutions than those two
extremes. Coming up with solutions that are neither of
those extremes is the really important thing. And my
guess is that you are able to come up with some good
ideas, if you stop and think. (Modeling dialectical thinking)
C: [Pauses] No. I can’t think of anything . . . [Looks away,
appears ashamed]
T: I notice you are starting to look away from me as you talk
more and more about this. Can you try to look up at me?
It’s really hard when you feel this way to look me in the
eyes, isn’t it? (Validation)
C: Yeah.
T: What are you feeling right now? Which emotion or
emotions are you experiencing, right now?
C: I don’t know . . . [Pauses for a long time] ashamed I
guess . . .
T: OK, that would make sense given that you keep looking
away and we are talking about something that you and I
both know you would like to do less of (Validation). So,
try as best you can to look up towards me as keep going.
This is the same skill to use when you are upset and want
to avoid others, but need to avoid avoiding. You know I
am going to support you through thick and thin here.
(Skill rehearsal)
C: OK. [Looks up]
T: Great. Let’s continue. We were trying to think of a solu-
tion to the problem of being angry, having urges to scream,
but neither screaming nor being too passive. Try and
think, for this situation with your mom, what is a skillful
thing you can do? (Modeling dialectical thinking)
C: I don’t know.
T: OK, we need to get you to be able to be open to finding
new solutions to this problem. Let’s take a minute or two

64 ROBINS, ROSENTHAL, AND CUPER

 and do a brief mindfulness practice, just as we have many
times before. OK?
C: Fine.
T: OK, I will ring my mindfulness bell several times to start,
and to finish the practice. During the practice, I would like
you to focus on your breath, noticing when your mind wan-
ders away from observing your breath, and gently returning
your focus back to your breath, without judgment. Remem-
ber, it is not important whether you lose your focus. It is
only important that you practice coming back to your
breath after you lose your focus. (Skill rehearsal)
C: OK. [Bell rings, followed by several minutes of mindfulness
practice]
T: [Bell rings to end practice] OK. Now, on a scale of 0 to 10,
with 10 being the highest, how much are you able to stay
focused right now on your breath, in this moment?
C: Pretty well. Like a 7.
T: Great work. You are so much more skillful when you can
bring your attention to the present moment. Now, let’s
think about solving this problem of being angry, without
screaming.
C: I don’t know. I realize that I should not yell, but I just
want to when she gets like that. The only thing I can
think of is if I got up and turned off the answering
machine, and then went back to bed.
T: Terrific idea. But you would still be mad, right?
C: Yes, definitely.
T: So what else could you do, in addition to turning off the
answering machine, to calm down and avoid screaming
at her?
C: I don’t know. I can’t just ignore her. I guess I could wait
until later to talk with her about it, after I cool down a bit.
T: Yes. Good idea. So let’s suppose you did those things
with her yesterday. Do you think you would have ended
up harming yourself?
C: Probably not.
T: OK, so let’s keep those two good solutions on the table, and
let’s go back to a chain analysis of yesterday. (Modeling

DIALECTICAL BEHAVIOR THERAPY 65

 dialectical thinking) You screamed at her, and then what
happened? Did you have urges to hurt yourself?
C: No. I hung up on her and then my stepdad called for her,
like five minutes later. And he just kept on with the same
attitude. So I’m pissed, right? And I finally told him,
look, you know what happens when she pisses me off?
And he says yes. And I said, so don’t keep it up or I’ll
probably end up doing something to hurt myself.
T: Did you have urges to harm yourself at that point?
C: Not until I said that. But we hung up, and then I started
to get to thinking about it, and it seemed like a pretty
good idea.
T: There’s nothing about self-harm that makes it a good
idea. (Irreverence) It’s just another thought in an unend-
ing stream of thoughts, neither good nor bad, that you
have across your life . . . But we can come back to this in
a minute. First, let me make sure I understand you. Once
you got off the phone and started to think about hurting
yourself did your anger go up or down?
C: It was really weird. It was like I realized I could just cut
myself and then I started thinking about it more and
more, and then I started to feel less and less angry. It was
kind of messed up how that happened, you know?
T: I’m not sure that it was weird or messed up. It was your
experience, and it is really great that you are able to
remember it so well. (Modeling nonjudgmentalism) This
will help us know what you can do differently next time.
But tell me more. When did you actually cut yourself?
C: Like five minutes later. I went into the kitchen, grabbed
the knife, and slit my wrist. Not too hard. It’s not like I
wanted to die. I definitely didn’t want to go to the hos-
pital or nothin’.
T: So you were aware at the time of your intent to hurt
yourself, but not to die or go to the hospital?
C: Yeah. I was thinkin’ about it. And then I just went ahead
and cut. And you know, it really didn’t hurt that much
(shows her wrist to the therapist, and it is a superficial cut).
T: And did your anger go down after you cut?
C: Yeah, a little. But I wasn’t really that angry any more. I
just needed to do it once I started thinkin’ about it.

66 ROBINS, ROSENTHAL, AND CUPER

T: Did you do anything right after you cut? Did you tell any-
one about it?
C: No, I didn’t tell anyone. Just you. I’m wearing long
sleeves to make sure no one sees. It’s really embarrassing,
you know? It just seems like it is the only thing I can do
when I get like that. But after I do it, there is no way I
want anyone to find out. The whole thing is kind of
pathetic [starts to cry].
T: OK. Notice you are feeling a strong negative emotion
right now. And when you feel strong negative emotions
in here you often start to be self-judgmental. (Valida-
tion) Would you be willing to say what you just again,
but this time without any self-judgment? (Modeling
nonjudgmentalism)
C: OK. I don’t want anyone to know when I cut because I
am embarrassed by it, and I wish I would stop doing it.
T: Very skillfully said. Nice. So you don’t want to keep cut-
ting yourself, but once you start getting the urge when
you are angry, you’re telling me that it’s as if nothing can
stop you.
C: Right.
T: If it’s literally true that nothing can stop you, then I’m
afraid there will be literally nothing we can do to make
things better. But let me ask you, do you think it is liter-
ally true that nothing can stop you for cutting once the
urge starts when you are angry?
C: [pauses] I guess I could go do something else.
T: I think we both know from everything we have ever
talked about over the past six months that there are
times when you have urges to hurt yourself and you use
skills to keep from doing so. Even when you are angry.
What I am suggesting is that you are not, as your emo-
tion[al] mind may tell you, a robot that has no ability to
choose not to cut yourself. You have proven over and
over again that you can choose not to cut yourself.
C: That’s true, I guess.
T: So coming back to the solutions you came up with your-
self a few minutes ago, what would have happened if you
did not answer the phone, and talked to your mom later,
after you had slept more and calmed down?

DIALECTICAL BEHAVIOR THERAPY 67

 C: Oh, I would not have cut myself.
T: Is this a solution, or are we missing something here?
(Modeling dialectical thinking)
C: I think if I keep the answering machine volume down or
off when I sleep I won’t get mad when she calls, because
I won’t even know until I wake up that she called.
T: And if you get mad once you check the machine after
you wake up?
C: Then I’ll . . . I guess I have to make a commitment not
to confront my mom when I am angry at her.
T: OK, that seems like a good idea. So how about this week
when you get mad at her, which just might happen, you
make a commitment to wait until your anger comes
down to a 4 out of 10 before you talk to her about why
you are angry?
C: OK. I’ll have to use those other skills we talked about last
time to tolerate my anger until it comes down. I’ll try
doing the pros and cons thing, and I’ll try to stay busy
with my Sudoku, or even go on the web.
T: Great.

Treatment of Comorbid Conditions

Individuals with BPD commonly present for treatment with a wide

range of problems. Diagnostically, co-occurring Axis I and/or II disorders are
more the rule, and not the exception, among individuals with BPD present-
ing for treatment. Among problems on Axis I, BPD is associated with post-
traumatic stress disorder, major depressive disorder, social anxiety disorder,
eating disorders, and substance use disorders (American Psychiatric Associa-
tion, 2000). The presence of BPD is associated with poorer treatment out-
comes for major depression and several other Axis I disorders (Robins,
Fenwick, Donnelly, & Lacy, 2008). On Axis II, BPD is commonly associated
not only with other Cluster B personality disorders (e.g., histrionic personal-
ity disorder) but also with Cluster A (e.g., paranoid personality disorder) and
Cluster C (e.g., AVPD) disorders. Perhaps of most concern, however, is that
these individuals are at high risk of self-injurious or suicidal behavior (Black,
Blum, Pfohl, & Hale, 2004).
In addition to the complicated diagnostic presentation, it is not uncom-
mon among treatment-seeking individuals with BPD for there to be multiple
persisting life crises that are deemed as highly important, in any given week, by

68 ROBINS, ROSENTHAL, AND CUPER

either the therapist or the client. For example, clients with BPD may present
with high negative affect due to an interpersonal situation, after using cocaine
and heroin that week, contemplating self-harm earlier in the day, and restrict-
ing food intake. In addition to the myriad treatment targets identified by the
client as problematic, in this same hypothetical therapy session the client may
be 20 minutes late, not have completed therapy homework from the previous
week, and be talking about how mad he or she is at the front desk staff in the
clinic. In such a session, there simply is no way to address all of these problems
adequately within the usual outpatient time frame of 50 to 60 minutes.
As we discussed earlier, DBT provides a principle-based framework for
organizing treatment targets. Using a hierarchy, the therapist would elect to
target problems associated with the client physically harming him- or her-
self or others. Self-harm, violence toward others, and changes in suicidal
ideation, for example, are treatment targets at the top of the hierarchy. If
none of these targets is relevant in any given session, the therapist will tar-
get therapy-interfering behavior. This class of behavior includes anything that
the therapist believes interferes with the client’s therapeutic progress. Not
completing therapy homework, coming to sessions late, missing sessions, and
arriving at sessions intoxicated are examples of therapy-interfering behav-
ior. The last category of treatment targets includes quality of life–interfering
behavior. These are often the problems that clients prefer to talk about and
include such things as difficulties in relationships or at work, problems with
sleep, mood and anxiety, eating, and anger. Using this treatment hierarchy,
the DBT therapist is able to make quick decisions about which problems to
try to address when there are many to choose from and a short amount of
time. As such, the hierarchy provides principles to inform decision making,
keeping the therapist from feeling easily overwhelmed with uncertainty
about in which direction to proceed.
Many co-occurring disorders can be targeted in the first year, or Stage 1,
of DBT. For example, major depressive disorder is targeted through behav-
ioral activation, cognitive restructuring, emotion regulation skill training,
and mindfulness-based interventions (Robins et al., 2008). Social anxiety dis-
order can be targeted by using exposure-based interventions to increase the
client’s willingness to tolerate anxiety associated with feared social situations,
until such anxiety extinguishes. Substance use disorders are conceptualized
as quality-of-life problem behaviors and treated using many of the same DBT
strategies (Rosenthal, Lynch, & Linehan, 2005).
Although many problems can be addressed in the first stage of DBT,
some co-occurring disorders are not immediately addressed. When DBT
clients have learned the skills in all skill modules, have demonstrated a capa-
bility to use these skills to prevent extreme behavioral dyscontrol (e.g., self-
injury), and are no longer displaying major therapy-interfering behaviors, the

DIALECTICAL BEHAVIOR THERAPY 69

second stage of DBT may begin. In Stage 2, the primary goal is to increase the
client’s ability to experience emotions without using dysfunctional means of
coping to escape from or otherwise regulate emotional arousal. In this stage
of treatment, clients with co-occurring posttraumatic stress disorder will
commonly begin exposure therapy targeting their hyperarousal, intrusive re-
experiencing, and avoidance symptoms (Foa & Rothbaum, 1998).

SUMMARY OF EVIDENCE-BASED PRINCIPLES AND STRATEGIES

Some guidelines may be relevant for treatment of all personality dis-

orders. For example, when considering specific behaviors to target, two
complementary forms of change will likely be needed: (a) the adoption and
practice of adaptive behaviors and (b) the reduction of maladaptive behav-
iors (Critchfield & Benjamin, 2006). Furthermore, although clinicians may
see similarities in the behavioral patterns exhibited by various clients (e.g.,
the behaviors that comprise DSM diagnoses), and adopt a particular treat-
ment model, a key element to treating individuals with personality pathology
is tailoring the treatment to the individual client (Piper & Joyce, 2001).
Because DBT was developed for BPD and there are no writings or data
regarding its utility with disorders in Clusters A or C, we include in this sec-
tion a discussion of what is known about the treatment of Cluster A and C
disorders with other cognitive–behavioral approaches.

Cluster A Disorders

Specific Treatment Considerations

No studies to date have examined the efficacy of any psychotherapy
interventions for Cluster A personality disorders in a randomized trial. Never-
theless, several authors of cognitive and behaviorally oriented treatment guides
suggest therapeutic techniques for treating specific behaviors that commonly
appear in the Cluster A disorders (A. T. Beck et al. 2004; Cuper, Merwin, &
Lynch, 2007; Farmer & Nelson-Gray, 2005). Within the emotional domain,
for example, clinicians may address general reactivity, anger, and anxiety,
using techniques such as skills training, graded exposure, and exposure and
response prevention. Maladaptive cognitive patterns in paranoid personality
disorder might include suspiciousness, paranoia, negative self-views, and low
perceived self-efficacy; vigilance to signs of bad intentions in others; and the
misinterpretation of benign acts as deceptive. In schizotypal personality dis-
order (STPD) and schizoid personality disorder, suspiciousness or paranoia
may also be present, as well as obsessiveness, maladaptive thoughts about

70 ROBINS, ROSENTHAL, AND CUPER

close relationships and independence, and thoughts of the self as abnormal.
When perceptual anomalies occur in STPD, A. T. Beck and colleagues
(2004) suggested psychoeducation about the prevalence of hallucinatory
experiences, and Farmer and Nelson-Gray (2005) indicated that techniques
used for clients with schizophrenia may be applicable.
In general, individuals with Cluster A disorders tend to exhibit experi-
ential avoidance and interpersonal detachment, which clinicians may influ-
ence with skills training and exposure exercises. More specifically, clinicians
can watch for and address such in-session behaviors as avoiding eye contact,
hiding affect, or reluctance to discuss personal information. Outside of the
therapy office, clients may avoid situations that elicit positive emotions,
interactions with other people, and confiding in other people, and they may
neglect to engage in small prosocial behaviors, such as saying “thank you” or
making small talk. To work on these behaviors, clinicians may give home-
work assignments that clients are to track with activity logs, such as those
used in behavioral activation (Martell, Addison, & Jacobson, 2001). Clini-
cians should be aware, though, that clients may not yet possess the interper-
sonal skills necessary to carry out these activities. After assessing abilities,
client and therapist can spend time in session conducting role plays and
watching videos of others interacting. For clients with paranoid personality
disorder who exhibit behaviors associated with entitlement or grandiosity
(e.g., overreaction to small slights or an unwillingness to compromise), vali-
dation and acceptance early in therapy can be followed by motivational inter-
viewing and then training in communication skills such as perspective taking,
listening and reflection, appropriate assertiveness, and anger management.

Attachment, Relational, and Familial Factors

Discussions of a client’s history may enhance self-awareness; however,
within most cognitive and behavioral approaches conversations about the
past will be limited to information that is relevant to the client’s current prob-
lems. For example, A. T. Beck et al. (2004) suggested that bullying or peer
rejection may be found in the histories of clients with STPD and schizoid per-
sonality disorder; both lead to views of self as bad, abnormal, or a “misfit,”
which in turn can lead to lack of engagement.
Focusing on the client–therapist relationship may shed some light on
interpersonal functioning. Critchfield and Benjamin (2006) described the
therapy relationship as a “crucible” in which new behaviors can be tried out.
As such, the relationship should be warm and genuine, with the therapist using
self-disclosure as appropriate and showing comfort with the expression of
affect. In Cluster A disorders in particular, enhancing the relationship should
be an emphasis of treatment. A. T. Beck and colleagues (2004) suggested

DIALECTICAL BEHAVIOR THERAPY 71

using relationship-building techniques. For example, early in therapy the cli-
nician may focus on less sensitive topics, or discuss the client’s difficulties
indirectly, by using phrases such as “Some people have difficulty with X.”
Beck et al. also suggested giving the client ample control over session content
and frequency, and they advised clinicians to respect the client’s goals for
treatment, even if they are less ambitious than the therapist’s goals. Clients
with Cluster A disorders may feel suspicious about therapy and/or the thera-
pist. Beck et al. suggested checking in with the client to see how much trust
he or she feels toward the therapist, and, if trust is low, asking the client
whether he or she would be willing and able to suspend disbelief early in treat-
ment. Also, as with all clients, the therapist should assess for any ambivalence
the client feels about giving up some of the symptomatic behaviors.

Extant Evidence Base for Clinical Intervention

As mentioned earlier, the treatment strategies described here are gen-
eral treatment strategies used across disorders to treat specific symptoms. Evi-
dence of their efficacy with individuals diagnosed with Cluster A disorders
would be a welcome addition to the personality disorders literature.

Cluster B Disorders

There has been relatively little research on the use of cognitive–behavioral

treatments for narcissistic, histrionic, and antisocial personality disorders. In
regard to the treatment of BPD using DBT, we have already discussed some
specific treatment considerations and attachment and relational factors. In
this section, we summarize the evidence base for DBT.
DBT has now been empirically evaluated in at least 10 randomized clin-
ical trials (RCTs). Overall, the clinical outcome data support the efficacy of
DBT as a treatment for women with BPD, warranting its designation as empir-
ically supported by Division 12 (Clinical Psychology) of the American Psycho-
logical Association. Four RCTs have found DBT to have superior efficacy
when compared with treatment as usual for women with BPD and suicidal or
other self-injurious behavior (Koons et al., 2001; Linehan et al., 1991, 2006;
Verheul et al., 2003), in particular in reducing the frequency and medical
severity of suicide attempts, self-injurious behavior, frequency and total days’
duration of psychiatric hospitalizations, and client anger, as well as in increas-
ing treatment compliance and social adjustment (Linehan, Tutek, Heard, &
Armstrong, 1994). These changes appear to endure over at least a one-year
follow-up period (Linehan, Armstrong, & Heard, 1993; van den Bosch et al.,
2002). The results of Linehan et al.’s (2006) study are particularly compelling,
because the comparison group was treatment by clinicians nominated by their
peers as experts in the treatment of BPD.

72 ROBINS, ROSENTHAL, AND CUPER

 Standard DBT also has been adapted for several other populations and
treatment settings. RCTs have supported the efficacy of adaptations of DBT
for women with BPD in a community mental health clinic (Turner, 2000),
women with BPD and substance abuse or dependence (Linehan et al., 1999,
2002), women with binge eating disorder (Telch, Agras, & Linehan, 2001)
and bulimia (Safer, Telch, & Agras, 2001), and depressed elderly individuals
(Lynch, Morse, Mendelson, & Robins, 2003). Controlled but nonrandom-
ized studies also suggest that adaptations of DBT may have efficacy for BPD
clients in longer term inpatient settings (Barley et al., 1993; Bohus et al.,
2004) and for suicidal adolescents (Rathus & Miller, 2002; for a review of
treatment outcome studies of DBT, see Robins & Chapman, 2004).

Cluster C Disorders

Specific Treatment Considerations

In treating clients with the Cluster C disorders—AVPD, dependent
personality disorder (DPD), and OCPD—clinicians can expect to devote a
good portion of treatment to problems related to anxiety. Cognitive treat-
ment targets that have been suggested (A. T. Beck et al., 2004; Cuper et al.,
2007; Farmer & Nelson-Gray, 2005) include obsessiveness, paranoia, mal-
adaptive thoughts about rejection and inferiority (including thoughts that
the therapist is rejecting), inaccurate self-evaluation, beliefs about abandon-
ment, dysfunctional beliefs about making mistakes, and chronic worry. Inter-
personal targets may include reducing dependency and increasing autonomy
in clients diagnosed with AVPD and DPD and working on detachment and
valuing the beliefs and opinions of others in clients with OCPD. Behavioral
goals for clients with AVPD could be increased social interactions, increased
expressions of intimacy and vulnerability, and not distracting oneself from or
avoiding distressing emotions. In DPD, potential behavioral targets include
not asking for assistance when making decisions, increasing the amount of
time spent alone, voicing opinions, and assuming responsibility for tasks (e.g.,
setting the therapy agenda) instead of asking for help. With clients diagnosed
with OCPD, overt behaviors to decrease include checking details of tasks,
spending excessive time on tasks, hoarding, working excessively, not delegat-
ing tasks to others, and procrastination.

Attachment, Relational, and Familial Factors

A. T. Beck and colleagues (2004) offered conceptualizations of the rela-
tional and familial factors that may shape Cluster C personality disorder
behaviors. They suggested that individuals with AVPD may have spent time
with a significant other who was critical or rejecting, which could lead to

DIALECTICAL BEHAVIOR THERAPY 73

assumptions that take the form of negative beliefs about the self (“I’m inade-
quate”) and others (“They’ll reject me”). As adults, these clients then expect
rejection and feel unable to cope with rejection, they may believe a façade is
necessary for approval, and they may misevaluate others’ reactions or dis-
count positive data. Beck et al. suggested that the key relational assumptions
for individuals with DPD are “I’m inherently inadequate” and “I’m unable to
cope.” These assumptions can lead individuals to rely on others instead of
learn skills for independent living and to resist asserting themselves within
relationships for fear of losing the all-important relationship.
A. T. Beck et al. (2004) also warned clinicians that, despite the fact that
clients diagnosed with Cluster C disorders may appear attentive and eager
to please, the therapy relationship may be challenging. Clients diagnosed
with DPD can be slow to change, and clients diagnosed with OCPD often
desire complete control over themselves and their environments and exhibit
dichotomous thinking about right and wrong. Beck et al. suggested that the
therapy relationship can be strained when these clients feel discomfort with
emotion and downplay interpersonal relationships.

Extant Evidence Base for Clinical Intervention

A small number of controlled and noncontrolled trials have shown group
cognitive–behavioral treatments to be effective in alleviating some symptoms
of AVPD. Alden (1989) examined the efficacy of three types of group treat-
ment: (a) graduated exposure, (b) graduated exposure plus skills training, and
(c) graduated exposure + skills training with an interpersonal focus. All three
groups showed significantly more improvement than a wait list control group
and maintained the gains at three months posttreatment. Overall, there were
no differences in the effectiveness of the three groups, leading Alden to con-
clude that the graduated exposure and common group elements were proba-
bly the most effective strategies. Indeed, when interviewed, clients stated that
the factors most helpful to them were meeting and talking with others who
had similar difficulties, analyzing specific social activities and behaviors, and
setting behavioral targets and getting the encouragement to follow through
in meeting them.
Rennenberg, Goldstein, Phillips, and Chambless (1990) conducted a
noncontrolled study of an intensive behavioral group treatment for AVPD.
Treatment targeted fear of criticism, fear of rejection, and negative self-image,
using techniques that included continuous monitoring of distress, progressive
relaxation and imaginal exposure to feared situations (desensitization), para-
doxical intention exercises (in which clients exaggerated feared symptoms
while reading aloud before the group), positive self-statements, coaching in

74 ROBINS, ROSENTHAL, AND CUPER

communication skills, and role playing anxiety-producing situations with
other clients. There were no dropouts, and clients improved or recovered
from pre- to posttreatment and maintained their gains at follow-up.
Finally, in an open trial of cognitive therapy for AVPD or OCPD,
Strauss et al. (2006) found that only two of 30 subjects (7%) still met crite-
ria for their respective personality disorder posttreatment.

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