Dialectical Behavior Therapy Reduces Self-Harm and Suicide Attempts

A new meta-analysis finds that DBT reduces self-harm, suicide attempts, and reduces the frequency of psychiatric crisis service utilization.

21
5754

A new meta-analysis, published in Behavior Therapy, has found that Dialectical Behavior Therapy (DBT) reduces self-harming behaviors, suicide attempts, and the frequency of using psychiatric crisis services. The research was led by Christopher DeCou at the University of Washington.

The study included 18 trials of DBT, all of which compared the psychotherapy to a control group who did not receive it. The three outcomes included in the analysis were self-injury (including suicide attempts), use of psychiatric crisis services, and having suicidal thoughts.

The analysis found that self-injury (including suicide attempts) was reduced, as was the use of crisis services. Suicidal thoughts were not reduced, which indicates that self-injury and suicide attempts can be prevented even when people continue to think about suicide.

DBT was first manualized in the early 1990s, and its explicit focus is on reducing self-injury and suicide attempts. The therapy is a combination of cognitive-behavioral therapy with humanistic and mindfulness elements.

It involves full acceptance of the client, while at the same time providing skills for client change. For instance, it includes mindfulness skills for emotion regulation, interpersonal skills, and increasing psychological flexibility and adaptability so that the client can meet their own needs in various new situations. DBT usually includes individual therapy, group therapy, and extra support from the therapist.

There were several limitations to the current study. First, the effect sizes found (0.324 for self-injury, and 0.379 for crisis services use) are small-to-moderate. This may be due to the relatively low frequency of suicidal crises, which is a limitation of most research on reducing suicide attempts.

Additionally, the studies included in the analysis had different populations (such as inpatient or outpatient services) and measured self-injury and suicidal ideation differently. To account for this, the authors used a random-effects approach to calculating effect sizes, which they say is a conservative method that accounts for some of the variances in study populations and the use of differing measurements. However, there is still the possibility that DBT is more effective in some populations than in others.

 

****

DeCou, C. R., Comtois, K. A., Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior Therapy, 50(1), 60-72. https://doi.org/10.1016/j.beth.2018.03.009 (Link)

***

Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

21 COMMENTS

  1. “Dialectical behavior therapy is effective for the treatment of suicidal behavior”

    Big statement, considering that therapist and client variables as well as the relationship between them account for 70% of therapeutic change and the particular approach account for only 15% of that change according to common factors research.

    • Well, most trials had psychotherapy as control conditions. Thus, the effects are in addition to (psychotherapeutic) treatment as usual. Replications of independent groups may lead to smaller effects. Nonetheless, psychotherapies such as DBT or CBT have much clearer suicide-preventive effects compared to for example, antidepressants. Also consider that these trials include patients who usually are excluded from clinical research (because of being suicidal).

      • The language you use such as “patients”, “being suicidal” (I assume to be a symptom of some or other made-up disorder) and “suicide-preventative effects” suggest that you have been seduced by the simplicity that medical model thinking offers about people and their distress.

  2. I question this. The creator of DBT is actually a psych survivor who hid her status for years. Dr Marsha L something. She was given a SMI type of dx.
    When I was in the life of trauma one psychologist referred me to a day treatment DBT program. It was awful for me, for my family, and my extended family. It was summer and my kids were left on their own. During the cigarette breaks- I don’t smokeI wouldcallthem to check in. My one daughter baked brownies and I was not there to help her when she burned herself. It was her first time making brownies. If I hadn’t been so compromised by trauma and over medication Iwould have not gone and tried but it was pushed on me.
    The groups were ridiculous and devoid of any sense of good. YES MASTER is one of the acronyms the treatment uses. I cringed when I was forced to listen to that sexist drivel.
    Yes it had mindfulness and supposed spirituality fake , fake, and more fake.
    The reason there is any positive outcome is that there are no lap tops in the group therapy rooms. And most people don’t have twenty years postgraduate work to evaluate the program and its providers.
    I was able to chalkenge the spirituality group leader and she left the room in session. The other group members applauded.

    • I posted my own comments below but I wanted to respond to CatNight here directly because I had the same sorts of experiences with DBT only I was in one of Marsha Linehan’s year long studies on DBT and Prolonged Exposure Therapy for borderlines and trauma survivors. I only stayed in the groups for six-eight months but dropped the therapist assigned to me after four sessions. I am very educated and found DBT to be a very overrated system that verges on cult indoctrination. It’s one of those sorts of systems that seems to help only the indoctrinated. If you doubt the system then you’re considered non-compliant. I met Linehan several times and listened to her speak and found her to be quite condescending. Though I know and understand why she hid her diagnosis for so long I found that to only point out even more clearly why psychiatry and psychology are highly suspect practices. I did a great deal of online searching for individuals who have been critical of Linehan and DBT and there’s actually quite a few of us, many clients as well as doctors and other researchers. Linehan made a name for herself and found efficacy for her DBT in several studies but more studies need to be conducted showing how DBT and other modalities actually fail many clients. Just my opinion.

    • Thanks yes. I had known peers who worked there and the attrition rate was fast and furious. No one wanted to work the program. They actually had me do most of the work- messed up on meds and a mother in crisis. I appreciate their kind efforts to help a peer so very much. The others group leaders not good some awful. One way of doing mindfulness was walking through the hospital and appreciating the indoor plants. There was no – none type of Jon Jabari Zinn and Harvard Mind Body techniques. Trauma was not labeled as such and all of us where in various types of and levels of trauma.
      There was no caring or empathy.
      Our insurance paid for this travesty.
      Therapist don’t care re about last labeling just get the patient in the door.
      The best form of help for parenting trauma was the program I had been Co- Director of so not an option.
      Everyone in the family of was compromises d by cancer survivorship or missing because of death from cancer or compromised by other tragic illnesses.
      And I had been the rock of gilbrater that had been utterly shattered.
      Looking based Ca any money that was a copay could and should have been used for a long family extended time away somewhere. That for some reason did not seem possible. Help at home which if one had sisters or cousins or friends would have worked with support for them. But no one was there. No one.
      The kids paid the price. I call child abuse and neglect by proxy.

  3. The last research I read indicated that the “positive outcomes” were short lived (effects began to fade in months after the DBT stopped) and the coping mechanisms, that never really left, regained their place in the tool box over time. “Borderline Personality” itself has come under criticism as a gendered diagnosis (as has anti-social personality disorder) which further weakens it’s credibility. And though there is one accepted way to treat using DBT, it’s unlikely that many populations would be capable of affording, either financially or from a time perspective, the demands. This is not news nor is it significant. It’s a spin on the same old “let’s focus on you and ignore how messed up your environment is” mentality. Any “therapy”or “profession” that fails to improve the environment people have to struggle in with no chance of escape (current society and no upward mobility for those who are at or near the bottom, for example) is doing absolutely nothing for mental health except making sure it continues to be an income stream.

  4. I was in an outpatient DBT class in 2003 for two months in between 4 one-week hospitalizations (2 in 2002 and 2 in 2005). I was still deep in the medical model and on several meds during this time. I found the therapy helpful while giving me hope. I had a husband, teen son and 6yr old daughter at home and was fortunate they were at school and work while I attended this therapy. DBT gave me a refresher course on what I intuitively knew but was too drugged to remember. I am a more spiritually minded person anyway but was not acquainted with eastern thought at that time. Even though I was inpatient 2 more times after the class, those were much less intense. One never knows what you can glean from an encounter that will serve you later on. I have a personal story on this site published back in Sept 23rd 2018- A Healing Journey: Leaving Psychiatry Behind. I credit this class for beginning my journey to become psych-drug-free since 2011.

  5. I was in one of Marsha Linehan’s studies at the University of Washington some years ago for about six months of a year long study on DBT for BPD and PTSD and it was a thorough test in patience for me. At first I was excited because the therapy was touted as “cutting edge.” I am very educated myself so I also have a very analytical mind. I am extremely well read so attending the long DBT sessions every week became an exercise in critical thought for me. I kept an open mind at first, of course, because I wanted to be helped by the therapy and therapist assigned to me. What I found was graduate students leading the groups and therapy sessions who behaved in very authoritarian ways. There was only one who didn’t. A great deal of coercion was employed to get us to comply with their approach and if we questioned it we were made to feel uncomfortable for any of our doubts or skepticism.

    I found the grad student leaders’ resistance to doubt and skepticism to be increasingly concerning because of the potential for emotional abuse. Linehan herself made appearances to our group several times and her demeanor was one of superiority, condescension, and arrogance. What I saw were graduate students and study participants fawning all over her “authority” and for this thinker I found all that quite repugnant. It looked very much like a psychiatric cult movement.

    The therapist who was assigned to me absolutely refused to allow me to tell her about my extremely traumatic past which I found to not only be insulting but counterproductive to therapy. She made it rather impossible for me to develop any trust in her. When I questioned her routine rejection of me attempting to discuss my past she repeatedly told me that DBT doesn’t address the client’s past and only works with the present moment. Insert eye roll here. I kept asking her how she was going to help me if she wouldn’t allow me to tell her anything about my past. She just kept telling me to “stay in the moment.” Insert another eye roll here. I was basically treated as non-compliant every session, both with her and in the group because I had serious questions about what they were doing. They were very resistant to us questioning them about anything and they would basically shut down anyone who exhibited any resistance to them. They kept claiming how people with BPD are very resistant to therapy. Ha! Cult much?

    And yes, I studied Linehan’s DBT manual for six months and found it extremely tedious verging on silly and ridiculous. All DBT is is a mishmash of CBT and diluted mindfulness training. It is clearly a product of pop psychology and American culture that has been marketed as the best new thing for borderlines and trauma victims. Insert yet another eye roll here. I have found the proponents of DBT typically to be over zealous and moon eyed over Linehan’s so-called major contribution to psychiatry. I found the approach to be highly suspicious and off-putting especially due to all this zealotry and I felt very concerned for the clients who were unstable emotionally or who didn’t have questioning minds or any healthy skepticism because that made them quite vulnerable to DBT indoctrination. Yes, indoctrination, because that is exactly what it is. It is a psychological doctrinal system created by Marsha Linehan, a system that requires complete adherence without questioning.

    Though I know a couple of people who feel DBT helps them I am quite dissatisfied by their explanations about why they think it helps them. They usually can’t explain why they think it helps. From what I’ve seen it looks like it “helps” in the same way many people think religion or spirituality helps them, but for me those sorts of reasons raise a great deal of skepticism.

    DBT and Marsha Linehan are both highly overrated, in my opinion. They’ve gotten far too much widespread attention.

  6. Thirty days of antibiotics to treat my Lyme disease has done more to boost my mental state than any treatment in twenty five years of “therapy” and fourteen years of psychiatric drugs.

    It’s an amazing concept to grasp, I know! Who knew that trauma victims could have a physical illness and that not all distress is due to one’s past or present circumstances.

    In the process of trying anything I could think of to treat my depressive episodes, including exercise and meditation, my heart muscle was swelling (literally), my joints were swelling and disintegrating due to inflammation, my eyes became inflamed, my skin deteriorated, and the suicidal depression was NOT helped by any therapy, by any drug, or by any treatment other than the one that kills bacteria.

    Nearly all of the articles published on psychological or psychiatric practice start with the assumption that the patient isn’t actually physically ill (other than the dignosense brain diseases in the DSM.) Patients who are sick with any number of infectious diseases known to effect behavior and cognition (lyme, STARI, bartonella, babesia, erlichiosis, etc) are getting the short end of the stick with all of these “treatments” designed to change their thinking, either through purseusion (therapy) or chemical means (psych drugs).

    A more holistic view is needed in order to not leave physically ill people behind.

  7. From GGGreen:

    “…She made it rather impossible for me to develop any trust in her. When I questioned her routine rejection of me attempting to discuss my past she repeatedly told me that DBT doesn’t address the client’s past and only works with the present moment. Insert eye roll here. I kept asking her how she was going to help me if she wouldn’t allow me to tell her anything about my past. She just kept telling me to “stay in the moment.” Insert another eye roll here. I was basically treated as non-compliant every session, both with her and in the group because I had serious questions about what they were doing. ”

    Talking about DBT and its denial of people’s lives as a prerequisite for acceptance. How can anyone by promoting research where the subjects were treated in this manner — somehow connect it to something that anyone would consider less than manipulative? Since when did Mad In America tolerate this sort of journalism? Why in the world would a system that promotes bad science in bio-psychiatry and toxic medicines think they would find better fidelity in research on “behavior modification” of folks diagnosed with Borderline Personality Disorder which is the most stigmatizing diagnosis right after sociopathy, and child molester?

    How anyone can even begin to try these sorts of diagnostic exploits when each of the criteria for BPD can otherwise be explained by trauma, and otherwise is completely without any sort of required trauma screening. DBT has, since its beginnings been accepted because it was a way to deal with the Borderline problem… IE “an agency’s worst clients” who are frequently borderlined as a matter of rote.

    Take a common harm or retraumatization by the system… consider annoying behaviors and assumptions about attachment and BPD clients’ “clinginess”, take a person deeply traumatized by extreme abandonment or betrayal and give them a diagnosis that basically says that you must keep the person at arms length, avoid entanglements, and isolate them in limited session therapy, … and you are harming someone in the exact way that they have been harmed by their formative environment, essentially trying to cure a broken arm by stepping on it with enough force to break it again. This makes the case for the WHO studies that have people recovering in third world countries at higher rates where there is no mental health system.

    Wake up, Mad in America! A little less cheerleading for pseudo-science please, the back story at Marsha Linehan’s Borderline Academy is what should be told before one assumed that suicide is not more probably at higher rates… which would be found in the earliest untracked groups at the University of Washington hospital complex. Find one of those people and ask them how much their experience is at variance with GGGreen here.

  8. They’ve been claiming this for years. They sell the powers that be on the idea that the “crisis behaviors” of people with borderline DX (the target group for DBT) will decrease as a result of DBT. Meanwhile, they tell patients that they can have a “life worth living” and that that is what the treatment is about. In reality, the program is to make people more manageable and to silence them. This is the big lie of DBT. But there are other lies built into the way DBT is practiced.

    They make a huge deal out of their gold standard evidence-based protocol and state that it’s important to find a fully certified DBT therapist. If the DBT therapist is fully certified (something that therapist will have paid a lot of money for), then supposedly there is a guarantee that they are practicing DBT with fidelity to the evidence-based protocol. This is nonsense. There are no guarantees and there is no one to complain to, no governing board, that hears complaints from people who had a bad experience with dbt. I know because I tried.

    Interesting since one of their core assumptions is that patients cannot fail treatment and if a patient is not doing better after treatment, the fault is with the treatment, not the patient. You would think that if they really believed in this core assumption then they would want to speak to people who had bad experiences in DBT or felt harmed by it. They will not speak to people about bad experiences in DBT.

    Hypocrisy runs through the entire program. As one example, you are told to listen to your wise mind when making decisions about your life, but if your wise mind tells you that the antipsychotics or whatever else they have you on are hurting you, they consider that treatment interfering behavior, which is a top target of DBT treatment. I was in DBT programs where people’s basic life problems never got addressed because the therapists were always focused on one treatment interfering behavior on another. There was a line on the diary card that said, urge to skip medication. If the urge was high or if the person actually skipped the medication and noted that on their diary card, that would be the subject of discussion. They would be asked, “are you a doctor? Did you go to medical school?”.

    In my experience, people who wind up in DBT are already very traumatized and vulnerable because of experiences in their families, and experiences with psychiatry. The least that the DBT practitioners could do is tell the truth about what their program is for and whether or not they have any intention of following their core assumptions,which they use to sell people on at the start of a program.

  9. As others have pointed out, DBT, from the time of it’s inception, held a philosophy that the past is irrelevant, including any traumas. In my experience the treatment providers go to great lengths to avoid talking about the past, even recent past, and that includes experiences of iotrogenic harm that the patient/client experienced prior to landing in the program.

    Given that many psychiatric patients only wind up with a borderline diagnosis following a negative/harmful experience with psychiatry or other component of the mental health system, and many patients who engage in what the system calls problem behaviors have early childhood trauma, it’s not a small thing to declare that the past doesn’t matter.

    As the core assumption goes (unless they’ve updated it), “borderlines may not have caused all of their problems but they are the ones who need to fix them.”

    They assume that their patients wound up in DBT/wound up with a borderline diagnosis due to a skill deficit and the focus of treatment is teaching the patient coping skills. This is problematic in all sorts of ways, not least in regard to interpersonal effectiveness skills: when the patient tries to put them into practice to advocate for herself with, say, a psychiatrist, there is a huge power imbalance that gets ignored. You can do the best DEAR MAN of your life and still be told that you don’t know what you’re talking about. The DBT therapists are then at the ready with reminders about crisis survival skills and radical acceptance skills so that you can accept once again that you didn’t get your needs met even though you tried your best.

    Since I have been out of the program, my understanding is that they have changed their philosophy regarding trauma, to some extent, and now some of the DBT programs include a component of trauma therapy. But for people who went through the program prior to this trauma therapy being added, they’re pretty much out of luck. There’s not a lot of trauma therapy in the world for people with a borderline diagnosis who have been through DBT and are now disabled and on Medicare. After 35 years in the system I never received any form of trauma therapy, although it was probably the thing I needed from the start.

      • I’ve had the same experience. I really hope that whoever is running DBT now sees these comments and takes them seriously. Change needs to happen. They need to stop focusing so much on all of the problem behaviors of the people they profess to want to help and focus more on the incredible, life altering stigma that comes with a Borderline diagnosis. Changing the name to emotionally unstable personality disorder is not going to help. They need to address the reality that this diagnosis, and maybe any psychiatric diagnosis, constitutes a hate crime. When the diagnosis can be used against a person in a court of law, that’s a problem. When it can prevent a person, and often does prevent a person, from getting needed medical care, even when the medical problems result from forced/coercive drugging, that’s a problem. If they really cared about patients, and really believed in their core assumption that patients can’t fail in treatment, they would spend less time marketing DBT as the gold standard treatment for BPD and more time listening to patients and ex patients who have been hurt by the system that’s currently in place.

        • Actually I don’t know why I said anything about I hope they’re listening. They (the people who run and market DBT) clearly know what they’re doing and have known for a long time. They lie and lie and lie. it’s all about money.

          I looked on the DBT website, about the fees to become and then to stay certified DBT therapist. There is a fee for every step of the process and even afterward you need to pay to maintain your certification. And it’s complete BS because the things that they say they need the money for are things that they don’t even do. I was in treatment with a fully certified DBT therapist for over a year. I had been referred to her by another fully certified DBT therapist. Problem was the fully certified DBT therapist I was referred to was not in consultation at any point during the time she was treating me and when I brought this up she used it as another way to attack me, saying, “I wouldn’t need consultation if it wasn’t for you.”. She played a power trip on me with a psychiatrist and they both tried to get me brain shocked again before dumping me with no notice and then sending me certified letters in the mail, harassing me.

          DBT charges therapists for the following:

          “Annually, to maintain your certification status, a Maintenance of Certification fee of $95 covers DBT-LBC’s review of the information needed to assure you continue to meet the on-going requirements for Certification. These include: maintaining a license to practice with no restrictions; updating the website with the required 15 CEU’s for every two-year period following certification; continuing your professional liability insurance; being a participating member of a DBT consultation team; on-going mindfulness practice.”

          I can attest that no one was making sure this woman was participating in a consultation team. She didn’t. And when I reported the fact, literally no one cared. They all refused to speak with me about any of it.

          DBT is a money grab just like every other “treatment” in the corrupt “mental health system.” Patient beware.

          • “Every day that passes she further proves Doctor Curry’s diagnosis!! Borderline Personality disorder

            She has Borderline Personality Disorder. Classic behavior. This is what they do. Please get her a therapy coupon asap”

            This is what DBT counts on. Hatred of”borderlines” who get coerced into DBT by some therapist or psychiatrist who calls them a failure and convinced everyone around them that they’re the problem which abusive “loved ones” are only too happy to hear. The entire process is disgusting.

  10. “Suicidal thoughts were not reduced, which indicates that self-injury and suicide attempts can be prevented even when people continue to think about suicide.”

    Great, but let clients know at the start that this is the goal of treatment and not “a life worth living.”
    I once heard a DBT therapist tell another patient, in group, that the goal of DBT is “Getting out of hell, not better managing being in hell.”. I’m not sure anymore what’s true. In any case, in this particular program, the treatment ended at the end of an 8 month period, regardless of the patient’s status.

LEAVE A REPLY