1.
Revisioning &
Recapturing E.B.P:
Dialectical Behavior Therapy (DBT) as Example
Scott D. Miller, Ph.D.

2.
Dialectical Behavior Therapy (DBT):
•Defined as, “a mode of treatment designed for people with
borderline personality disorder (BPD)”;
•Aims to help people to validate their emotions and behaviors,
examine the negative impact of emotions and behaviors on their lives,
and make a conscious effort to bring about positive change.
•Currently identified by professional organizations, funding
bodies, and government agencies as an “evidence-based,”
“empirically-supported,” “best practice.”
http://www.medterms.com/script/main/art.asp?articlekey=34212
http://www.apa.org/divisions/div12/cppi.html
http://www.mhreform.org/policy/ebs.htm

3.
•Recommend that “consumers seek out
that have been studied and show to be
beneficial in controlled studies”;
•Empirically supported therapies meet
several “stringent” criteria:
•Controlled (randomization, manuals,
equality in delivery);
•Results better than no treatment;
•Results equal to an alternative
treatment;
•More than one study by more than
one researcher or team.
http://www.apa.org/divisions/div12/cppi.html
http://www.mhreform.org/policy/ebs.htm

4.
DBT:
What do the data say?
•Currently 15 studies published on
DBT (1991-2006);
•Nine of the fifteen qualify as
“randomized clinical trials” (RCT);
•Three of the nine RCT’s were
conducted by researchers other than
the developer.
http://depts.washington.edu/brtc/sharing/publications/research-and-
articles-on-dialectical-behavior-therapy

5.
DBT:
What do the data say?
•All of these studies but one compared
the approach to “treatment as usual” or
wait-list control;
•The one study compared DBT to an
approach that “proscribed use of
cognitive-behavioral change
techniques or any overt suggestion of
new behaviors or advice about what to
do.” (p. 16)
•An example…
Linehan, M.M., Dimeff, L.A., Reynolds, S.K., Comtois, K.A., Welch, S.S.,
Heagerty, P., Kivlahan, D.R. (2002). Dialectical behavior therapy versus
comprehensive validation plus 12-step for the treatment of opioid dependent
women meeting criteria for borderline personality disorder. Drug and Alcohol
Dependence, 67(1), 13-26.

6.
DBT:
What do the data say?
•NIMH funded study of DBT:
• Compared DBT to services
offered by “community-
nominated” treatment experts;
Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow
up of DBT. Archives of General Psychiatry, 63, 757-766.

7.
DBT:
What do the data say?
•DBT therapists:
•Received 45 hours of specialized
training;
•Pre- and during-study supervision.
•Gave 38 more hours of contact
dedicated to keeping people out of
the hospital
• Community experts:
•Received no training, supervision, or
consultation;
•No control of type, amount, or quality
of services .
•Provided significantly less direct
service than DBT therapists.
Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow
up of DBT. Archives of General Psychiatry, 63, 757-766.

8.
Vari-ability between Therapists:
What do the data say?
“When individuals,
based on their
extensive experience
and reputation, are
nominated by their
peers as experts, their
actual performance
is…found to be
unexceptional…”.
Ericsson, K.A. (2006). The influence of expertise and deliberate practice
on the development of expert performance. In K.A. Ericcson, N.
Charness, P.J. Feltovich, & R.R. Hoffman (eds.). The Cambridge
Handbook of Expertise and Expert Performance (pp. 683-704). New York:
Cambridge University Press.

9.
DBT:
What do the data say?
Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow
up of DBT. Archives of General Psychiatry, 63, 757-766.

10.
DBT:
What do the data say?
Linehan, M. et al (2006) Two-Year Randomized Control Trial and Follow
up of DBT. Archives of General Psychiatry, 63, 757-766.

11.
Study RCT Comparision Gender Race & Ethnicity Age Drop out rate Participants
Group (DBT/other)
Linnehan et al. Yes Treatment as usual 100% female Not reported 18-45 4/24 (16.7%) v. 6/12 24/24
1991 (Dosing not (50%)
BPD reported) 1 Suicide
Linnehan et al. Yes Treatment as usual 100% Female Not reported 18-45 3/13 (23%) 13/13
1994 (Dosing not Mean = 26 1 suicide v. 0
BPD reported)
Linnehan et al. Yes Treatment as usual 100% female 78% White 18-45 5/12 (41.6%) 12/16
1999 (significantly lower 11% Unspecified Mean = 30 1 death v. 0
BDP/Drug dose) 7% Black D.O. in TAU dropped
DBT received 2X 4% Hispanic out prior to treatment
as much therapy
Linnehan et al. Yes DBT plus 12 steps 100% female 87% White 28-43 4/11 (36%) v. 0/12 11/12
2002 12% Unspecified Mean = 36
BPD/Drug
Koons et al. 2001 Yes Treatment as usual 100% female 75% White 31-46 3/14 (21%) v. 2/14 14/14
BPD (significantly lower 25% Black (14%)
dose)
Van den Bosch et Yes Treatment as usual 100% Female Not reported Mean = 37.5 14/31 (45%) v. 20/27 31/27
al 2002 (significantly lower (74%)
Verheul et al. 2003 dose)
BPD/Drug
Telch et al. 2001 Yes Wait list control 100% Female 94% White Mean = 50 4/22 (18%) v. 6/22 22/22
Binge Eating 6% Unspecified (27%)
Safer et al. 2001 Yes Wait list control 100% Female 87% White 18-54 2/14 (14%) v. 1/15 (7%) 14/15
Bulimia 13% Unspecified Mean = 34
Lynch et al. 2003 Partial (n Medication v. Meds 85% Female 85% White 66-80 Not reported 17/17
Depression = 4) plus DBT 15% Male 9% Black Mean = 66
(significantly higher 6% Hispanic
dose)
Linnehan et al. Yes Community 100% Female 86% White 18-45 11.5% v. 28.6% 52/49
2006 nominated experts 3.8% Black Mean = 29
BPD Asian 1.9%
Other 5.8%
TOTAL 8.5 1 semi- BPD = 100% Female 81.5% White 18-45 25.9 v. 35.6%
Allegiance direct Mean = 31.7 BPD =
comparison
http://www.nrepp.samhsa.gov/programfulldetails.asp?PROGRAM_ID=72 157

12.
DBT:
What can we conclude?
1. Extremely small and restricted sample (n = 157;
100% female, 81% White);
2. Allegiance effects in 7/9 studies;
3. No real direct comparisons with another bonafide
therapy;
4. Inequalities in dose and intensity of services;
5. No control over known confounds and contributors
(especially, therapist and alliance effects).

13.
What Works in Therapy:
Direct Comparisons & Allegiance Effects
Direct Comparisons & Allegiance Effects
•Meta-analysis of all
studies published between
1980-2006 comparing
bona fide treatments for
children with ADHD,
conduct disorder, anxiety,
or depression:
•No difference in outcome
between approaches intended
to be therapeutic;
•Researcher allegiance
accounted for 100% of
variance in effects.
Miller, S.D., Wampold, B.E., & Varhely, K. (2008). Direct comparisons of treatment modalities for youth disorders: A meta-analysis. Psychotherapy Research, 18(1), 5-14

14.
What Works in Therapy:
Alliance & Therapist Effects
Researchers found SFT superior to TFP in
work with borderline-diagnosed clients:
•Significant differences in outcome
between therapists;
•Alliance significant predictor of retention
and improvement, independent of
outcome;
•“In the more semistructured and long-
term treatment of Axis II disorders, the
development and maintenance of the
therapeutic alliance constitutes a central
issue of therapy and may constitute a
central curing mechanism.”
Spinhoven, P. et al. (2007). The therapeutic alliance in schema-focused
therapy and transference-focused psychotherapy for borderline personality
disorder. Journal of Consulting and Clinical Psychology, 75(1), 104-115.

15.
Smoke and Mirrors
Real World Applications
DBT for “BPD”
• In a large CMHC serving
SPMI clients: Of 382
eligible by dx, only 25
(6.5%) thought it was for
them; 25% of those
dropped out before
program started; another
25% dropped out…is it
worth the cost? Haynes, M. (2006). Real world applications of evidence based practice.
Heart and Soul of Change 3. Bar Harbor, ME.

16.
DBT:
What can we conclude?
Doing
~
Better = D.B.T.
Therapy