









































Graduate Student Journal of Psychology                                                                             Copyright 2005 by the Department of Counseling & Clinical Psychology 


Graduate Student Journal of Psychology                                                                             Copyright 2007 by the Department of Counseling & Clinical Psychology  
2007, Vol. 9                                                                                                                          Teachers College, Columbia University                          ISSN 1088-4661 
 
 
 

Application of Dialectical Behavior Therapy to  
Disorders Other Than Borderline Personality Disorder:  

A Critical Review 
 

Ananda B. Amstadter 
Auburn University  

 

Lindsay M. Squeglia 
Medical University of South Carolina

Dialectical Behavior Therapy (DBT) has recently been used to treat disorders other than Borderline 
Personality Disorder (BPD). Despite DBT’s widespread use, no paper summarizes its use for con-
ditions other than BPD; therefore, a synthesis of the literature is warranted. In this paper, we aim to 
(a) briefly summarize the treatment and its empirical basis for treating BPD; (b) explore the theo-
retical underpinnings of the application of DBT beyond BPD; (c) review studies that implemented 
DBT for other forms of psychopathology, such as eating disorders and posttraumatic stress disor-
der; (d) discuss DBT’s use for comorbid conditions; (e) examine the applicability of components of 
DBT to supplement other treatments; and (f) provide a summary of the state of the literature and di-
rections for future research. Our review suggests that although further randomized controlled stud-
ies are warranted to validate the efficacy of DBT for these and other disorders, the initial results 
seem promising. 

 
 

Dialectical Behavior Therapy (DBT; Linehan, 1993a; 
1993b) was originally developed to treat severe behavioral 
manifestations of Borderline Personality Disorder (BPD), 
such as emotional instability, suicidality, and parasuicidal 
acts (Diagnostic and Statistical Manual of Mental Disorders 
4th edition [DSM-IV]; American Psychiatric Association 
[APA], 1994). This comprehensive cognitive-behavioral 
treatment (CBT) package was originally developed to meet 
the intense treatment needs of those with BPD, as well as to 
rectify previous snares in the therapeutic thread associated 
with treating this disorder. Prior to the development of 
DBT, there was a lack of empirically supported therapies 
for this hard-to-treat condition (Scheel, 2000). In fact, in a 
review of empirically supported treatments, DBT was the 
only therapeutic method categorized as “probably effica-
cious” for treating BPD; no treatments were placed in the 
“well-established” category (Crits-Christoph, Frank, Cham-
bless, Brody, & Karp, 1995). According to standards from 
the clinical psychology division of the APA, DBT warrants 
the label “empirically supported” based on the outcome 
data from randomized controlled trials (RCTs) conducted 
with BPD women (Robins & Chapman, 2004). DBT re-
mains the only data-supported outpatient treatment for 
BPD.  

Since the development of DBT, numerous randomized 
clinical trials have supported its efficacy for the treatment 
of BPD, and several review papers summarize this literature 
(e.g., Westen, 2000). We begin with a brief synopsis of the 
treatment package and a summary of the existing empirical  
 
Correspondence concerning this article should be adressed to 
Ananda B. Amstadter; email: amstadt@musc.edu.

support. Recently, DBT has been used to treat a wide range 
of mental health phenotypes, and to date, a comprehensive 
review of this literature does not exist. Therefore, in this 
paper, we aim to (a) briefly review the treatment and its 
empirical basis for treating BPD; (b) explore the theoretical 
application of DBT beyond BPD; (c) review studies that 
implemented DBT for other forms of psychopathology, 
such as eating disorders and posttraumatic stress disorder 
(d) discuss DBTs use for comorbid conditions; (e) suggest 
the possibility of supplementing other treatments with com-
ponents of DBT; and (f) provide an overall summary of the 
state of the literature and future directions for research. 

 
Dialectical Behavior Therapy: An Introduction 

 
Biosocial Theory 

 
From a DBT perspective, the clinical presentation of 

BPD is conceptualized through a biosocial lens (Linehan, 
1993a; 1993b). A biosocial theory of BPD demands atten-
tion to the joint outcome of biological disposition, envi-
ronment, and the transaction between the two during one’s 
early learning history. It is posited that BPD individuals 
possess a biological vulnerability resulting in deficits in the 
emotion regulatory systems; specifically, an overactive 
limbic system (Davidson, 1998). This over-activation of the 
limbic system is believed to predispose individuals to emo-
tional vulnerability manifested by high sensitivity to emo-
tional stimuli, elevated emotional intensity, and a slower 
return to baseline following emotional arousal (Linehan, 
1993a). In addition to the biological predisposition, BPD 
individuals often have invalidating environments in their 

16 



APPLICATION OF DBT BEYOND BORDERLINE PERSONALITY DISORDER 
 

17 

formative years. From the biosocial perspective (Linehan, 
1993a), the environmental insult could be physical (e.g., 
sexual abuse, physical abuse, neglect) or emotional (e.g., 
emotional abuse, invalidation). The theory posits that the 
diathesis of biological vulnerability in combination with an 
environment that is erratic, abusive, and unpredictable, 
leads to the failure to learn adaptive means of regulating 
one’s emotions, which is one of the hallmark symptoms of 
BPD. This emotion modulation skills deficit has far-
reaching effects, and individuals with this condition also 
have extreme difficulty expressing their inner experiences. 
Additionally, the biosocial theory suggests that the expres-
sion of emotions may be met by responses indicating that 
they are invalid, which leads the individual to believe that 
their emotions are not accurate representations of the truth 
and therefore, cannot be trusted. Over time the biological 
deficit and the invalidating environment influence and ex-
acerbate each other, making emotion dysregulation progres-
sively more pervasive.  

 
The Creation of DBT 

 
DBT was tailored to address three pitfalls common in 

the treatment of this population (Linehan, 1993a). The first 
difficulty was treatment dropout or lack of therapeutic alli-
ance due to therapists’ concentration on change. Tradition-
ally, CBTs focused on change, which many BPD clients 
perceived as invalidating. To address this, acceptance-based 
interventions, which are often referred to as validation 
techniques, were added. Theoretically, radical acceptance 
imparts to the client a message that the client is doing the 
best that can be expected given his or her situation. One 
main job of the therapist is to search for aspects of truth in 
the client’s response, which may at face-value, appear irra-
tional and unfounded, and communicate this truth to the 
client as a form of validation. The role of validating the 
truth in a client’s situation engendered the adage that one 
must accept before one can change.  

The second difficulty was that BPD clients presented 
with many crises that demanded attention, as the crises 
were often of a life-threatening nature. Because crisis man-
agement was the top priority, therapists did not have ade-
quate time to address skill building, which would enable 
long-term change. Group skills training sessions were thus 
added to teach and practice skills; this allowed for individ-
ual therapy sessions devoted to the application of skills.  

The third difficulty was that clients were inadvertently 
reinforcing the delivery of iatrogenic treatment (e.g., they 
were reinforcing the therapist for avoiding the discussion of 
their suicide and parasuicide attempts). Linehan’s research 
team coded standard cognitive-behavioral therapy sessions 
with BPD clients and found that clients were reinforcing the 
therapist (e.g., positively by increased participation, nega-
tively by halting attacks on the therapist) for switching from 
heated topics to more neutral topics. Further, it was found 
that clients would punish the therapist for application of 
effective treatment strategies (e.g., self-harm after the 

therapist does not comply with client demands such as 
longer treatment sessions). In response to this pattern of 
unintentional reinforcement, DBT instilled a structure of 
treatment that reinforces the client for engaging in therapeu-
tic enhancing behaviors, thereby enhancing both the clients’ 
and therapists’ abilities. DBT was thus developed from 
these modifications to standard cognitive-behavioral treat-
ment. 

 
East Meets West – The Dialectic 

 
As it is a form of CBT, DBT utilizes many change 

principles that are common to other CBTs such as contin-
gency management, behavior analysis, exposure, problem 
solving, and cognitive restructuring (Linehan, 1993a; 
1993b). Acceptance strategies are based on eastern Zen 
contemplative studies and include mindfulness, assuming a 
non-judgmental stance, and validation tactics (Dimeff & 
Linehan, 2001). As the word ‘dialectic’ refers to the synthe-
sis of two opposites, the addition of acceptance principles to 
a change oriented CBT not only afforded the name, but also 
forms the foundation of DBT. Of note, the two opposites—
acceptance and change—are not applied at the exclusion of 
the other. Rather, the two poles are used in concert to 
achieve the goal of DBT: to build a life worth living. The 
primary tension within and across treatment sessions is to 
accept the client as he or she is (i.e., validating the client) 
while concurrently promoting change.     

 
Treatment Modalities 

 
Comprehensive psychotherapy, according to Linehan 

(1993a), must serve five functions: (a) foster the client’s 
motivation to change, (b) develop the client’s resources and 
skills, (c) allow for generalization of treatment effects to the 
client’s natural contexts, (d) configure the therapeutic envi-
ronment such that the client’s and therapist’s competences 
are fostered, and (e) cultivate and maintain the therapist’s 
ability and desire to provide effective therapy. There are 
four treatment modes that serve the functions of DBT 
(Linehan, 1993a). One treatment modality is individual 
psychotherapy, which typically entails 50-minute weekly 
sessions. Individual therapy serves to increase the client’s 
motivation and ability to change (Dimeff & Linehan, 2001). 
A second modality is group skills training, on average 
meeting for two and a half hours weekly to foster skill 
building. Phone consultation is another mode, used at the 
client’s will and serving to enhance skill application during 
crises. Last, there is the therapist consultation team, held 
weekly or bi-weekly, to provide DBT therapists with peer 
supervision and support. In addition to helping to prevent 
therapist burnout, it also assists in adding treatment integ-
rity, as therapists are reviewed on their adherence to the 
principles of treatment. DBT encompasses this entire treat-
ment package. Although Linehan hopes to conduct disman-
tling studies to ascertain specific component effectiveness, 



AMSTADTER AND SQUEGLIA  
 

18 

the empirical support for DBT with BPD presently applies 
to the inclusion of all four treatment modalities. 

One of the main problems with traditional treatments 
for those with BPD has been that each therapy session 
serves only to manage the crisis of the moment; in contrast, 
there is structure imposed to the progression of DBT that is 
theoretically grounded in logical and behavioral principles 
(Linehan, 1993a). Individual therapy within DBT is organ-
ized into four stages. Within stage one there is a hierarchy 
of priorities that structures each session, all aimed at mov-
ing from behavioral dysregulation to regulation. The basis 
of stage one is to increase safety by decreasing life-
threatening behaviors; a life worth living can only be built 
if the client is indeed alive. Suicide and parasuicide, which 
is self-harm without intent to die, are addressed first. A 
thorough discussion of these serious behaviors is beyond 
the scope of this paper; the reader interested in learning 
more about the treatment of parasuicide and suicide behav-
iors is referred to the manual (Linehan, 1993b).  The second 
priority is to decrease behaviors that interfere with the pro-
gression of therapy, such as missed appointments and fail-
ure to complete homework.  The third priority is to decrease 
behaviors that interfere with the client’s quality of life. The 
last priority is to increase skills to enhance the client’s life. 
This structure is intended to reinforce non-parasuicidal be-
havior. If the client does not engage in parasuicidal behav-
ior, functional analyses of said behaviors do not need to 
occur, and the client’s session time is left for discussion of 
issues of the client’s choosing. 

Stage two addresses the client’s emotional suffering 
that likely still exists despite the behavioral control gained 
through stage one. During this stage, issues such as post-
traumatic stress are attended to. Stage three is aimed at 
problems in living and attaining normal emotional experi-
ences, both positive and negative. This stage is likely the 
most similar to standard outpatient treatment. Stage four, 
which not every client enters, aims to help with insight 
building, spiritual connectedness, and to further life satis-
faction. 
 
Group Skills Training 
 

Overall, the purpose of skills training is to cultivate and 
refine skills in modifying maladaptive ways of behaving, 
thinking, and experiencing emotions (Linehan, 1993b). 
Four modules of skills are taught in DBT group skills train-
ing.  Each module was designed to ameliorate a behavioral 
deficit or symptom often found in BPD. First, the mindful-
ness module was created to address difficulties in maintain-
ing a sense of self, feelings of emptiness, and cognitive 
aberrations such as dissociation. Second, the interpersonal 
effectiveness module centers on the chaotic interpersonal 
relationships that are often present in the lives of BPD indi-
viduals. Third, the emotion regulation module was tailored 
to manage volatile affect, another characteristic of the dis-
order. Lastly, the distress tolerance module was created due 
to the impulsive and self-destructive nature of BPD; it was 

meant to provide clients with alternate behaviors that are 
not of a destructive nature in the face of stress. In manual-
ized DBT, skills groups cycle through all four modules 
twice because many clients are too behaviorally and emo-
tionally dysregulated at the beginning of treatment to incor-
porate new proficiencies. It has been demonstrated that 
memory and comprehension are dampened by intense emo-
tion (Richards & Gross, 2000). Subsequently, clients may 
be in a more regulated state the second time around, after 
being in treatment for 6 months, and likely retain more than 
they did at first exposure. Though the modules were created 
to treat specific behavioral difficulties pertaining to both 
BPD and an array of other psychological disturbances, they 
are also successful in refining skills of well-functioning 
individuals. In fact, skills trainers have been found to per-
sonally benefit from learning the DBT modules (M. M. 
Linehan, personal communication, August, 2005).  

 
Efficacy of DBT for BPD 

 
DBT as an outpatient treatment for a primary diagnosis 

of BPD has been examined in six RCTs (Koons, et al., 
2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 
1991; Linehan, Schmidt, Dimeff, Craft, Kanter, & Comtois, 
1999; Linehan, Dimeff, Reynolds, Comtois, Shaw Welch, 
& Heagerty, et al., 2002; Turner, 2000; Verheul, van den 
Bosch, Keoter, De Ridder, Stijnen, & van den Brink, 2003) 
in addition to a two year RCT follow-up of DBT as therapy 
for suicidal behavior and borderline personality disorder 
(Linehan, et al., 2006). Women ranging in age from 18 to 
70 who met criteria for BPD served as participants in all of 
the RCTs. In three studies, the participants were also sub-
stance dependent (Linehan et al., 1999; Linehan et al., 
2002; Turner, 2000). Across studies, DBT was associated 
with decreased parasuicidal behaviors, medically severe 
parasuicidal behaviors, inpatient days, and treatment drop-
out, and increased global and social adjustment as com-
pared to the control group, which were either treatment as 
usual community treatment by experts (Linehan et al, 
2006), or client centered therapy (Turner, 2000). Further-
more, these group differences were by and large maintained 
one year post-treatment (e.g., Linehan, Heard, & Arm-
strong, 1993). In sum, these investigations support the effi-
cacy of DBT for this population. Notably, support for DBT 
has been yielded from the Linehan lab as well as from other 
research groups.  

 
Application to Other Disorders 

 
DBT was designed to treat borderline patients, and its 

effectiveness has primarily been studied in regards to that 
disorder. Clearly, sufficient empirical support for generali-
zation of treatment efficacy is needed prior to DBT being 
adopted as a treatment for other disorders. Yet, from a theo-
retical perspective, sufficient support exists to warrant the 
study of this treatment for other disorders. Our review of 



APPLICATION OF DBT BEYOND BORDERLINE PERSONALITY DISORDER 
 

19 

the literature has afforded four theoretical reasons to sup-
port the study and perhaps subsequent implementation of 
DBT to populations other than BPD. First, given the robust 
treatment effects found with such a difficult-to-treat popula-
tion, it is likely that DBT might be even more effective for 
less clinically severe client populations. Second, given 
DBT’s ability to positively affect outcome variables such as 
impulsivity, disruptive behavior, distress, and depression in 
BPD clients (e.g., Linehan et al., 1991), it can be hypothe-
sized that DBT will also be effective in treating these dis-
crete behaviors in clients with other disorders. Third, a core 
component of DBT is skills training and, independent of 
diagnosis, adaptive coping skills may be beneficial for cli-
ents to learn (Lynch, 2000). Fourth, and perhaps most im-
portantly, is the concept of emotion regulation. Dysfunc-
tional behaviors present across diagnoses can be thought of 
as maladaptive coping skills or poor attempts at emotion 
regulation. For example, binge eating, substance abuse, and 
parasuicidal behavior can all be conceptualized as emotion 
regulation attempts (Telch, Agras, & Linehan, 2000). Fol-
lowing this line of reasoning, DBT has recently been ap-
plied to other disorders (e.g., eating disorders, depression) 
in which affect regulation is an issue.   

 
Eating Disorders 

 
In clinical practice, DBT has been used to treat many 

categories and variants of eating disorders (McCabe & 
Marcus, 2002), including bulimia (Safer, Telch & Agras, 
2001), binge eating disorders (BED) (Telch et al., 2001), 
and comorbid BPD and eating disorders (Palmer, Birchall, 
Damani, et al., 2003). Binge eating disorder (BED) to date 
is the only eating disorder in which systematic outcome 
studies have been conducted (i.e., Telch et al., 2001), and 
results from these studies have provided promising empiri-
cal support for the use of DBT over treatment as usual. 

From a theoretical perspective, many lines of reasoning 
suggest that DBT would be effective in treating eating dis-
orders. One such angle concerns the similarities between 
BPD and eating disorders. A hallmark symptom of BPD is 
life-threatening behaviors (i.e., suicide attempts, parasui-
cide); similarly, symptoms of eating disorders may be life-
threatening. Specifically, a main criterion for anorexia ner-
vosa is being less than 85% of expected weight, which pre-
sents a health risk (APA, 1994). Further, purging behavior, 
which may be present in both anorexia and bulimia, has 
been shown to have detrimental health effects (Safer et al., 
2001). DBT has specific strategies to decrease life-
threatening behaviors. Another similarity between BPD and 
eating disorders is ambivalence. A common dialectic is that 
clients fear living with the disorder for life while simulta-
neously fearing change. McCabe and Marcus (2002) noted 
that clients with anorexia nervosa are often initially resis-
tant to therapy and have difficulties maintaining treatment 
gains. Specific techniques in DBT have been designed to 
work with ambivalence without resulting in invalidation of 
the client’s perspective (Linehan, 1993a). Techniques such 

as using pros and cons, devil’s advocate, and a myriad of 
social psychological principles of persuasion center on the 
balance of acceptance and change, with a constant focus on 
commitment (Linehan, 1993a). 

Another similarity between DBT and eating disorders 
is what Linehan terms “apparent competence” (Linehan, 
1993a). This term suggests that BPD clients are often com-
posed on the exterior and suffering internally. Likewise, 
McCabe and Marcus (2002) noted that clients with eating 
disorders are often successful and intelligent. In other 
words, clients appear competent, but have basic deficits at 
regulating their painful inner experiences, creating a dis-
crepancy that engenders more distress. To counteract this 
discrepancy, DBT has been developed from a skills deficit 
perspective and therefore addresses ostensible competence 
by providing basic skills training to all clients. A fourth 
similarity between work with BPD clients and eating disor-
ders clients concerns therapist’s reactions, including burn-
out and emotional over-involvement. Mortality may occur, 
which can be difficult for therapists to accept. The consulta-
tion team in DBT provides support for therapists and en-
sures treatment credibility (Linehan, 1993a); like BPD 
therapists, eating disorders therapists would most likely 
benefit from such consultations. Lastly, and perhaps most 
importantly, an emotion regulatory function of maladaptive 
behaviors may be a common similarity between BPD and 
eating disorders. This is best explicated by examining binge 
eating disorder (BED). 

BED, a condition in which an individual consumes a 
markedly large amount of food in a small amount of time 
without compensatory behaviors (APA, 1994), has been 
theoretically conceptualized from two standpoints. One is 
housed within general CBT theory, assuming that BED 
results from extreme attempts at weight control and dieting; 
a cyclical pattern is thought to occur from extreme depriva-
tion to extreme eating episodes (Wilfley & Cohen, 1997). 
BED has been treated with standard CBT, yet some af-
flicted with the disorder do not show improvement (Telch, 
et al., 2001).  

A second theoretical account of BED, which is rapidly 
accumulating empirical support, frames binge eating as an 
attempt to regulate negative emotions. From this perspec-
tive, binge eating serves as a reinforcing agent, as negative 
emotions are temporarily relieved (Heatherton & Baumeis-
ter, 1991). For example, in a recent study of women with 
BED, negative mood induction led to an increase in binge 
eating, which then led to a decrease in the elicited emotion 
(Telch & Agras, 1996); results implied that binge eating 
was reinforced as an emotion regulatory strategy.  In this 
manner, binge eating can be conceptualized as a similar 
behavior to regulatory behaviors in BPD, such as parasui-
cide. Wiser and Telch (1999) posited that in both disorders, 
negative emotional states are viewed as unbearable and are 
therefore followed by maladaptive modification attempts. 
In her work with BPD patients, Linehan (1993a; 1993b) 
adopted a deficit approach and argued that BPD individuals 
lack sufficient ability to regulate their volatile emotional 



AMSTADTER AND SQUEGLIA  
 

20 

states adaptively. Similarly, Wiser and Telch (1999) stated 
that BED clients lack ample skills to regulate their emo-
tions. 

An adaptation of the DBT protocol to treat BED is a 
natural fit: nearly half of clients with this disorder are 
treatment resistant (Wilfey & Cohen, 1997), and binge eat-
ing can be viewed as a regulatory behavior (Telch & Argas, 
1996). An uncontrolled pilot study, using a modified ver-
sion of Linehan’s (1993b) protocol, was conducted to in-
vestigate the possible usefulness of DBT for this population 
(Telch et al., 2000). DBT skills were tailored to BED to 
constitute a 20-session group therapy protocol. Only group 
skills training sessions were conducted; individual therapy 
sessions, phone consultation, and consultation groups were 
not included. Tenets of DBT were customized for this pro-
gram; instead of a traditional order of topic discussion (life-
threatening, therapy interfering, etc.), this program instilled 
a hierarchy fitting BED. The hierarchy was as follows, in 
order of decreasing severity: treatment interfering behavior, 
binge eating, mindless eating, preoccupation with food, 
capitulating, and irrelevant behaviors (e.g., behaviors that 
make binging more likely). During each session, clients 
were encouraged to discuss their most severe behavior on 
this hierarchy.  

Mindfulness skills were thought to address the central 
assumption that binge eating occurs due to a negative emo-
tional arousal coinciding with a lack of emotional control 
(Wiser & Telch, 1999).  If binge eating is repeatedly occur-
ring to avoid emotional experiencing, it may become an 
automatic response to negative emotional arousal. Mindful-
ness, by definition, increases awareness of emotions and 
experiences and suggests a nonjudgmental stance towards 
internal experiences (Linehan, 1993a; 1993b). Therefore, it 
is believed that mindfulness may break the association be-
tween negative emotional states and binge eating. Teaching 
clients to focus on their experiences connects them to their 
internal experiences and provides behavioral evidence that 
they can, in fact, sit with “intolerable” emotions. Further, 
the nonjudgmental stance serves to decrease possible emo-
tional reactions to binges, such as shame or guilt, which 
may trigger more distress and more binging episodes. The 
emotion regulation module was thought to increase emo-
tional awareness and to teach clients more adaptive means 
of dealing with their emotional experiences, replacing bing-
ing. These skills were thought to not only help in the short 
term, but also to be prophylactic in that they likely decrease 
negative emotions and increase positive emotions, thereby 
making the conditions in which binging occurs less fre-
quent. Distress tolerance skills were taught to address cop-
ing with circumstances not able to be changed. For those 
with BED, the key of this module was to increase tolerance 
of internal or external events that may be triggers for bing-
ing without engaging in the maladaptive behavior. The in-
terpersonal effectiveness module in the original DBT proto-
col was not utilized.    

Eleven women with BED served as participants in this 
uncontrolled pilot study of DBT (Telch et al., 2000); all 

eleven women completed treatment and, under the protocol 
outlined above, positive effects were found. Post-treatment 
data indicated that binge eating ceased (i.e., no episodes for 
four consecutive weeks) in 82% of participants and that, on 
average, emotion regulation skills improved. Therapeutic 
gains were maintained at three- and six-month assessments.  

Due to the promising outcome of the uncontrolled trial, 
an RCT was conducted to further ascertain the efficacy of 
DBT for BED (Telch, et al., 2001). Female BED patients, 
randomly assigned to DBT of wait-list, served as subjects.  
Groups, each of which consisted of 22 patients, did not dif-
fer on demographic variables, binge eating severity, self-
esteem, depression, or mood regulation at pre-treatment. 
The DBT condition entailed 20 sessions of group skills 
training using a protocol identical to the one used in the 
uncontrolled trial (Telch et al., 2000). Following the com-
pletion of treatment, those in the DBT condition had sig-
nificantly fewer days of binge eating and fewer binge epi-
sodes than did those in the wait-list condition. In fact, a 
large percentage of those in the DBT condition (89%) did 
not have any binge eating for four weeks straight, whereas 
only a small percentage (13%) of those in the wait-list con-
dition met this criterion. DBT was also associated with 
lower concerns about weight, shape, and eating. Further-
more, treatment decreased the participants’ urges to eat to 
regulate their anger. At the three- and six-month follow-up, 
respectively, 67% and 56% of DBT participants continued 
to abstain from binge eating. Following the completion of 
treatment for the DBT condition, 14 of the 22 participants 
in the wait-list condition accepted the offer to begin DBT 
treatment. Of these participants, 90% had ceased binge eat-
ing at treatment completion, and 80% and 67% maintained 
this status at the three- and six-month follow-up, respec-
tively.  

  Theoretically, DBT might be effective for the treat-
ment of BED as it teaches more adaptive emotion regula-
tion skills, thereby providing alternative behaviors to binge 
eating for regulating emotion. If DBT was effective, there-
fore, it would be expected that decreased negative affect 
and increased emotion regulation skills would be present 
post-treatment. Partial support for this hypothesis was ob-
served. DBT’s superiority to no-treatment in reducing binge 
eating seemed to be moderated by DBT’s reduction of pa-
tients’  urges to binge eat when angry, though not their 
urges to eat when anxious or depressed. Furthermore, lower 
depression scores were not found post-treatment. In sum, 
DBT may be effective due to providing alternative skills at 
regulation of specific emotions, such as anger. Though 
DBT yielded a higher percentage of treatment responders 
than reported in previous CBT trials for BED (Wilfley & 
Cohen, 1997), future research should directly compare CBT 
with DBT. Additionally, implementing the other compo-
nents of DBT, such as phone consultation, may further add 
to treatment gains and should be studied.  

Extending DBT’s applicability to other eating disor-
dered patients, Palmer et al. (2003) conducted an uncon-
trolled outcome study with women having comorbid diag-



APPLICATION OF DBT BEYOND BORDERLINE PERSONALITY DISORDER 
 

21 

noses of BPD and an eating disorder (n=7), although their 
exact diagnoses were not provided in the article. After 18 
months of standard DBT, no client met criteria for a spe-
cific eating disorder, although 4 clients met criteria for eat-
ing disorder not otherwise specified. Furthermore, self-
harming behaviors decreased, as did hospitalizations. Al-
though this study has notable limitations, such as lack of a 
control group, inadequate reports of diagnoses, and inade-
quate outcome variables, results suggest the usefulness of 
DBT to treat those with comorbid BPD and eating disor-
ders. 
 
Geriatric Depression 

 
Although there is evidence of pharmacotherapeutic ef-

fectiveness for some elderly individuals with depression, 
many individuals do not respond to behavioral, cognitive, 
or brief psychodynamic psychotherapy. For example, in one 
study, approximately 30% of elderly adults with depression 
did not respond to treatment (Thompson, Gallagher, & 
Breckenridge, 1987). Furthermore, elderly adults are the 
most likely age group to complete a suicide (McIntosh, 
1992). DBT has been demonstrated to be effective with 
hard-to-treat clients, particularly those at risk of suicide 
(Linehan, Cochran, & Keltner, 2001), and for this reason, it 
may be an effective treatment for the depressed elderly.  

Following these reasons, Lynch, Morse, Mendelson, 
and Robins (2003) sought to test the efficacy of an adapted 
DBT program for depressed geriatric clients. According to 
Lynch (2000), the main difference between standard DBT 
and DBT for depression is that the latter focuses on behav-
iors functionally pertinent to depression, including inflexi-
ble coping and dependency. Several modifications to the 
standard DBT protocol were made. In standard DBT, 
weekly individual sessions occur in conjunction with phone 
consultation throughout the week (Linehan, 1993a; 1993b). 
Lynch and colleagues (2003) combined these two compo-
nents to create scheduled weekly 30-minute phone consul-
tations. This adaptation attempted to decrease the clients’ 
dependency on the therapist and to reduce travel for a popu-
lation where mobility may be a concern.  Second, the skills 
group met weekly for two-hour sessions; all four modules 
of skills were taught and were tailored to late-life depres-
sion. For example, the mindfulness module entailed a psy-
choeducational component on late-life depression with a 
focus on radical acceptance (e.g., accepting physical de-
clines that cannot be changed); the emotion regulation 
module focused on behavioral activation, which in DBT 
terms is opposite to emotion action; the distress tolerance 
module had a focus on tolerating physical pain; and the 
interpersonal effectiveness module focused on decreasing 
dependency, saying no, and effectively asking for assis-
tance when needed. All skill modules were taught twice 
within the 28 weeks of treatment. 

Thirty-four individuals (85% female) over the age of 
60 who met criteria for unipolar depression served as par-
ticipants (Lynch et al., 2003). Participants were randomly 

assigned to a medication-only condition or to a DBT plus 
medication condition. All participants were on an antide-
pressant prescribed by a physician; the majority of partici-
pants received a selective serotonin reuptake inhibitor. Fol-
lowing treatment, both groups showed significant decreases 
in interviewer-assessed depression, but only the DBT group 
showed a significant decrease in depression on self-report 
measures. At treatment completion, 71% of the DBT par-
ticipants were in remission, compared to 47% of the medi-
cation-only participants. Six months following treatment, 
significantly more DBT participants (75%) were in remis-
sion as compared to medication-only participants (31%). 
Furthermore, post-treatment, only DBT participants showed 
significant increases in active coping and decreases in de-
pendency and sociotropy. Taken together, the data from this 
study indicate that a modified DBT program may be a bene-
ficial extension to medication treatment for the depressed 
elderly.               

This study’s findings, that DBT and medication de-
creased depression to a greater extent than medication 
alone, is at odds with findings regarding DBT for BPD cli-
ents, where DBT typically decreases depression, but not to 
a greater degree than the comparison treatment (e.g., Line-
han et al., 1991). Perhaps one year of treatment for person-
ality disordered clients moves them through stage one (i.e., 
decreases behavioral dysregulation) and stage two (i.e., 
decreases “silent suffering” such as PTSD), but does not 
always entail reaching stages three and four (i.e., engender-
ing normal emotional experiencing, and greater spiritual 
advancement, respectively). It is possible that Lynch et al.’s 
(2003) findings of a group difference in depression might 
be accounted for by the fact that the depressed elderly cli-
ents possess a higher level of socioemotional functioning 
than BPD clients. In other words, perhaps DBT for clients 
without such extreme difficulties may move quickly 
through stages one and two, leaving more time for stage 
three in which depression is addressed.  

 
Multi-disordered Clients 

 
In addition to its application to eating disorders and 

geriatric depression, DBT has been used in treating multi-
disordered clients. Spoont, Sayer, Thuras, Erbes, and 
Winston (2003), in a largely descriptive article, discuss the 
application of DBT to a Veterans Affair (VA) medical cen-
ter. The authors note that there are two populations within a 
VA center that are not adequately served: women and 
treatment-resistant men. Women, many of whom have been 
sexually victimized while in the military (Coyle, Wolan, & 
Van Horn, 1996), were traditionally sent to group counsel-
ing with predominantly male group members (Spoont et al., 
2003). Although significant effort is put into treating com-
bat-related PTSD, there remains a group of treatment-
resistant veterans who are chronically ill. DBT was thought 
to be the treatment of choice, as these treatment resistant 
veterans shared characteristics with BPD individuals. These 
common characteristics included excessive hospitalization 



AMSTADTER AND SQUEGLIA  
 

22 

history, substance abuse, impulsiveness, mood volatility, 
and interpersonal turbulence (Rosenheck & Fontana, 1999).  
A DBT program was implemented to treat these two popu-
lations. Modifications to Linehan’s (1993a; 1993b) protocol 
were made, including holding phone consultations only 
during business hours, providing a skills tutor for cogni-
tively disadvantaged clients, creating a “step-down” group 
for graduated clients needing more services, and changing 
the length of skill group training sessions to 90 minutes 
over a period of 3, rather than 6, consecutive months. In an 
informal outcome survey, most clients and therapists re-
ported that DBT was helpful (i.e., they derived at least 
some overall benefit from the treatment). No gender differ-
ences in reaction to the treatment were found. 

 
Integration of DBT Techniques into  
Existing Treatments 
 

DBT was created to treat the multifaceted symptoms 
from which BPD clients suffer; as a result, in addition to its 
overall effectiveness as a treatment package, DBT has spe-
cific components that can be applied to existing treatments. 
As BPD clients posed such a clinical challenge, Linehan’s 
experience treating them has afforded a number of tech-
niques to ensure client participation and retention (1993a). 
A number of clinical researchers and therapists have written 
about implementing aspects of DBT (i.e. modifying action 
tendencies) into existing evidence-based treatments (e.g., 
Barlow, Allen, & Choate, 2004). Alternatively, many have 
suggested broadening the scope of DBT to cover multiple 
impulse control disorders, including, but not limited to, 
substance abuse and binge eating disorders (van den Bosch, 
Verheul, Schippers, & van den Brink, 2002). 

Exposure treatment for Posttraumatic Stress Disorder 
(PTSD) will be used to demonstrate the supplementation of 
DBT components to facilitate treatment. Exposure therapy 
is an empirically supported treatment modality for PTSD 
sufferers (e.g., Foa & Kozak, 1986). Despite the support for 
this treatment, a number of issues exist that can pose barri-
ers to successful outcomes and may lead to an arduous 
process for both therapist and client. First, at the beginning 
of treatment, clients tend to display an increase rather than a 
decrease in symptoms (Resick & Schnicke, 1992). DBT 
strategies taught in the distress tolerance and emotion regu-
lation modules could benefit clients dealing with increased 
symptomotology during the beginning stages of treatment. 
PTSD clients could be taught how to tolerate distress that 
they cannot change, and how to regulate their emotions 
surrounding aspects in which they do have a choice.  Sec-
ond, perhaps also related to symptom exacerbation prior to 
symptom improvement, client retention is an issue. DBT 
has specific techniques, based in social psychological prin-
ciples of persuasion, to obtain and maintain commitment. 
Such strategies may improve retention for exposure therapy 
clients. Third, emotional experiencing, in the form of acti-
vation of the fear structure, is a necessary ingredient for 

exposure treatment to be effective (Foa & Kozak, 1986); 
PTSD clients may have dissociative tendencies (Resick & 
Schnicke, 1992) circumventing emotional experiencing. 
Teaching clients mindfulness skills such as observation and 
participation in emotional experiences could enhance emo-
tional experiencing and thereby possibly make exposure 
more effective. Fourth, there is recent evidence that numb-
ing symptoms in PTSD may be a result of emotional avoid-
ance, suggesting faulty emotion regulation (Roemer, Litz, 
Orsillo, & Wagner, 2001). Teaching clients the emotion 
regulation module of DBT may afford them with alterna-
tive, and more adaptive, skills to use in this arena.  

There are other principles of DBT not necessarily re-
lated to exposure that may be advantageous for those with 
PTSD; one such issue involves treatment timing (Becker & 
Zayfert, 2001). Stage one of DBT focuses on behavioral 
regulation. If a client with PTSD has a chaotic life and is 
dysregulated, going forward with exposure techniques may 
not be the best option, as they may elicit more distress. 
Such clients may benefit from sessions addressing dysregu-
lation prior to the commencement of exposure. Another 
concept from DBT that can be applied to PTSD is that of 
radical acceptance (Becker & Zayfert, 2001). Working with 
PTSD clients through a radical acceptance framework helps 
patients recognize that while the trauma cannot be undone, 
the emotional reactions to the trauma can be modulated. 
Additionally, DBT has an emphasis on treating self-
invalidation, a behavior often present in PTSD clients. 
From a DBT framework, educating the client on ways in 
which he or she invalidates his or her experience would be 
a useful part of treatment. It should be noted that these con-
cepts and techniques are not distinct to DBT, as DBT is a 
theoretically grounded approach that has common factors 
with other treatments as well.  

In addition to its relevance to PTSD, DBT has been ap-
plied to substance abuse treatments. In a recent study of 
BPD women who are also substance dependent, DBT was 
associated with significantly less substance use throughout 
the course of treatment, as well as at follow-up (Linehan et 
al., 1999). However, another study found that though DBT 
could be effectively applied with borderline patients who 
had co-occurring substance abuse problems, this treatment 
was not more successful compared to standard cognitive 
behavioral therapy in reducing the substance use (van den 
Bosch et al., 2002). This discrepancy may arise from the 
fact that the Linehan group focused treatment primarily on 
the substance abuse, while the van den Bosch group fo-
cused primarily on BPD. From their results, van den Bosch 
and colleagues (2002) conclude that the current version of 
DBT does not generalize to behavioral domains not specifi-
cally targeted. However, they do support the idea that de-
veloping a multitargeted DBT program would broaden the 
focus of treatment to include a wide range of impulse con-
trol disorders, such as binge eating and substance abuse.  
 

 



APPLICATION OF DBT BEYOND BORDERLINE PERSONALITY DISORDER 
 

23 

Conclusion 
 

The DBT literature as a whole is encouraging, espe-
cially given its relatively recent development. DBT has 
only existed for about 13 years, and within that time, six 
RCTs with BPD clients have been conducted, producing 
promising results of the treatment’s efficacy (Koons et al., 
2001; Linehan et al., 1991; Linehan et al., 1999; Linehan et 
al., 2002; Turner, 2000; Verheul et al., 2003). All six RCTs 
with BPD clients have demonstrated that DBT is more ef-
fective than the comparison treatment on a variety of out-
come measures, such as decreasing parasuicidal behavior, 
inpatient days, hopelessness, and even substance use; these 
positive treatment effects were maintained at follow-up 
assessments (e.g., Linehan, Heard, & Armstrong, 1994). 
Further, numerous uncontrolled clinical trials have been 
published, and countless case studies continue to emerge 
(e.g., Katz & Cox, 2002). 

DBT has been successfully applied to disorders other 
than BPD. In regards to eating disorders, theoretical (e.g., 
McCabe & Marcus, 2002; Wiser & Telch, 1999) and em-
pirical (e.g., Palmer et al., 2003; Telch et al, 2000; Telch et 
al., 2001) support exists to suggest DBT may be an advan-
tageous treatment. BED is the only eating disorder with 
both uncontrolled and controlled clinical trials for DBT. In 
the RCT for BED, a treatment comparison group was not 
included, and should be in subsequent research. Systematic 
DBT studies should be conducted with both anorexia ner-
vosa and bulimia nervosa to determine the usefulness of 
this treatment for these disorders. In addition to eating dis-
orders, DBT has also been shown to be more effective in 
treating late-life depression than medication alone (Lynch 
et al., 2003). Furthermore, DBT has been adapted to VA 
settings in which clients present with a number of BPD 
features (Spoont et al., 2003). 

In sum, the current state of the literature suggests that 
DBT is an empirically supported treatment for BPD. Addi-
tionally, there is limited evidence to suggest that DBT is an 
effective treatment for BED and geriatric depression. To 
date, DBT has only been studied as a treatment package. 
Therefore, though there are theoretical reasons to supple-
ment existing therapies with DBT components, the effects 
of augmentation still require empirical validation. The ap-
parent applicability of DBT for disorders outside of BPD 
has surpassed the empirical evidence to support the efficacy 
of such approaches, underscoring the need for more re-
search.  
 

References 
 
American Psychiatric Association (1994).  Diagnostic and 

statistical manual of mental  disorders, fourth edition 
(DSM IV).  Washington:  APA. 

Barlow, D. H., Allen, L. B. & Choate, M. L. (2004). To-
ward a unified treatment for emotional disorders. Behav-
ior Therapy, 35, 205-230. 

Becker, C. B., & Zayfert, C. (2001). Integrating DBT-
Based techniques and concepts to facilitate exposure 
treatment of PTSD.  Cognitive and Behavioral Practice, 
8, 107-122. 

Coyle, B., Wolan, D., & Van Horn, A. (1996). The preva-
lence of physical and sexual abuse in women veterans 
seeking care in a Veterans Affairs medical center.  Mili-
tary Medicine, 161, 588-593. 

Crits-Christoph, P., Frank, E., Chambless, D. L., Brody, C., 
& Karp, J. F. (1995). Training in empirically validated 
treatments: What are clinical psychology students learn-
ing? Professional Psychology:  Research and Practice, 
26, 413-522. 

Davidson, R. J. (1998). Affective style and affective disor-
ders:  Perspectives from affective neuroscience. Cogni-
tion and Emotion, 1998, 307-330. 

Dimeff, L. A., & Linehan. M. M. (2001). Dialectical behav-
ior therapy in a nutshell. The California Psychologist, 34, 
10-13. 

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of 
fear:  Exposure to corrective information. Psychological 
Bulletin, 99, 20-35. 

Heatherton, T. F. & Baumeister, R. F. (1991). Binge eating 
as escape from self-awareness. Psychological Bulletin, 
110, 86-108. 

Katz, L. Y. & Cox, B. J. (2002). Dialectical behavior ther-
apy for suicidal adolescent inpatients: a case study. Clini-
cal Case Studies, 1, 81-92. 

Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., 
Gonzalez, A. M., Morse, G. K., Bishop, G. K., 
Butterfield, M. I., & Bastian, L. A. (2001). Efficacy of 
dialectical behavior therapy in women veterans with bor-
derline personality disorder.  Behavior Therapy, 32, 371-
390. 

Linehan, M. M. (1993a). Cognitive behavioral treatment of 
borderline personality disorder. New York: Guilford 
Press. 

Linehan, M. M. (1993b). Skills training manual for treating 
borderline personality disorder. New York: Guilford 
Press. 

Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., 
& Heard, H. L. (1991). Cognitive-behavioral treatment of 
chronically parasuicidal patients. Archives of General 
Psychiatry, 48, 1060-1064. 

Linehan, M. M., Cochran, B. N., & Keltner, C. A. (2001).  
Dialectical behavior therapy for borderline personality 
disorder. In D. H. Barlow (Ed.), Clinical handbook of 
psychological disorders (3rd ed., pp. 470-522). New 
York:  Guilford. 

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. 
Z., Gallop, R. J., Heard, H. L., Korslund, K. E., Tutek, D. 
A., Reynolds, S. K., & Lindenboim, N. (2006). Two-year 
randomized controlled trial and follow-up of dialectical 
behavior therapy vs. therapy by experts for suicidal be-
haviors and borderline personality disorder. Archives of 
General Psychiatry, 63, 757-766. 



AMSTADTER AND SQUEGLIA  
 

24 

Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, 
K. A., Shaw Welch, S., Heagerty, P., & Kivlanhan, D. R. 
(2002). Dialectical behavior therapy versus comprehen-
sive validation plus 12-step for the treatment of opioid 
dependent women meeting criteria for borderline person-
ality disorder.  Drug and Alcohol Dependence, 67, 13-26. 

Linehan, M. M., Heard, H. H., & Armstrong, H. E. (1993).  
Naturalistic follow up of a behavioral treatment for 
chronically parasuicidal borderline patients. Archives of 
General Psychiatry, 50, 971-974. 

Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., 
Kanter, J. & Comtois, K. A. (1999). Dialectical behavior 
therapy for patients with borderline personality disorder 
and drug dependence. American Journal on Addictions, 
8, 279-292. 

Lynch, T. R. (2000). Treatment of elderly depression with 
personality disorder comorbidity using dialectical behav-
ior therapy. Cognitive Behavioral Practice, 7, 468-477. 

Lynch, T. R., Morse, J. Q., Mendelson, T. & Robins, C. J. 
(2003). Dialectical behavior therapy for depressed older 
adults. American Journal of Geriatric Psychiatry, 11, 33-
45. 

McCabe, E. B., & Marcus, M. D. (2002). Questions and 
answers. Eating Disorders, 10, 335-337. 

McIntosh, J. L. (1992). Epidemiology of suicide in the eld-
erly. Suicide Life Threat Behavior, 22, 15-35. 

Palmer, R. L., Birchall, H., Damani, S., Gatward, N., 
McGrain, L., & Parker, L. (2003). A dialectical behavior 
therapy program for people with an eating disorder and 
borderline personality disorder – description and out-
come.  International Journal of Eating Disorders, 33, 
281-286. 

Resick, P. A., & Schnicke, M. K. (1992). Cognitive proc-
essing therapy for sexual assault victims. Journal of Con-
sulting and Clinical Psychology, 60, 748-756. 

Richards, J. M., & Gross, J. J. (2000). Emotion regulation 
and memory: The cognitive costs of keeping one’s cool.  
Journal of Personality and Social Psychology, 79, 410-
424. 

Robins, C. J., & Chapman, A. L. (2004). Dialectical behav-
ior therapy: Current status, recent developments, and fu-
ture directions. Journal of Personality Disorders, 18, 73-
89. 

Roemer, L., Litz, B. T., Orsillo, S. M., & Wagner, A. W. 
(2001). A preliminary investigation of the role of strate-
gic withholding of emotions in PTSD. Journal of Trau-
matic Stress, 14, 149-156. 

Rosenheck, R., & Fontana, A. (1999). Changing patterns of 
care for war-related posttraumatic stress disorder at De-
partment of Veterans Affairs medical centers:  The use of 

performance data to guide program development. Mili-
tary Medicine, 164, 795-802. 

Safer, D. L., Telch, C. F., & Agras, S. W. (2001). Dialecti-
cal behavior therapy adapted for bulimia: A case report. 
International Journal of Eating Disorders, 30, 101-106. 

Scheel, K. R. (2000). The empirical basis of dialectical be-
havior therapy: Summary, critique, and implications.  
Clinical Psychology Science and Practice, 7 68-86. 

Spoont, M. R., Sayer, N. A., Thuras, P., Erbes, C., & 
Winston, E. (2003). Adaptation of dialectical behavior 
therapy by a VA medical center. Psychiatric Services, 54, 
627-629. 

Telch, C. F., & Argas, W. S. (1996). Do emotional states 
influence binge eating in the obese? International Jour-
nal of Eating Disorders, 20, 271-279. 

Telch, C. F., Argas, W. S., & Linehan, M. M. (2000). 
Group dialectical behavior therapy for binge eating dis-
order: A preliminary uncontrolled trial. Behavior Ther-
apy, 31, 569-582. 

Telch, C. F., Argas, W. S., & Linehan, M. M. (2001). Dia-
lectical behavior therapy for binge eating disorder. Jour-
nal of Consulting and Clinical Psychology, 69, 1061-
1065. 

Thompson, L. W., Gallagher, D., Breckenridge, J. S. 
(1987).  Comparative effectiveness of psychotherapies 
for depressed elders. Journal of Consulting and Clinical 
Psychology, 55, 385-390. 

Turner, R. M. (2000). Naturalistic evaluation of dialectical 
behavioral therapy-oriented treatment for borderline per-
sonality disorder. Cognitive Behavioral Practice, 7, 413-
419. 

van den Bosch, L. M. C., Verheul, R., Schippers, G. M., & 
van den Brink, W. (2002). Dialectical behavior therapy of 
borderline patients with and without substance use prob-
lems: Implementation and long-term effects. Addictive 
Behaviors, 27, 911-923. 

Verheul, R., van den Bosch, L. M., Keoter, M. W., De 
Ridder, M. A., Stijnen, T., & van den Brink, W. (2003).  
Dialectical behaviour therapy for women with borderline 
personality disorder. The British Journal of Psychiatry, 
182, 135-140. 

Westen, D. (2000). The efficacy of dialectical behavior 
therapy for borderline personality disorder. Clinical Psy-
chology:  Science and Practice, 7, 92-102. 

Wilfley, D. E., & Cohen, C. F. (1997). Psychological treat-
ment of bulimia nervosa and binge eating disorder. Psy-
chopharmacology Bulletin, 33, 437-454. 

Wiser, S. & Telch, S. (1999). Dialectical behavior therapy 
for binge-eating disorder. In Session:  Psychotherapy in 
Practice, 55, 755-768. 

 

 


