Dialectical behaviour therapy

Introduction

What is borderline personality disorder? 
The importance of emotion regulation

What is dialectical behaviour therapy (DBT)?
The importance of validation
Dialectics

Who benefits and how effective is the treatment?

What form does the treatment take?
Individual therapy
Group sessions – skills training
Crisis telephone coaching
Therapists’ consultation groups

Can you learn DBT techniques by yourself?

Finding a DBT therapist

DBT in action

Useful organisations

Further reading
Mind factsheets
Mind booklets
Other publications

References

Introduction

This factsheet is for people interested in dialectical behaviour therapy (DBT), a psychological therapy for people with borderline personality disorder (BPD), self-harming behaviour or suicidal ideas.

The factsheet describes how this treatment was developed, how it works and how effective it is. It should be noted that all theories for BPD presented in this factsheet represent the assumptions and explanations of DBT; other treatments may be based on different theories.

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What is borderline personality disorder?

People with BPD experience intense negative emotions (anger, shame, guilt, sadness, fear) and have difficulties in controlling them, usually engaging in impulsive behaviours to control their emotions; for example self-harm, misuse of alcohol or drugs, binge eating, purging, etc. They also often have unstable relationships, sudden mood swings, feelings of emptiness and chaotic lifestyles. Suicide attempts and/or self-harming are common, and the rate of completed suicide is particularly high in this group. DBT was specifically designed to address the problems that people with BPD experience.

Mind has produced booklets and factsheets relating to BPD, suicide and self-harm (see ‘Further reading’).

The importance of emotion regulation

DBT sees BPD as primarily a set of deeply entrenched problems around regulating emotions. More specifically, according to the biosocial model that DBT follows, people with BPD may be more emotionally sensitive than others, a vulnerability that may be biological. As a result, they experience emotions more intensely than most people, and have more difficulty in letting go of intense emotions. At the same time, they may have grown up in an ‘invalidating environment’ – one in which an individual’s emotional responses to events are dismissed as incorrect, inappropriate or silly. For example, if a child gets upset because she has lost a toy, the parents might tell her that she ‘can’t possibly be upset for just losing a toy’, and to ‘stop over-reacting’. In such environments the individual is expected to be ‘perfect’ and not to display any negative emotions. Because in this environment a ‘normal’ display of emotions is not attended to or validated, individuals may end up expressing their emotions more intensely (i.e. screaming and crying, instead of just saying that they are feeling sad) in order to get a response.

When people are punished or ignored for displaying emotional reactions to negative experiences, and are only taken notice of when their negative emotional displays are extreme, they learn to switch between emotional inhibition (i.e. not showing any emotions at all) and showing extreme and intense emotions.

The biological predisposition of people with BPD, combined with their experiences in invalidating environments, contributes to the development of ongoing difficulties in coping with emotions. People with BPD have not learned how to label, accept and regulate intense emotions, how to tolerate distress, or when to trust their own feelings and interpretations in a situation. As adults, they adopt the features of the invalidating environments they grew up in – they do not trust their own emotions, and they feel that they shouldn’t be feeling the way they do, and that they should be able to deal with life’s problems. They therefore set unrealistic goals and feel frustrated, ashamed and angry at themselves when they fail to reach these goals.

In order to overcome these problems, people with BPD need to learn how to regulate their emotions. The first step towards emotion regulation is to learn to experience, label and accept emotions. This is likely to sound paradoxical and extremely difficult to people with BPD, as they usually try to avoid their emotions and distance themselves from them. However, the only way for people to be able to control their emotions is through acknowledging that they exist. Once they have learned to experience and accept their emotions, they then have to learn ways of reducing the intensity of their emotions and letting go of negative emotions more quickly. In DBT, people are taught specific skills regarding how to do this, explained below.

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What is dialectical behaviour therapy?

DBT was developed from cognitive behaviour therapy (CBT) and adapted to suit the specific needs of people with BPD (see Mind’s booklet Making sense of cognitive behaviour therapy).

The main aim of CBT is to change behaviour, which is done by applying techniques with a focus on problem-solving, including skills training, homework, diary cards and behavioural analysis. Marsha Linehan, who developed DBT, initially used CBT strategies to treat people with BPD. However, some people with such intense emotions felt rejected and invalidated by the strong focus on change, and felt that their suffering and perceived loss of control over their lives were underestimated. As a result, they became increasingly frustrated or dropped out of treatment. This does not mean that the CBT techniques were not effective, but rather that, when applied on their own, they sometimes caused distress among emotionally sensitive clients.

The importance of validation

The above realisation led Linehan and her team to add ‘acceptance strategies’ into the treatment. This aims to balance acceptance with change and therefore meet the needs of people with these emotional problems. Acceptance techniques focus on validation. With these techniques, DBT therapists can point out to clients that their behaviour (e.g. self-harming, drinking, etc.), even though not in their best interest in the long term, makes sense, as it is often the only way they have learned to deal with intense emotions; furthermore, in the past such behaviour might have led to positive consequences in the short term.

However, this does not mean that a therapist cannot challenge a client to change their behaviour and learn more effective ways of dealing with their distress. For example, a therapist might understand that a client misuses drugs to overcome intense feelings of sadness, and that when this client misuses drugs, he or she self-harms. In this situation, misusing drugs makes sense, as it might be the only way to deal with sadness that the client has learned. It might also be that his or her friends deal with sadness in the same way. Similarly, it makes the client feel less sad in the short term. Thus, a therapist can validate that the drug misuse makes sense, based on the client’s history. At the same time, however, the therapist does not have to agree that misusing drugs is the best solution to the client’s problems, and can point to more effective ways to deal with sadness.

Dialectics

This attempt to balance acceptance and change in therapy forms the main ‘dialectic’ in DBT, and so became part of its name. 'Dialectics' is a philosophical school of thought which, in short, is about balancing and bringing together contradictory ideas and being open to interpretations different to one’s own. Such techniques are particularly relevant to people with BPD, as they tend to have rigid ‘black and white’ thinking patterns. For example, they may believe that their friends can only be either ‘perfect’ or ‘useless’, or that ‘the only way’ they can tolerate distress is by self-harming. A DBT therapist can stay dialectical by validating but also challenging a client’s behaviour. This means that the therapist conveys his or her understanding that the client’s behaviour makes some sense in the current circumstances, and yet still asksthe client to change. Changing will involve trying to replace behaviours that have been identified as both harmful to the client and ineffective in meeting their long-term goals with less harmful, more effective behaviours.

Dialectical strategies are also used in DBT to help clients get ‘unstuck’ from rigid ways of interpreting situations and experiencing life, and to motivate them to change. The idea is to be able to acknowledge different interpretations and perspectives of the world and to synthesise them in an effective way.

In addition to the focus on acceptance as well as change and the use of dialectical processes, DBT differs from CBT in other respects. DBT also focuses on behaviours that interfere with therapy, and the importance of the therapeutic relationship. For emotionally sensitive and suicidal individuals, relationships are often a key factor in keeping them alive; the therapeutic relationship is therefore particularly valued and is used as a tool to motivate people to change.

DBT differs from some other forms of psychotherapy, e.g. psychodynamic psychotherapy, in that it focuses on specific behaviours and aims to change dysfunctional behaviours that have been identified as being harmful to the individual. By contrast, the main goal of psychodynamic psychotherapy is for people to gain a better understanding of themselves, often by linking their present experience with early childhood experiences. For example, someone might realise in therapy that they feel insecure in relationships as an adult because their mother had neglected them when they were a child. It is assumed that this insight will then lead to the solution of relevant problems. In DBT, however, treatment does not focus on insight; changing people’s behaviour in the present is the key target.

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Who benefits and how effective is the treatment?

As explained, DBT is a treatment designed for people with BPD and self-harming behaviour. It has been evaluated and found effective for this group in seven clinical trials that compared DBT with other treatments.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10][11] These trials were conducted by four independent research teams in different countries, making the positive results more robust. More specifically, DBT led to reductions in various problems related to BPD, such as self-harming behaviours, suicide attempts, depression, bulimic behaviour and feelings of hopelessness.

In its recent draft guidelines on the treatment and management of BPD, the National Institute of Health and Clinical Excellence (NICE) proposed DBT as the treatment of choice for women with BPD for whom reducing recurrent self-harm is a priority.[12]

DBT has also been applied to different groups with different problems, such as substance abuse, depression and eating disorders. Several trials have tested the efficacy of the treatment in these groups, with promising results.[13] [14] [15] [16] Nevertheless, more research is needed to establish the efficacy of DBT for problems other than BPD.

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What form does the treatment take?

Standard DBT has four elements:

• weekly individual therapy sessions
• weekly group sessions
• crisis telephone coaching with a one-to-one therapist
• a therapists’ consultation group.

DBT teams may not necessarily offer all four elements, and teams may have slightly different structures and schedules. Each of the elements is described below.

Individual therapy

Stages and targets
Individual therapy involves one-to-one weekly psychotherapy sessions with a DBT therapist. The treatment is organised into four stages, with distinct targets for each stage. This provides structured and meaningful goals for therapy and ensures that it is not just addressing the crisis of the moment at each session.

The overall goal of stage 1 is for clients to move from not being able to control their behaviour to gaining control over their actions. This stage has three main treatment targets:

• to keep the client alive and safe
• to reduce behaviours that interfere with therapy
• to improve quality of life.

The first target focuses on reducing and eliminating suicidal and self-harming behaviours. The second target addresses issues that might come in the way of clients getting treatment (e.g. missing sessions, issues between clients and therapists, etc.) The third addresses anything that interferes with the client’s quality of life (e.g. other mental health problems, such as depression or hearing voices, or employment or relationship problems, etc.) DBT programmes usually offer clients stage 1 treatment for a year, though this may vary across different services.

In stage 2 of treatment it is assumed that clients can control their behaviour, but are still suffering emotionally. Thus, the overall goal in this stage is to move clients from quiet desperation to being able to tolerate negative emotions and experience positive emotions fully. Post-traumatic stress issues related to possible childhood traumas are addressed at this stage.

Stage 3 focuses on problems with everyday living, with the overall goal of establishing an ordinary life with happy and unhappy moments, as most people experience.

Stage 4 addresses issues of further spiritual development for those clients who have established an ordinary life and are struggling with existential issues.

Clients do not have to complete all stages. In fact, the first stage is the one most commonly offered, and clinical trials have evaluated only this stage of DBT.

How does individual DBT work?
Clients have weekly sessions with their individual therapist, which last 50–60 minutes. At the beginning of treatment the client and therapist set treatment goals, which include the defined DBT goals described above, as well as individually defined changes that the client wants to make in his or her life. The sessions focus on identifying and working with agreed treatment goals and solving problem behaviours, such as self-harming, alcohol and substance misuse, not attending sessions, and depression.

Clients are asked to complete diary cards, which they use to monitor their emotions and actions, and to bring these cards to therapy sessions. The client and therapist use this information to agree on what they will work on in their sessions.

In DBT clients do not talk about their problems in general terms, but target and analyse specific behaviours. For example, if the targeted problem behaviour is self-harming, a specific incident of self-harming that occurred during the previous week will be targeted and analysed in detail, and solutions for the problem will be sought. This is called ‘behavioural and solution analysis’, and involves the client and therapist understanding what led to that incident, including factors in the environment that might make the client vulnerable, and the consequences of the behaviour. Once the client and therapist understand what led to the incident, they work together to develop realistic solutions that could prevent it from happening again. For example, if alcohol makes a client more vulnerable to self-harming, then not drinking could be a possible solution.

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Group sessions – skills training

These sessions are not group psychotherapy sessions; they are teaching sessions in a group format. DBT therapists teach a group of clients skills that can help them deal with life situations more effectively. Four main modules are taught:

• distress tolerance – how to deal with crises in a more effective way, without having to resort to self-harming or other problem behaviours
• interpersonal effectiveness– how to ask for things and to say no to other people, while maintaining self-respect and relationships that are important
• emotion regulation– skills clients can use to understand, be more aware and have more control over their intense emotions
• mindfulness – a set of skills that help people to focus their attention and live in the present, rather than being distracted by unpleasant memories about the past or worries about the future.

The distress tolerance, interpersonal effectiveness and emotion regulation modules are repeated twice during the year. The mindfulness module (which lasts only two weeks) is repeated at the end of each of the other modules – so six times in total. The mindfulness module is repeated more often because this skill is fundamental to the treatment, but it takes a lot of practice to master.

There are usually two therapists in a group and the sessions last approximately two hours. Clients are given homework or tasks each week on the skills that have been covered during that particular skills training session. The purpose of the homework is to help the clients practise making use of the skills in real-life situations. By completing the homework weekly it is hoped that using the skills gradually becomes second nature to the client and difficult situations can therefore be dealt with more effectively.

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Crisis telephone coaching

Clients can telephone their individual therapist outside of therapy sessions, when they need help to deal with a crisis situation (such as feeling suicidal, or the urge to self-harm), when they are trying to use their skills but want some advice on how to do it, or when they want to repair their relationship with the therapist. In DBT, crisis coaching is used to help clients learn how to use their skills effectively in real-life situations.

Therapists’ consultation groups

DBT therapists work in teams rather than independently because working with people with suicidal ideas and self-harming behaviours can be stressful. Therapists therefore have a weekly session in which they discuss with each other issues that come up in the treatment of their clients. These sessions are used as a way for therapists to express their feelings and concerns about therapy or to ask for advice and different ideas that may help them to treat their clients more effectively. Thus DBT clients are effectively treated by a team of therapists, rather than by individual therapists alone.

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Can you learn DBT techniques by yourself?

People starting DBT often feel overwhelmed by intense emotions, and they are likely to find it hard or even impossible to attempt to solve their problems on their own. Clients may find that they understand the skills, but find them hard to apply in their daily lives.

The structure of the DBT individual and group teaching sessions are considered more appropriate than trying to learn the techniques by oneself. Discussions with therapists can help to highlight potential situations where DBT skills can be practised, and successes are acknowledged and congratulated. Therapy sessions also help clients to stay motivated if they have a difficult patch and feel like giving up. Also, being with other clients for the skills training can be very supportive, as people realise that they are not alone with their problems – there are others who understand what they are experiencing and they can identify with.

It is relatively easy to find DBT ‘lessons’ online and to download diary cards, exercises and behavioural analysis sheets. The DBT Self Help website (see ‘Useful organisations’) is a good source of information and resources. Clients often feel that the self-help materials are suitable for refreshing or supplementing the DBT training, but that they cannot take the place of attending therapy sessions.

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Finding a DBT therapist

DBT may be available on the National Health Service (NHS) in some areas, and it is also available in the private sector, though there is no register of therapists at the time of writing. The availability of DBT is increasing; 175 DBT programmes have been initiated in the UK since 1995. These programmes were built up in both the NHS and privately for various client groups (those with personality disorders, inpatients, outpatients, people in maximum-security hospitals or prisons, children and adolescents, those with drug or alcohol problems, eating disorders, complex needs or learning disabilities). It is not known how many of these 175 programmes are still active, or how many deliver the complete DBT model described above. Your local GP or Community Mental Health Team should be able to provide information about local services.

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DBT in action

Angela completed a DBT programme when she was 27. Self-harming had been a significant part of Angela’s life between the ages of 15 and 26. During this time she had felt depressed, frustrated and hopeless, but was desperate to maintain an image that would convince everyone around her that she was fine and ‘normal’. This façade continued until one day, when the pressure of keeping it up for so long finally became too much, she told her doctor how she really felt.

The next few months were very difficult for her. She was secretly going for assessments with various mental health professionals and trying to accept the fact that she was about to embark on a long-term treatment in the form of DBT. In the beginning, she believed that she did not really have a mental health problem – that she just needed to ‘pull herself together’, ‘get a grip’ and ‘stop wasting everyone’s time’.

Angela’s problems did not go away instantly when she started DBT. For months she felt that she understood the skills that were being taught but she could not actually apply them to herself. As a result she felt ashamed and awkward that she had to do positive things for herself to decrease any kind of emotional distress. She was much more accustomed to using a razor to self-injure in such situations, and she was not sure that she liked the idea of that being taken away from her.

Over time, however, Angela started to get better at using some of the skills she’d learnt, and cut down on negative judgments about herself for having to use those skills. There were many times, though, when she felt that carrying on with DBT was a waste of time because she did not feel that she was genuinely changing.

After finishing the DBT course, she recognised that some aspects of DBT had enabled her to gradually manage her intense emotions in a different way. The repetition of the modules in the skills training sessions meant that even though she was fighting it, she was constantly being reminded of alternative ways to deal with difficult situations. Also the weekly individual therapy sessions suggested skills to try in direct relation to problems that had occurred during the week. Had the programme been any shorter than a year, she feels that she would have remained ‘stubborn’ and resorted to her old ways as soon as it was over.

Angela also found that things became much clearer when she completed and discussed behavioural analyses with her individual therapist. Over time she began to see a pattern in situations that could provoke her to consider self-harm and so became able to make some changes.

Angela had been keeping her family ‘safe from her secret’ for 11 years, and she was determined not to ‘hurt them with it’. But by building up slowly, her therapist helped her to realise that she could face things head on, and that problems or worries became much less problematic once dealt with. Angela did not find it easy, and she had moments of thinking she would give up DBT because she was being asked for too much. But after a year and a half, she told her family about her self-harming, invited them to a ‘family group’ to find out about DBT skills, and invited her mother to a session with her individual therapist where Angela told her everything about traumatic experiences she had suffered in the past.

Looking back, Angela felt that an enormous burden had been taken off her shoulders and she was able to accept her past, and become more concerned with enjoying the moment and looking to the future. She also felt more confident and able to manage social situations without feeling ashamed or inadequate.

Although Angela found some success with DBT, not everyone benefits from this therapy. Some people either drop out of treatment or find it ineffective. These clients often say that DBT is too hard and requires too much effort, or that they find it too technical to use diary cards and the terms and definitions used by therapists, sometimes feeling that the professionals do not understand or accept them as they are, since they focus so much on changing their self-harming behaviours.

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Useful organisations

Behavioral Tech
website: http://behavioraltech.org 
This is the ‘official’ DBT website, created and updated by Marsha Linehan and her team. It offers information on BPD and DBT.

Borderline UK
PO Box 12, Haltwhistle, Northumberland NE49 0WY
email: info@borderlineuk.co.uk website: www.borderlineuk.co.uk 
A national UK user-led website providing information about BPD.

BPD World
22 Revenue Chambers,St Peters Street,Huddersfield HD1 1DL
tel: 0870 005 3273
email: mail@bpdworld.org web: www.bpdworld.org 
Provides information, advice and support to those affected by personality disorder. Also provides a directory of therapists.

DBT Self Help
email: lisa@dbtselfhelp.comwebsite: www.dbtselfhelp.com 
A US user-led website giving information on DBT and relevant material (handouts, diary cards, skills training etc.) The aim of the website is to provide support to people being treated with DBT.

FirstSigns
email: info@firstsigns.org.uk (cannot accept messages from Hotmail/MSN)
website: www.firstsigns.org.uk 
A user-led website providing comprehensive information on self-injury and self-harm. The website includes discussion forums, a message board, leaflets and real-life training.

Mindinfoline
PO Box 277,Manchester, M60 3XN
tel: 0845 766 0163 email: info@mind.org.uk 
For information on a variety of mental health topics and both national and local services.

National Institute for Health and Clinical Excellence (NICE)
MidCity Place, 71 High Holborn,London WC1V 6NA
tel: 0845 003 7780 email: nice@nice.org.uk web: www.nice.org.uk 
The government body responsible for developing guidelines for treatment within the National Health Service. NICE has developed guidance on current treatments for mental health problems, including self-harm, depression and BPD.

National Personality Disorder Website
website: www.personalitydisorder.org.uk 
Offers information, resources and learning opportunities on personality disorders and their treatment, including self-management. Also supports development of the National Personality Disorder Programme. The website includes areas for carers, service providers and commissioners.

Rethink
89 Albert Embankment,London SE1 7TP
tel: 0845 456 0455 (information); advice line 020 7840 3188
email: info@rethink.org or advice@rethink.org website: www.rethink.org 
A charity working with people affected by severe mental illness, providing services, support and information.

Samaritans
Chris, PO Box 9090, Stirling, Falkirk FK8 2SA
helpline: 08457 90 90 90 textphone: 08457 90 91 92
email: jo@samaritans.orgweb: www.samaritans.org
Samaritans offers a 24-hour telephone helpline to provide emotional support for people who are experiencing distress or despair, including suicidal ideas. Support is also available by email, letter or face to face.

SANEline/SANEmail
helpline: 0845 767 8000 email: sanemail@sane.org.uk web: www.sane.org.uk 
SANEline and SANEmail offer emotional support and information to those experiencing mental health problems, their families and carers. The website provides information on mental health issues, including personality disorders.

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Further reading

Mind factsheets

• Mental health statistics 2: suicide 
• Suicide rates, risks and prevention strategies 

Mind booklets (available to purchase from Mind Publications on 0844 448 4448 or at publications@mind.org.uk or from the bookshop)

• About self-harm: a guide for young people 
• How to cope with suicidal feelings 
• How to help someone who is suicidal 
• Making sense of cognitive behaviour therapy 
• Understanding borderline personality disorder 
• Understanding personality disorders 
• Understanding self-harm 

Other publications

• Chapman AL, Gratz KL. (2007) The Borderline Personality Disorder Survival Guide. New Harbinger Publications, Oakland
• Dimeff LA, Koerner K. (2008) DBT in clinical practice: Applications across disorders and settings. The Guilford Press, New York and London
• Linehan M. (1993) Cognitive behavioural treatment of borderline personality disorder. The Guilford Press, New York and London
• Linehan M. (1993) Skills training manual for treating borderline personality disorder. The Guilford Press, New York and London
• Rothbaum B, Foa E, Hembree E. (2007) Reclaiming your life from a traumatic experience. Oxford University Press, Oxford
• Williams M, Teasdale J, Segal Z, Kabat-Zinn J. (2007) The mindful way through depression: freeing yourself from chronic unhappiness. The Guilford Press, New York and London

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References

[1] Linehan M, Armstrong H E, Suarez A, Allmon D, Heard HL. (1991) Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry 48: 1060–4.
[2] Linehan, M., Heard H L, Armstrong H E. (1993) Naturalistic follow-up of a behavioural treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry 50: 971–4.
[3] Linehan M, Tutek D A, Heard H L, Armstrong H E. (1994) Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry 151: 1771–6.
[4] Linehan M, Schmidt H, Dimeff L A, et al. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug dependence. American Journal on Addiction 8: 279–92.
[5] Linehan M, Dimeff L A, Reynolds S K, et al. (2002) Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence 67: 13–26.
[6] Linehan M, Comtois K A, Murray A M, et al. (2006) Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry 62: 1–10.
[7] Lynch T R, Trost W T, Salsman N, Linehan M. (2007) Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology 3: 181–205.
[8] Turner. R M. (2000). Naturalistic evaluation of dialectical behavior therapy for suicide attempts in borderline personality disorder patients. Cognitive and behavioral Practice 7: 450-462.
[9] 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 problems: implementation and long-term effects. Addictive Behaviors 27: 911–23.
[10] Van den Bosch L M C, Koeter M W J, Stijnen T, Verheul R, van den Brink W. (2005). Sustained efficacy of dialectical behavior therapy for borderline personality disorder. Behavioural Research and Therapy 43: 1231-41.
[11] Verheul R, van den Bosch LM, Koeter M W, De Ridder M A, Stijnen T, van den Brink W. (2003). Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. British Journal of Psychiatry 182: 135–40.
[12] National Institute for Health and Clinical Excellence. Borderline personality disorder: treatment and management. (2008) NICE guideline Draft for consultation (accessed 05/09/08)
[13] Linehan M, Schmidt H, Dimeff LA, et al. (1999). Dialectical behavior therapy for patients with borderline personality disorder and drug dependence. American Journal on Addiction 8: 279–92.
[14] Lynch T R, Morse J Q, Mendelson T, Robins C J. (2003) Dialectical behavior therapy for depressed older adults: a randomized pilot study. American Journal of Geriatric Psychiatry 11: 33–45.
[15] Safer D L, Telch C F, Agras W. (2001) Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry 158: 632–4.
[16] Telch C F, Agras W, Linehan M. (2001) Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology 69: 1061–5.